Ethical Issues in Insurance Company

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					Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                   21

                 Ethical Issues in Medical Insurance
                             Hilton P. Terrell, M.D., Ph.D.

An attempt was made in residency to teach           rales, elevated WBC) and a story that
me that the economics of medical practice           matched the findings. After dealing with
mattered a great deal. I disregarded the            that patient, I found a fourth room to
effort, mostly out of a sense that my               contain yet another member of the same
primary priority ought to be mastery of             household who had complaints with no
facts about diseases and treatments. In             physical finding to match. The complaints
addition, it was easy to disdain monetary           sounded like a viral upper respiratory
concerns coming from a group of                     infection which could be expected to be
physicians who seemed comfortably fixed             self-limited in this otherwise healthy young
with fine homes, second homes, expensive            person. All four of the patients were
clothes, hobbies and automobiles. It                Medicaid.
seemed that they were speaking of
"looking out for number one" financially,           When realization struck as to what had
and some of them were. Less than a year             probably occurred, I decided to chick it
out of residency, I discovered that some of         our. I voiced my suspicions to a Navy-
my teachers had been referring to other             veteran medical assistant who had known
powerful influences upon medical practice           the family for years. He laughed at my
that attention to their own incomes.                naivete and suggested asking within the
                                                    family. the matriarchal head of the
The practice I was in was rural and heavily         household was not one of the four patients,
Medicaid. The "Aha!" experience, when               but was present and answered my
the light dawned on me regarding the                delicately phrased question: I understood
influence of the financing of medical care,         why the patient with pneumonia had come,
began after I had examined two patients in          but was puzzled as to the reasons why the
succession from the same family. Each had           other three had come, since they did not
a complaint which usually is not                    seem very ill. Without hesitancy or
accompanied by physical findings or                 embarrassment, she explained that the trip
helpful laboratory tests. I don't recall now        was occasioned by the ill patient. Since
what the complaints were, but they were of          they were coming to the doctor anyway,
the nature of an occasionally recurring             she had thought it a good idea to have the
tension headache. In a third examination            others "checked".
room, I discovered yet a third patient from
the same household. This time, there was            Of the three whose illness was determined
an unmistakably ill patient, who had                only on the basis of their history, two had
physical findings (fever, productive cough,         already left the office with a prescription

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                         22

given by me, based upon their symptoms.               underrated. For this reason I am convinced
Given the risk of any medication, they                that, in our current situation, lack of access
were probably more at risk from having                to medical care due to lack of money is no
come to the doctor than if they had stayed            more problematic than is lack of financial
home! Behavior of this sort was alien to              restraint in seeking medical attention.
me. Even if a doctor visit had cost me                Inability to obtain wanted medical care is
nothing, as it had these four, I had always           commonly        lamented       without     any
had better things to do than sit in a doctor's        recognition that broadening access without
office to be examined. Unfortunately, with            restraint may also be cause for lament.
many variations on the theme, this sort of
episode occurs regularly in American                  It is inevitable that we must pay to sift an
medicine. IT is exceedingly costly. The               increased number of not-very-ill patients
Medicaid system paid the same amount for              presenting because of Medicaid and other
my service to the patient with pneumonia              insurance plans, possibly putting them at
as for the three who would have recovered             risk, in order to find the one in whom
had they never come, if indeed they were              medical care will make a positive
ill to begin with. In the one case of the             difference? Are occurrences of this sore an
patient with pneumonia, I was underpaid               irreducible characteristic primary care
for the value of the service rendered. In the         medicine, or are they related to the
other three cases I was underpaid for the             insurance scheme? A clue came when I
time spent with them, but grossly overpaid            noted later that self-pay patients almost
for the service rendered, since it was either         never seemed to behave in such a fashion.
of little worth or actually hazardous to              Moreover, their health did not seem to be
them.                                                 any worse than those for whom insurance
                                                      coverage, of one sore or another, reduced
Though part of the fault lay with my naivete          barriers to a medical encounter.
in not considering the family as a whole,
part lay with the family's lack of financial          For a while, I developed a positive hatred
restraint in seeking medical care. I have             of all medical insurance, and invested it
since tried to mend my practices, though              with a large share of blame for what ails
certainly I am not able to catch all such             American medicine. Many bible passages,
visits, classified a "opportunity visits". The        however, strongly support the idea of
notion of restraining anyone's access to              insurance as a good idea. Proverbs 27:12
medical access to medical care by financial           states, "The prudent see danger and take
considerations is usually presented as a              refuge, but the simple keep going and
problem to be solved. As this example                 suffer for it." Though we cannot predict it
demonstrates, lack of financial restraint can         in detail, illness is virtually certain to strike
cause medical problems, as well as                    each of us at some time in our life. Medical
unnecessary expense. The effectiveness of             insurance can provide a kind of refuge, if
medical care tends to be overrated, while             we are willing to foresee probable illness.
the hazards of medical treatment tend to be           Provision for the foreseeable future is also

