Did You Know This Fundamental Bioethics Principle Can Shape Benefit Design?
December 10, 2018
“Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end.” These words were spoken by Immanuel Kant over 200 years ago – but how does the current U.S. health care system embody this philosophy?
To understand how our health care system has evolved over time, let’s take a look at where it started. In the beginning, the medical profession was rooted in medical paternalism, where doctors made decisions on behalf of their patients, with the assumption that those decisions would be best. However, in the 1900s this attitude began to change as society began to recognize the active role of the patient in their care. Moreover, as atrocities such as the Tuskegee syphilis experiment came to light, the rise of the bioethics movement began and led to the creation of the landmark Belmont Report for research ethics and its principle of autonomy.
Expanded beyond the realm of research ethics, autonomy in health care centers on the idea that patients have a right to make free, conscious, and informed decisions about their health care. In this way, patients were no longer viewed as merely a means to an end, but an end in-and-of themselves. Issues of respecting autonomy can also arise in situations of patient confidentiality and privacy, a physician acting as a fiduciary to the patient, and truth-telling at the bedside. Autonomy has become a cornerstone philosophy underlying modern health care and has opened the door to a variety of health care reforms.
For employers and other health care purchasers, autonomy plays a role in employee decision-making about care and needs to be considered when designing benefits.
Consider the rise of programs that leverage shared decision making between the provider and their patient (made possible by autonomy). Giving patients the opportunity to discuss their preferences for care could lead to lower cost, higher quality, and higher patient satisfaction. For instance, patients who may have otherwise undergone a C-section recommended by their physician have the opportunity to discuss their options for delivery and attempt a vaginal birth. On the other hand, shared decision making could also result in more expensive and lower quality care. For instance, if patients insist on having spinal surgery for lower back pain when less invasive alternative treatments exist.
Rapid advancements in medical technologies also create bioethical dilemmas related to autonomy. For instance, genetic testing has raised issues around patient consent, confidentiality, privacy, and disclosure. In order to preempt and address these issues, employers considering offering genetic testing as a benefit should take steps to help employees understand genetics and genetic testing data, how that data can and will be used, and provide access to assistance interpreting results. Purchasers offering a mental health benefit also encounter similar issues centered on privacy and confidentiality. Due to the enduring stigma associated with mental health disorders, employers should take measures to help protect employees’ privacy when seeking this type of care.
Whether autonomy is expressed as consumers making joint-decisions about their care with providers, understanding issues and using relevant information to decide whether to seek certain types of care, or treating employees as rational, free consumers that will react to incentives and disincentives accordingly when it comes to their care, recognition of and respect for autonomy underlies a variety of benefit designs. When pursuing any benefit design, purchasers should consider the role autonomy plays and try to optimize for it.