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Opinion 2.095 - The Provision of Adequate Health Care

Because society has an obligation to make access to an adequate level of health care available to all of its members regardless of ability to pay, physicians should contribute their expertise at a policy-making level to help achieve this goal. In determining whether particular procedures or treatments should be included in the adequate level of health care, the following ethical principles should be considered:

(1) degree of benefit (the difference in outcome between treatment and no treatment),

(2) likelihood of benefit,

(3) duration of benefit,

(4) cost, and

(5) number of people who will benefit (referring to the fact that a treatment may benefit the patient and others who come into contact with the patient, as with a vaccination or antimicrobial drug).

Ethical principles require that a just process be used to determine the adequate level of health care. To ensure justice, the process for determining the adequate level of health care should include the following considerations:

(1) democratic decision making with broad public input at both the developmental and final approval stages,

(2) monitoring for variations in care that cannot be explained on medical grounds with special attention to evidence of discriminatory impact on historically disadvantaged groups, and

(3) adjustment of the adequate level over time to ensure continued and broad public acceptance.

Because of the risk that inappropriate biases will influence the content of the basic benefits package, it may be desirable to avoid rigid or precise formulas to define the specific components of the basic benefits package. After applying the five ethical values listed above, it will be possible to designate some kinds of care as either clearly basic or clearly discretionary. However, for care that is not clearly basic or discretionary, seemingly objective formulas may result in choices that are inappropriately biased. For that care, therefore, it may be desirable to give equal consideration (eg, through a process of random selection) to the different kinds of care when deciding which will be included in the basic benefits package. The mechanism for providing an adequate level of health care should ensure that the health care benefits for the poor will not be eroded over time. (VII)

Issued June 1994 based on the report "Ethical Issues in Health System Reform: The Provision of Adequate Health Care," adopted December 1993 (JAMA. 1994; 272: 1056-62).