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                        23

counseled in Proverbs 30:25. "Ants are the             aspect of the commandment he states,
creatures of little strength, yet they store up        "...let [each man] pay his debts faithfully."1
their food in the summer." The arrival of              Medical insurance is one means of being
the seasons is more predictable than the               ready to pay for the debts that illness or
arrival of illness, but the two are                    injury may suddenly cause.
comparable. Proverbs 6:6 commends us to
"Go to the ant, you sluggard; consider its             In summary, it is fair to state that the Bible
ways and be wise! It has no commander,                 commends foresight. We can foresee
no overseer or ruler, yet it stores its                probable medical trouble in general, and
provisions in summer and gathers its food              insurance enables us to deal with it
at harvest." Our responsibility to provide             financially in detail.
for our household is explicit in I Tim. 5:8:
"But if any provide not for his own, and               Insurance,m not just medical insurance, has
specially for those of his own house, he               certain advantages of economy. If I have
hath denied the faith and is worse than an             insurance I do not have to maintain a fund
infidel." It is reasonable to include medical          adequate to replace necessary housing or
care among the expected provision. John                other property, should it be destroyed. It
19:26,27 records Jesus' provision for His              can share my small risk with others and use
mother.                                                the money freed for more profitable
                                                       investments. Insurance plans can help
Medical care cannot easily be stored by                avoid slavery to enormous debts for which
individuals, but participation in an insurance         we are liable. Certain Old Testament
program can perform the same function;                 passages make clear our financial liability
one is "storing" a fund to be expended on              for damage which was careless or
anticipated future services. Proverbs 21:20            foreseeable. Exodus 22:6, for example,
states: "In the house of the wise are stores           warns: "If a fire breaks out and spreads
of choice food and oil, but a foolish man              into thorn bushes so that it burns shocks of
devours all he has." Clearly, something can            grain or standing grain or the whole field,
be set aside for future exigencies, rather             the one who started the fire must make
than devoured foolishly. Would it be wise              restitution." A physician might cause more
for me to spend surplus money on a classy              economic damage by careless use of his
sports car when I have failed to store                 prescription pad than h would have
something for medical care for my                      personal resources to cover. Liability
household and for theirs?                              insurance enables us better to compensate
                                                       anyone we have so damaged. (I will pass
John Calvin did not mention insurance in               over negative aspects of liability insurance).
his passage on the eighth commandment
(thou shalt not steal) but did summarize the           Because medical insurance is used to pay
fullness of the teaching of this                       for medical care, it is often confused with
commandment in both its positive and                   biblical passages commending charity and
negative aspects. As part of the positive              compassionate acts.

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                      24

Medical insurance must be clearly                     Also, whereas categorical exclusion is not
distinguished from charity. Charity includes          charitable, individual exclusion may be.)
the following features which are absent in            The outcasts, e.g., uninsured and
insurance:                                            underinsured, are part of the perceived
                                                      problem in our current medical care
1. Charity is giving to a specific known              system. Nationally, we have been trying to
need, already existing. IT is not a financial         meet the needs of such groups by
hedge entrusted to others because they                extending to more and more of them
might need it. (1 John 3:17: "if anyone has           categorical entitlement to insurance.
material possessions and sees his brother             "Undeserved" charitable provision for their
in need but has no pit on him, how can the            care will go farther in meeting their need
love of God by in him?")                              than installing an undeserved entitlement to
                                                      medical insurance which bypasses needed
2. Charity is not a quid pro quo contract. It         restraints and participation by the recipient.
lacks the contractual accounting so
characteristic of medical and other                   MEDICAL INSURANCE IS UNIQUE
insurance. (Matt. 6:3: "But when you give
to the needy, do not let your left hand               Not only must medical insurance be
know what your right hand is doing.")                 distinguished from charity, it has two
                                                      special features that require special rules
3. Charity is the wise use of resources               for it to work well. One special feature is
belonging to me to meet a need of another             the way claim validation and adjusting is
person. It is not the idea of the most for me         managed; the other feature is the fact that
at the least cost (II Cor. 8:1-4,13-15,20-            the patient is usually not the person who
21).                                                  purchases his medical insurance. The two
                                                      features are a problem individually and
4. Charity is ignorant of any outcasts. there         their interaction is especially a problem.
is no in-group (policyholders) and outcasts           We will deal with these two unique
(non-policy holding Samaritans). This is              features in separate sections.
bet illustrated by the parable of the Good
Samaritan (Luke 10:29,30,33,37). by                      I. Claim Validation and Adjusting
contrast, an insurance company controls its
risk and increases its profits by                     Let us consider some other types of
categorically excluding certain high risk             insurance in order to understand how claim
groups: the old, smokers, those already               validation and adjustment is different for
chronically ill, those who have been                  medical insurance. Life insurance requires
seriously ill in the past, alcoholics, the un-        a death certificate which must show causes
employed. Charity may include meeting                 and times that fit the policy restrictions.
needs of any of these. (There is some                 Homeowner's insurance utilizes an adjuster
comparison in that charity biblically begins          who inspects the damage and is supposed
at home. It, however, doesn't end there.              to be knowledgeable about local repair

