Table of Contents
Morals and Ethics
Utility-based ethics by Bentham and Mill
Kant's duty-based ethics
The German health insurance system
Statutory health insurance vs. private health insurance
Different access for outpatient care
The dual health insurance system consists of statutory health insurance (SHI) and private full health insurance (PHI) in Germany is unique in Europe. About 72 million people in Germany are covered by one of the 110 statutory health insurances and around 9 million by the private sector. In 2016, a total of around 356.5 billion euros were spent for healthcare. Outpatient treatment in doctors' practices accounted for 14.9% of this total. Different research papers has shown, that the waiting time for a treatment is a indicator to measure imbalance access to health services. In two reports, different waiting times for SHI and PHI insured persons at a doctor's appointment could be determined. The length also depends on the distance to the end of the quarter, which is due to different rates paid to the doctors. This unequal treatment was considered from an ethical point of view from the point of view of Utilitarianism and Kantianism. Both legitimize this procedure, but it must be questioned whether a fundamental change would not be more beneficial. However, the different access to health care does not represent a lower quality of medical treatment. Recent studies have shown that SHI insurants even receive the better benefits and that there is only a difference in service.
Keywords: health-insurance-system, outpatient-care, utilitarianism, kantianism, ethics
Does the dual health insurance system produce a imbalanced access to health provision? A reflection of outpatient care under ethical aspects.
The dual health insurance system consists of statutory health insurance (SHI) and private full health insurance (PHI) in Germany is unique in Europe. About 72 million people in Germany are covered by one of the 110 statutory health insurances and around 9 million by the private sector.
The headlines that keep coming up are placing PHI at the centre of debates about fair or equal treatment for the different patient groups, which has meanwhile led to the demand for a citizens' insurance as first defined by SPD. In a different characteristic also the "Grüne" and "LINKE" pursue a citizen insurance (Kröger, 2018). Health expenditures in Germany amount to 1 billion euros per day and average 4,330 euros for each inhabitant. This corresponds to 11.3% of the gross domestic product (GDP) (Statistische Bundesamt, 2018).
The outpatient sector was selected on the basis of medical progress in view of the ever-increasing number of treatments (Gibis & Tophoven, 2017, p. 191). These include SHI-accredited physicians, dentists, pharmacies and outpatient care institutions (Simon, 2017, p. 83). The shortage of resources of money and of doctors in the German healthcare system necessitates that decision-makers balance the efficiency and the costs of established medical services (Kopf-Schiller & Rottenkolber, 2014, p. 135). As a result of the economization of medicine in this field in recent years, the current progress in Germany in the area of inpatient and outpatient medicine would not be achieved (Jörg, 2015, p. 14). However, regardless of the success, the question also arises as to whether unequal payment by doctors based on the patient's insurance status also leads to unequal treatment of the patient (Jörg, 2015, p. 41).
Doctors once swore the Hippocratic Oath, which is now no longer a necessary condition for the final approbation. What effect does the dual health insurance have on medical care in the outpatient sector, which stakeholder groups are still affected in addition to patients, and what is the ethical outcome?
Answering these issues, the terms morality and ethics are defined below and two prominent ethical viewpoints, utilitarianism and Kant's categorical imperative, are introduced. In the following, an overview of the German health insurance system is given and the differences between PHI and SHI. This will serve as a base to explore the question of a different access to health provision as a result of the different insurance status. At the end, the results are summarized and reviewed under the described ethical principles.
Morals and Ethics
The expressions morality and ethics are sometimes used synonymously in daily life, which is incorrect. Therefore, both terms are clearly defined in the following. The expression morality is to be understood as the set of rules, notions, convictions and institutions that judge whether an action or institution is unjustified or justified and evil or good. It also judges whether a person has a virtuous or a good character or not. Morality can be defined as the sum of the aspects of rules, ideas, institutions and beliefs by which a person is judged (Steinvorth, 1999, p. 25). The designation and classification of good and evil is, however, strongly influenced by the observer's judgment. Nonetheless, it is still possible to make a statement that has a tendency towards both, because mostly good and evil are related to the effect on third parties. Therefore, an action is good when it benefits others and bad when it harms them (Conrad, 2016, pp. 9–10).
