Elimination of a public insurance option to curb health care costs by competing with private insurers. Comparative effectiveness research that can’t be used to make coverage decisions. These are just two of the many compromises that have been made, and will be made, in an effort to write health care reform legislation. Compromise is inevitable, but how much compromise is too much – so extreme that it is unethical? Philosophy offers some insights.

Health reform is a moral imperative; our health care system is peppered with injustices that must be remedied. But no health care system will be perfectly just. This may have nothing to do with social “weakness of will” in bringing about a just health care system. Rather, the very complexity of health care systems today (economically, technologically, organizationally) and the heterogeneity of health needs will result in “built-in” injustices, no matter how we reorganize, refinance, or rebuild those systems. Health reform can reasonably hope to achieve only a “just enough” health care system. This raises a challenging moral problem.

If we have minimalist health reformers, satisfied to rid the system of a few injustices (as I believe is true of the Republican reform proposals), do they deserve moral praise for having brought about a somewhat more just reformed health care system? Or do they really deserve moral criticism for being too timid or too indifferent to serious injustices preserved in the system?

Alternatively, there is nothing morally commendable about being uncompromising, dogmatic or fanatical about health reform, even in the name of justice. Defeating substantial but imperfect health reform efforts to maintain one’s own purity of heart at the price of prolonged injustices in an unreformed system yields a “purity” that is deeply stained. Both the Catholic bishops and abortion rights activists could be criticized on this point.

We are left then with this problem: How should we judge that certain compromises regarding health reform are “just enough,” more worthy of moral praise than moral criticism? No simple moral principle or moral formula will yield an answer to this question. But we do have some capacity to distinguish more serious from less serious injustices. 

Our health reform efforts will not be “just enough” if we fail to provide secure access to needed, effective, cost-effective health care for the medically least well off. Patients whose health problems threaten them with a premature death or functional disability if they cannot get care that is available to insured individuals should be at the top of the list. Thus, a just enough health reform plan ought to reduce to near zero from 45,000 the number of uninsured or underinsured individuals who die prematurely for lack access to effective medical treatments. 

I should add that being terminally ill does not automatically get someone included in the category of medically least well off, as far as health care justice is concerned. Although those individuals are unfortunate, their fate is not a product of unjust social policies (for the most part). They do have just claims to cost-effective and effective palliative care. But they may not have a just claim at social expense to extraordinarily expensive interventions (many of these new cancer drugs) that yield only extra weeks or months of life on average, especially if those massive social costs would threaten our commitment to meeting the just claims for health care of those who can benefit much more.

A “just enough” health reform effort ought to minimize overtreatment of terminally ill patients. This is directly related to the next point.

A “just enough” health reform effort ought to assure equal access for all to a comprehensive range of effective and cost-effective medical interventions. They should constitute a “basic” plan guaranteed to all. Perhaps such a plan is an ideal, not politically achievable right now, but approximating this ideal deserves moral praise.

A “just enough” health reform effort will require shared sacrifice from all. Serious cost control is essential to the long-term viability and justness of a reformed health care system. Hospitals, physicians, drug manufacturers, and insurers cannot charge “whatever the market will bear” for their services. 

Prospective payment mechanisms will need to be widely deployed to nudge all of these parties into more cooperative and efficient health care delivery practices. Strong regulatory and competitive pressures, such as would be created by a national health insurance exchange open to all and risk-adjusted to preserve a level playing field would help to motivate insurers to improve efficiency with or without a public plan option. It would also likely reduce dramatically the number of health insurers.

Patients must be willing to give up marginally beneficial costly health services, at least at social expense, in order to protect the affordability of the basic plan guaranteed to all. Doing so would reduce the aggregate size of the government subsidies needed to make the plan affordable to the working poor and possibly also the middle class. Even with subsidies many households will still feel some financial pain, but this will be marginal pain relative to the current plethora of bankruptcies precipitated by health expenses. 

If these recommendations are closely approximated in the health reform legislation that emerges from Congress, we will have compromise that is sustainable, affordable, and “just enough.” But even then the morally appropriate stance for the advocates of these limited reform efforts would require these words: “We are sorry that we were unable to accomplish more to remedy what we acknowledge are serious remaining injustices in our health care system. We will redouble our efforts to reduce them through continued advocacy for policies that will achieve that goal.”

Leonard M. Fleck, Ph.D. is professor of philosophy and medical ethics in the Center for Ethics and Humanities in the Life Sciences at Michigan State University. He is the author of Just Caring: Health Care Rationing and Democratic Deliberation(Oxford University Press, 2009). He recommends a recent book by Richard Thaler and Cass Sunstein Nudge: Improving Decisions about Health, Wealth, and Happiness (Yale University Press, 2008). fleck@​msu.​edu; 517–355-7552.