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                         25

and replacement costs. In addition, there is           surgery is life-saving. Until high policy limits
a realistic maximum amount written into the            are reached, there is no one other than the
policy and certain exclusions, generally for           patient to say, "Stop!" When one is in
high value items which must be separately              distress, self-governance is extraordinarily
insured. Auto collision insurance utilizes             uncommon and that one is in danger of
multiple garage estimates or a claim                   dishonoring God by desperate actions
adjuster. A limit on coverage is also written          (Prov. 30:7-9).
into the policy.
                                                       Hope springs eternal in the human breast.
Health insurance claims, however, are                  For those with chronic or recurrent and
often valid simply on the claimant's                   inadequately treatable illnesses, such hope
statement. If my patient tells me she has a            combined with insurance policy, becomes
headache or dysmenorrhea or dizziness or               expensive. Fear also springs out of the
tinnitus or nausea or back pain, neither I             human heart. Allaying fear can become
nor anyone can gainsay that. Such a patient            expensive when an insurance policy is
can continually utilize insurance resources.           present. In a real sense, a fearful people
Sometimes the resources end up being                   who are well-insured medically, can
used helpfully, sometimes wastefully,                  attempt to purchase with insurance
sometimes actually to the patient's physical           freedom from their slavery to fear of
harm, as in the case of hazardous                      disease and death (Cf. Heb. 2:14,15).
treatments or diagnostic testing. In this
system the patient can persistently act as             People also occasionally malinger as did
his or her own claims adjuster.                        David in Philistia. (I Sam. 21:13: So he
                                                       feigned insanity in their presence; and while
This feature of being one's own                        he was in their hands he acted like a
incontrovertible claim adjuster is different           madman, making marks on the doors of
from other types of insurance policies have            the gate and letting saliva run down his
maximum coverage limits written into them,             beard.") Primary care physicians also see a
the effect is not the same as with policies to         fair number of people whose social,
cover property losses. For one thing, the              economic, marital, or legal problems are
maximum amounts of coverage are usually                transmogrified into a medical problem.
very high. Utilization and, therefore,                 Though the physician may suspect early on
expense to the policy, may bear no good                in the diagnostic process that the problem
relationship to the significance of the illness        is basically not medical in nature, the proof
or the potential efficacy of treatment                 of that suspicion is expensive if it is
available. An insured patient with persistent          possible at all.
weak spells, or headaches, or abdominal
pain for which multiple practitioners in                          AN HISTORICAL
various specialties admittedly have no                           INTERPRETATION
effective remedy, can expend more
insurance money than one for whom major                Historically, health insurance was not

