Today's Washington Post article about a budding Bush administration proposal to extend the rights of health care workers to opt out of participation in a range of procedures that they object to was all over the blogosphere within minutes of publication.
The proposal, which would deny federal funding to any hospital, clinic, health plan or other entity that does not accommodate employees who want to opt out of participating in care that runs counter to their personal convictions, including providing birth-control pills, IUDs and the Plan B emergency contraceptive, is an obvious effort to heat up the abortion debate. Opponents of abortion say the regulations are needed. Supporters of choice see it as another effort to thwart access to legal care options.
Quite apart from the torch the regulations would toss into the abortion debate, they construe society as composed of individuals who look inward to conscience with no need to engage with others. They embody no sense of a moral community that must deliberate and struggle with difficult questions and develop creative ways of living with differences. In a similar vein, observers of the legislative process comment on the trend towards polarization without deliberation, accomodation, and compromise.
This moral solipsism is a major impediment to guiding our health "system" towards better quality and more sustainable costs. Our default moral reflex is that every physician has a "right to autonomy" and every patient has a "right to the treatment he wants." When these moral reflexes are applied to insurance systems they result in the runaway costs and suboptimal quality we see today. When they are applied to individuals they result in ever wider disparities of access and outcomes.
With skillful leadership, communities have shown that they can come to grips with potentially explosive ethical issues. The Oregon Death with Dignity Act shows how over the course of several years a state developed a viable approach to a deeply divisive question. (Read about it here.) The Century Foundation effort to make Medicare a demonstration project for collaborative oversight of health policy reflects the same vision.