Moral norms therefore standardize behaviour and are based on generally recognized core values. The reflection of morality is ethics.
It should help to judge and weigh up in the sense of a "thus or that", to set up and evaluate alternatives for acting. This, however, is not in the sense of a "just thus", whereby certain acts are enforced with compulsion or by pressure and other are excluded (Jäggi, 2018, p. 16). This critical reflection of morality finally results in ethics and is the scientific theory of morality. It takes part on many levels. This is the organizational level, the level towards third parties, the interpersonal level and the individual level, known as Moral Intelligence. We can see that ethics is much more complex than morality, making it neither valid for the general public nor easily legitimizable by institutions or other individuals (Kartini, Reichert, Rüb, & Savanin, 2018, p. 4).
Ethics can be understood as a theory that describes and justifies the aspects of morality (Steinvorth, 1999, p. 26). The adherence to a value system with the core values of human dignity, justice, charity, well-being, equality, autonomy, honesty and transparency is to be understood as ethical behaviour (Jörg, 2015, p. 8). Ethics can affect a moral and even become a moral, but it has to be differentiated from a moral. Generally, it can be stated that every human being is necessarily following a moral, but does not always knows ethics. Ethics can be understood as the grammar of morality (Steinvorth, 1999, p. 26).
Business is increasingly under scrutiny with regard to ethical or unethical practices. Companies are regularly evaluated there on the basis of responsible behaviour or condemned for failing to behave correctly (Kartini et al., 2018, p. 3).
Following the Utilitarianism and Kantianism will be examined. Centered around a single major principle, both meld a variety of moral considerations into a surprisingly systematized framework. Much is appealing in these theories, and they were the important models in ethical theory throughout much of the 20th century (Beauchamp, Bowie, & Arnold, 2009, p. 30).
Utility-based ethics by Bentham and Mill
All theories by which a measure of good or morally positive value can be given to actions and institutions, or how they produce happiness or desired circumstances, are utilitarian. Theories differ in the definition of happiness, the calculation of its magnitude, the comparison of alternative actions, and the definition of actions. But basically they agree that the moral quality of an action is measured by the magnitude of a positive circumstance created by it, for the one who enjoys it, is of no importance (Steinvorth, 1999, pp. 39–40). Evaluating the consequences of actions on others allows to balance them. The most extreme concept in the form of a quantitative balancing of consequences in utilitarianism was developed by Jeremy Bentham, the pioneer of this theory (Conrad, 2016, pp. 33–34). His idea was, that utilitarianism is bounded to the maximization of the good and the minimization of harm and evil. It states that society needs always to establish the greatest possible balance of positive value or minimum unbalance for all persons concerned. The key to maximization is efficiency, a congenial goal for business people because it is highly valued throughout the economic sector. Many companies and authorities have adopted specific tools such as cost-benefit analysis, risk assessment or target-oriented management, which are all strongly influenced by a utilitarian philosophy. A further essential feature of utilitarian theory is a theory of goodness.
Efficiency alone is simply as an instrumental good, i.e. it is strictly considered valuable as a means to something else. Even expansion and profit maximization are only instruments to the end of intrinsic goods.
Utilitarianism based solely on subjective preferences is therefore only satisfactory if a number of acceptable preferences can be formulated. Preferences that serve to block the preferences of others would then be disqualified by the ideal of utilitarianism (Beauchamp et al., 2009, pp. 19–21).
Bentham thought that all people have one ultimate goal: to be happy. For this reason, this view is typically labeled hedonic utilitarianism as Bentham understands the utility as happiness (Scharding, 2018, p. 52).
Mill, in contrast to Bentham, has a different vision of utilitarianism. He thought that the aim is not as simple as happiness maximization. In the sense that he thinks that something other, then purely (physical) happiness, is the most valuable thing, ethically spoken, we could call Mill a non-hedonic utilitarian. From Mill's point of view, decision-makers must ensure that their decisions protect certain very valuable ethical ideals. As a utilitarian, Mill believes these ideals create utility. He uses the concepts of higher and lower pleasures, to distinguish these more and less valuable kinds of utility. Lower pleasures are always trumped by higher once. In Mill's utilitarian calculus, they must always count for more, quantitatively (Scharding, 2018, p. 57).