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                   26

common in this nation until after World            government realization would come after
War II. It began to grow in the early              private efforts had placed refrigerators in
1950's. The additional money in the health         the homes of many people, stimulating an
care system stimulated its expansion, as it        increase in refrigerator designs (and price).
would any industry. New techniques,                After a significant fraction of the population
higher standards and better hospitals              was discovered to be without basic
resulted. The prices also went up. Higher          refrigerator availability, a government
prices made the financial threat of illness        program would be instituted to meet this
greater. Health insurance thus became              need. Through government subsidies to
more attractive and more people bought it.         manufacturers       and      other     means,
Government allowance of insurance                  refrigerator production would rise.
premiums as a deductible item encouraged           Refrigerator technology would advance
employers to purchase it as a benefit for          rapidly with the new infusion of money.
employees. Some people perceived a                 Standards for what constituted a "decent"
contrast between the health care delivery          refrigerator would be drawn up and
to the insured and to the uninsured elderly        updated annually, along with prices.
and poor. Believing health care to be a
right to be secured by government, these           A new government bureau, Humane Cool
people created a political clamor for these        Food Agency (HCFA), would be set up to
lesser-served groups to be included in the         enforce Slobbovian refrigerator guidelines.
health care smorgasbord. They had their            Private advocacy and political groups
way in the mid-1960's.                             would be continually finding geographic
                                                   and demographic pockets of refrigerator
Medicare and Medicaid were spawned.                deficiency, developing these pockets into
More money was turned into the industry            new private markets and political
and it responded with ever more                    constituencies. With such a national effort,
sophisticated therapies, ever higher               and given the fact that refrigerators are
standards, and higher costs. Ordinarily,           completely        designed       by       and
supply would keep up with demand, or the           understandable to their designers, there
price would restrain the demand.                   would come a time in lower Slobbovia in
However, if someone else is paying most            which you could leave beautiful new, high
of your health care costs, price is no             quality refrigerators on street corners to be
restraint. Demand for health care is               taken for free, and no one would bother.
quantitatively unlike other human wants. It
is more difficult to saturate.                     I don't believe you could reach such a
                                                   saturation point with medical care. Though
Suppose, for example, that the government          most people would behave reasonably,
of Lower Slobbovia (with apologies to the          there are plenty who would sop up all the
late Al Capp) decided that possession of a         resources provided to them, and demand
refrigerator was a basic human right, to be        more. Furthermore, unlike refrigerators,
guaranteed by the government. This                 the human body was not designed by man,

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                     27

and is little comprehended by any man.               hand. We are closing in on that limit. (The
There will be no end to researching the              much-vaunted increased average life
human body.                                          expectancy is severely reduced if all the
                                                     people aborted since 1973 are counted in
As medical care has apparently reduced               the averaging). Future extensions of life will
disease, the response in our culture has             depend more and more on non-medical,
been to medicalize more and more of life's           behavioral changes. Most youthful deaths
hazards and problems. We have more                   in our country are lifestyle-caused:
medical problems now than 50 years ago,              accidents, alcohol cirrhosis, suicide,
simply because of the expanding definition           homicide and, soon AIDS.
of what is a medical problem.2 A popular
advice columnist recommends medical                  The flood of government and insurance
treatment for shoplifting. Gambling is               money over 30 increased the sophistication
considered a disease. Everyone (except               and     expense      of medical care.
God) knows that alcoholism is a disease.             Simultaneously and out of proportion to
Children who squirm and talk too much in             the facts, it increased public expectations
school are brought before physicians for             of medical care. Finally, the bottom of the
cure. Young women who starve and cause               deep pockets of the insurance companies
themselves to vomit in order to fit our              and government was reached and, having
culture's preoccupation with a slender               captured much control, they began to turn
figure are determined to have a disease, a           the screws to govern individuals where
strange disease, unknown in other cultures.          individuals refused to govern themselves.
                                                     The basically good idea of indemnity
According to Dr. James Maloney,3 we are              insurance has been perverted by removal
reaching an asymptote in the efficacy of             of the governing effects of a free
medicine to extend life. Each medical gain           marketplace.
now is ever so much more costly than the
earlier gains. Over the 35 years ending in                WE NEED GOVERNMENT
1975, average life span increased 15%,
whereas per capita expenditures for                  Medical care must have a governor.
disease care increased 314%, after                   Anyone who governs it will make errors.
                                                     The best governor is the patient's wallet,
correction for inflation.4 There is an
                                                     the nexus between the values and needs in
academic dispute as to whether there is an
                                                     all aspects of the patient's life. Try a
absolute upper limit of life span. The Bible
                                                     rewrite of the account of the woman with
suggests strongly that there is an absolute
                                                     the issue of blood, assuming that she had
upper limit of life span. The Bible suggests
                                                     medical insurance. (Mk 5:25-26: "She had
strongly that there is (Ps. 90:10, Gen. 6:3).
                                                     suffered a great deal under the care of
You can still read the research either way,
                                                     many doctors and had spent all she had,
but the studies supporting an absolute
                                                     yet instead of getting better she grew
upper limit seem to me to have the upper
                                                     worse.") Perhaps, if she had access to

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                    28

modern medical insurance, she would have            among the measures of health outcome
missed her cure altogether. She might have          used. The only difference in outcome
been off at the Supercalifragilistic Medical        among the groups was in diastolic blood
Clinic undergoing a fourth PiMeson Scan             pressure and vision as measured by
(at $1,250 a throw).                                Snellen chart. For the group which did not
                                                    have to pay any money for their health care
Governors in medical insurance are the              the average diastolic blood pressure fell 3
price of the policy and the method of claim         mm and there was a 0.2 line improvement
validation and adjustment. To determine             in far vision. Due to the large size of the
the method of government, let us examine            study, these differences were statistically
three common types of third-party                   significant. Though the authors of the
payment systems: indemnity insurance and            report seemed to regard these differences
two types of pre-paid insurance.                    as also practically significant, their
                                                    reasoning on that point is strained.
Indemnity insurance is still a common type
of medical insurance. The patient is the             GOVERNMENT BY INSURANCE
claims adjuster; therefore there are not
restraints except the deductibles, co-              Another common medical insurance plan
payments and the tenurial hassle of going           today is pre-paid insurance. Health
to a doctor. Co-payments do make a                  Maintenance Organizations (HMO's) are
difference. Brooke, et al., reported an             the best example. In HMO's an adjuster is
extensive experiment in which there was             installed other than the patient alone.
random assignment of about 4,000 people,            Usually there is a coalition of adjusters: the
aged 14-61, none disabled, to one of 14             patient (through limited reimbursement, and
insurance plans.5 All of the plans were free        profit-sharing incentives), and the insurer
in the sense that no premium was required.          (through profit-sharing and enforcement on
Only one plan required no co-payment, all           "provider" hospital or physician).
the others required incremental degrees of
co-payment by the patients for each                 In addition to the possibility that medical
service they received. The study lasted 7           costs will not be controlled by such a
years.                                              bureaucratic scheme, HMO's pose ethical
Patients with no co-payment or deductible
made one-third more visits than those with          1. Is it morally proper for a competent free
co-payments, achieving only slight                  agent (the patient) to turn responsibility,
demonstrable improvement in health                  hence authority, over medical care to
outcome. Several measures were used for             someone else? As the temple of the Holy
health outcome: role functioning, social            Spirit, may decisions regarding the care of
contacts, physical functioning, smoking,            our bodies be turned over to others who
weight, cholesterol level, functional far           are subject to financial temptations to limit
vision, and diastolic blood pressure, were          what is done for temple maintenance? (1

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                      29

Cor. 6:19, 2 Cor. 6:16).                              telling during data gathering is another.
                                                      These have been the cornerstones of my
2. Is it morally proper for a physician to            decision making process regarding who
usurp the patient's responsibility? Is the            will and who will not continue to be a part
patient's responsibility for his own health an        of my practice).
inalienable trust from God? Should the
physician accept governance of what will,             In addition to HMO's and indemnity
or more importantly, what will not be                 insurance there exists a variety of other
provided?                                             arrangements which usually amount to a
                                                      pre-negotiated fee scheme. Patients pay a
3. Though the isuror and participating                fee for each service, but plan members
HMO physician may control costs in a                  have pre-negotiated a lower fee for
given group, can the physician ignore                 themselves compared to others. The plans
persistent self-inflected injury by an                go by various abbreviations such as PPO's
individual? Is it proper to continue                  or IPA's. In plans of this sort the physician
participation in a plan for which pays for,           becomes the adjuster for each visit, having
hence, endorses financially, persistent and           pre-adjusted the cost in negotiations with
willful self-destruction by the patient?              the patient's agent. If there is a co-payment
Oughtn't a physician encourage personal               required, the patient becomes the co-
responsibility, especially in a nation whose          adjuster. If there is no limit to number of
health is so substantially damaged by self            patient visits, the system will not save
inflicted diseases?                                   money, even though cost per visit may be
                                                      lower. Physicians can arrange to have the
I have no firm answers. My working                    number of visits increase to offset the
conclusion is that the patient has                    lower cost per visit. Patients can increase
responsibility for his own health, and I am           the number of visits if they think they are
responsible only as an adviser and                    not receiving all the time and service they
assistant. One obviously needs assistance             require. Presumable, a conscientious
to remove a sebaceous cyst from the                   Christian physician could resist the
interscapular region or to have one's                 temptation to arrange unnecessary visits
eardrum examined. Neither should patients             and a reasonable patient would not want
be expected to know as much about the                 do so. What, though, of the idea of a fee
human body and its malfunctions. But                  that is lower for some patients than for
physicians cannot simply sell a contract,             others, for the same service? Proverbs
like Orkin, to keep the bugs out. We need             20:23 states, "The Lord detests differing
patient's participation, and the wallet               weights, and dishonest scales do not
handle is one of the only ways some                   please him."
people can be induced to take the
necessary interest. (Compliance with                  Is the physician participating in a
reasonable       advice     is      another.          negotiated fee system as an act of
Appointment-keeping is another. Truth-                negotiated charity? Is charity negotiable? If