Utilitarian moral philosophers can be conventionally split into two groups - Act Utilitarians and Rule Utilitarians. An act utilitarian argues that in all situations the activity leading to the greatest benefit for most people should be performed. However, the rule utilitarian reserves a more valuable place for rules that he does not consider dispensable in order to maximize utility in a particular circumstance. His actions are thus justified by the appeal to abstract rules such as "do not kill", "do not bribe" and "do not break promise". Utilitarian rules are theoretically firm and protect all classes of individuals, just as human rights are rigidly protective of all individuals, independent of social convenience and momentary necessity (Beauchamp et al., 2009, pp. 21–22).
An act utilitarian argues that in all situations the activity leading to the greatest benefit for most people should be performed. However, the rule utilitarian reserves a more valuable place for rules that he does not consider dispensable in order to maximize utility in a particular circumstance. His actions are thus justified by the appeal to abstract rules such as "do not kill", "do not bribe" and "do not break promise". Utilitarian rules are theoretically firm and protect all classes of individuals, just as human rights are rigidly protective of all individuals, independent of social convenience and momentary necessity (Beauchamp et al., 2009, pp. 21–22).
Whether preference units or other utilitarian values such as happiness can be measured and compared to determine the best action among alternatives is a major problem for utilitarianism. Utilitarianism has also been criticized on the basis that it does ignore non-utilitarian factors that are required for moral decisions. In the long run, utilitarian argue that promoting utility does not produce overall unequal outcomes (Beauchamp et al., 2009, pp. 22–23).
In the contemporary debate on utilitarianism sufficient arguments are produced which make it impossible to recognize the aspiration of classical utilitarianism. Too many and too deep moral institutions disagree with place increasing the welfare of a society or the entire human race over all other possible aspects (Steinvorth, 1999, p. 40).
Kant's duty-based ethics
Nowadays, the universal principles of validity of ethics established by Kant are still valid and are experiencing a new flourishing in "New Kantianism". According to Kant, the human mind remains the original legislator of nature when nature is understood to mean the principles of phenomena in time and space (Wühle, 2015, p. 6).
While Bentham and Mill base their views on utility, Kant believes that the most important ethical value is duty. For Kant, the measure of ethical action is not maximizing happiness, it is acting in accordance with one's own duties. Like utilitarianism, Kant's standard has an intuitive appeal: it is easy to understand why Kant believes that it is right to fulfill one's duties. Finally, a duty is something we have to do - so it seems obvious that we should fulfill our duties (Scharding, 2018, p. 61). Kant argued that individuals should be treated as goals and never only as means to the end of others. In other words, disregarding individuals means treating them as a means to their own ends, as if they were not independent actors. Showing a lack of respect for a person means either rejecting the person's considered judgments, ignoring the person's concerns and needs, or denying the person the ability to respond to those judgments. Kant did not categorically outlaw the use of individuals as a means to benefit other people. He argued only that individuals should not treat another exclusively as a means to their end. Kant only seems to demand that each individual will accept these principles. If a person willingly accepts a certain form of action and it is not immoral in itself, that person is a free being and has the right to choose it. Kant's theory finds that motives for action to be of most importance by expecting people to make the right decisions for the right reasons (Beauchamp et al., 2009, pp. 24–25). Kant asserted that moral action must be motivated by a maxim (rule) of moral self-commitment. Kant stressed that all individuals must act in the name of that commitment - not simply in accordance with that commitment. Kant developed this concept into a fundamental moral law: 'I ought never to act except in such a way that I also want my maxim to become a universal law'. Kant called this axiom the categorical imperative. It is categorical because it permits all exceptions and is absolutely binding. It is imperative because it provides instructions about how one must conduct oneself (Beauchamp et al., 2009, pp. 26–27).