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                        30

not charitable, is he determined just to               decided to save money on insurance by
make less money? If not losing money on                choosing a high-deductible policy for one
them, is he providing less care of                     car and by simply dropping the collision
overcharging other patients who receive                coverage and assuming the collision risk on
the same service? The face appearance of               another older car. On fire and windstorm
pre-negotiated fees for some patients but              coverage for my house, I obtained a
not for others is one of differing weights.            combined policy with other risks to reduce
Other factors may rehabilitate the concept             costs, but convinced the company to allow
of negotiating fees for some patients. For             higher coverage than they initially wanted
example, some might defend them on the                 to allow. This decision cost me money. I
same principle as "loss leaders" in a                  was weighing my pocketbook against risk
grocery store. The physician makes it up in            protection. IF someone else were paying
volume, and thus keeps the overall price               the premiums, I would be tempted to
down for everyone. Or, perhaps the                     agitate for lower deductibles, and for
physician considers other priorities higher            coverage on the older vehicle.
than purity in billing, such as keeping a
unique service available. Participation in             Furthermore, though I find all insurance
prepaid systems may be the only way, a                 policies difficult to understand, I have
necessary compromise if some physicians                made an effort to understand the ones I
are to continue in practice.                           purchased. If someone else were buying, I
                                                       might tell them what I wanted, and then
  II. CONFLICT OF INTEREST IN                          assume that it was so, until I had a claim.
          PURCHASING                                   At that time I might find that the coverage
                                                       was not what I expected, and be angry
Though indemnity insurance is a good plan              either at the one who presented the bill for
for medical insurance, it combines poorly              the services, or at the one who bought the
with the feature by which someone else,                policy. Most physicians have been in the
usually an employer, pays the premium.                 former situation and, as employers, some
Proverbs 20:14 states, " 'It's no good, it's           of us may also have been in the former
no good!" says the buyer; then off he goes             situation and, as employers, some of us
and boasts about his purchase". A                      may also have been in the latter situation.
purchaser who is not personally going to               Not a tenth of my patients have any
use a service will have more concern with              rudimentary understanding of what their
the price than with the quality or availability        medical policies cover or do not cover, nor
of that service. Sixty per cent of the U.S.            what they cost. This is not a good situation.
population has employer-paid insurance,
10% has privately paid, 6% has no                      Medical insurance can also disrupt the free
insurance, the remaining 22% has some                  market interaction between buyer and
form of government insurance plan.6                    seller if the physician deals directly with the
                                                       insurance agent for payment instead of with
When shopping for automobile insurance, I              the patient. Years of profiting from an

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                    31

easygoing relationship with insurers               law in managing individual cases. A
hooked many physicians into dependence             government which will sanction millions of
upon the insurers for payment. Gradually at        abortions, which usurps family authority to
first, now with vigor, the insurers have           teach and discipline children, which allows
tightened the screws on physicians and             experimentation with human embryos, etc.,
attempt to dictate the price and many other        is not trustworthy to look after Aunt Mae's
features of medical care. Their dependence         best interests.
has caused physicians to hesitate to admit
to their insured patients that they are            Whoever pays for medical care will
rationing their care due to lower payment          determine what is done, including what is
and other constraints.                             not done. Government-paid medical
                                                   insurance will determine medical practice.
   GOVERNMENT INSURANCE                            Exceptions to government involvement in
                                                   individual medical care would be for those
By whatever insurance plan, the biblical           in its employ, such as soldiers, or under its
role of government in health care is much          sanction, such as prisoners of war and
more limited than now exists in U.S. There         jailed criminals. A government which has
is insufficient space to defend this               slaves can control their personal medical
controversial assertion here. The reader is        care, a caution to me when I consider our
referred to such biblical texts as Rom.            own elderly and poor, who themselves and
13:1-7, and 1 Pet. 2:13,14 for statements          through their political leaders are rapidly
regarding the purpose of government. I fail        selling their freedom to control their own
to find any biblical warrant for a                 health care for the security of having
government role in the provision of                generic health care at little out of pocket
individual medical care. A warrant for             cost. Trading freedom for security is one of
public health measures could be made               the ways to become a slave (Cf. Ex. 21:6).
from Old Testament texts. Whereas public
health concerns may include such issues as         Some might wish to include government in
environmental carcinogens, they do not             medical care on the basis of government-
include whether to irradiate Aunt Mae's            managed charity programs. Government
bone cancer, whether she should be                 welfare, even if it worked, cannot be
admitted to a hospital, or whether she             charity. That which is taxed, taken under
should be put on expensive intravenous             threat of force, is not charity (II Cor. 9:7).
hyperalimentation if the time comes when           Whether        government-paid        medical
she cannot eat.                                    programs "work", or whether the health of
                                                   those so covered is any better because of
Christians who insist upon government              the programs, is beside the point if
involvement in such issues must not only           government involvement is not God's plan.
show the biblical basis for the government         The finest experimental design cannot
involvement, they must show how to                 reveal "true truth" to us, but mere utilitarian
constrain the government to obey God;s             facts with a cultural relativity and a certain

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                    32

half-life.                                          them, who will? Should we just let them
                                                    suffer, remain disabled or die? Hopefully
Suppose research showed that a                      not. Yet we should not erect a system
completely             government-controlled        designed to provide medical care for all
comprehensive health plan improved a                while trampling on other biblical values. As
population's physical health significantly          stewards of limited resources we may seek
over a 10 year period. A government-                to see those resources wisely distributed,
mandated vigorous exercise plan for youth,          but we have no guarantee that each
government policies on agriculture to limit         individual's needs will be met, let alone his
the supply of excessive amounts of red              wants.
meats, government-subsidized vacation,
etc., could probably do this. Who would             Genesis tells us that the earth has been
doubt that the population's health would            cursed. Though it has many marvels, and
improve? Such government action has                 though God's hand is evident in it to those
already occurred -- in Nazi Germany. A              whose eyes are open to the fact, there is
population willing to be enslaved can, at           something wrong with it. Trying to work in
least for a time, be healthier under some           the southeast in a garden in the summer
regimes. Though we do not have formal               gives one an appreciation of the curse --
research into the effects on German health,         drought, weeds, hail, worms, bugs,
an eyewitness has testified to the contrast         animals, even small children all unite to
he noted between vigorous German youth              destroy a garden. Dealing with disease in
and scrawny British youth at the outbreak           patients can be must the same, only more
of World War II? What would have been               critical than tomatoes. If this premise of a
his assessment at the end of the war? The           curse, or a bent, damaged-but-not-
youth of Germany were decimated by                  destroyed nature is accepted as true, then
Nazism. Similarly, abortion is sometimes            we must realize that we do not have the
justified because it leads to a healthier           option of undoing the curse, only
population. Neither health nor longevity            ameliorating it for a time. All of my patients
should be set up as the ultimate values, but        die...sooner or later...of something. By no
rather God's revised will. Freedom comes            material means, by no system of human
at a cost; part of that cost is recognizing         organization, private or government, will
that some people will abuse their health or         we be able to eliminate disease and
ignore their illness to their own detriment.        suffering. Our job is to make the best of
                                                    what we have--stewardship. We are
   IF NOT GOVERNMENT, THEN                          stewards of an omnipotent.God, not
            WHO?                                    omnipotent ourselves. If He has not put the
                                                    material means within our control, we
This brings us to another question: what of         surely have no warrant from Him to seize
those who are truly afflicted with disease,         the means from others in the name of
who are not insured, or not properly                health.
insured. If government doesn't take care of

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                     33

In any nation people can be pointed out              Money saved by avoiding first-dollar
who do not have everything medically                 coverage should be invested to increase
possible being done for them. This                   family assets and thus enable even higher
observation does not necessarily constitute          deductibles, with more savings, in the
and indictment of the prevailing system.             future. The goal is to move toward
The gaps need to be viewed in context of             insurance for medical disasters and away
other accomplishments or drawbacks of                from insurance for more routine medical
that system. As mentioned, a slave state             problems.
could probably achieve greater health for
the population than a laissez-faire                  3. Encourage insurance policies which
government. If we have a commitment to               reward proper life-styles. Let those who
the "greatest health for the greatest                willfully endanger their health take the extra
number" without a commitment to other                expense. Let us not pretend that disease in
values such as freedom, we can have a                the U.S. is always a random event that falls
healthier, more nearly enslaved population.          out of the sky onto innocent, non-
                                                     participating victims. Except near the limit
            CONCLUSIONS                              of our life span, the evidence is that we
                                                     bring disease on ourselves much of the
Though neither is an absolutely top priority,        time.
we are biblically committed to maintain our
health (I Cor. 6:20) and to preserve or              4. As "providers", health care personnel
restore our freedom (I Cor. 7:21-23).                should refrain as much as possible from
What then, do we do about the gaps, if we            dealing directly with third parties. IT
are not to turn control over to government           disturbs the restraints of the marketplace
and insurance companies? From the                    and reinforces the already prevalent notion
foregoing the following strategies emerge            among people the their health care is
for Christian physicians and church leaders:         someone else's responsibility financially
                                                     and otherwise.
1. Encourage medical insurance; it is
encouraging a form of responsibility.                5. Laws that tend to reconnect the
                                                     purchaser of the policy with the beneficiary
2. Encourage, where possible, insurance              of the policy should be supported. At the
that has deductibles and co-payments                 present time this is seemingly an
which are substantial, i.e., as high as              unattainable    dream       as     Congress
affordable for the family. This goes for             contemplates requiring all employers, even
individually purchased policies as well as           small businesses, to offer medical insurance
for employers who offer plans to                     to all employees. An interim step might be
employees.       First-dollar    coverage            to allow employers to: (a) share savings in
encourages overuse of medical care.                  cheaper plans with their employees; (b) set
Virtually everyone is helped by having               up illness contingency funds within the
some hesitation to reach into his pocket.            company, which employees would have

Journal of Biblical Ethics in Medicine, Volume 1, Number 4                                              34

access to for expenses not met in                    are promoting the trend for both to restrict
otherwise high deductible policies, and in           medical care, very likely on ungodly
which the could share in revenues for sums           grounds, and otherwise enslave us.
not expended.
6. Encourage charity. The practice of it is
one of the better ways to encourage it.              1. Calvin, John, Institutes of the Christian
                                                     Religion, Book II, Chap VIII, 46.
Could your church begin in a small way its
own medical charity? Be sure not to                  2. Fox, Renee, "The Medicalization and
operate it the way insurance companies               Demedicalization of American Society",
do. Personal charity has the amazing                 Proceedings of the American Academy of Arts
advantages of including those frozen out of          and Science, 1977; 106(1), 9-23.
insurance, of the admission of limits to
                                                     3. Maloney, James V., Jr., M.D., "The Limits of
medical care, of taking into consideration           Medicine" Annals of Surgery, Sept. 1981, Vol.
all of the needs of the Kingdom, and of              194.
supervising individually the recipient's
participation in his/her own health. (Again,         4. Gori, G. and Richter, B., "Macroeconomics of
recently, a patient revealed some                    Disease Prevention in the United States,"
                                                     Science, Vol. 200, 9 June 1978, p. 1125.
substantial financial hardship regarding the
cost of her needed chronic medications.              5. Brook, et al. "Does Free Care Improve Adults'
My heart was soft but my head was hard.              Health?: Results from a Randomized Control
She was literally burning up $2.50 a day in          Trial, "New England Journal of Medicine, Vol.
                                                     309(23) Dec. 8, 1993.
cigarettes, more than the cost of the
medicine. My head prevailed. I am sorry              6. The American Health Care System, The
for her plight, but I will not underwrite her        American Medical Association, 1984, p.32.
self-destruction by cigarettes and call it
love. An insurance company cannot                    7. Shirer, William, The Nightmare Years, Little,
individualize its dealings in such a manner).        Brown & Co., Boston 1984.

7. Where possible, whatever the payment
source, reason with the patient and family
regarding the wisdom of unrestrained use
of medical care at death's doorstep. Those
deathbed dances are not only expensive
for somebody, they often merely prolong
the act of dying. We are not physically
immortal, and all the resources of our
selves, our insurer, our physician and our
government cannot purchase immortality
for us. If we try to pretend that government
or insurance resources are sufficient, we


Description: Ethical Issues in Insurance Company document sample