Genetics and the Moral Mission of Health Insurance
Murray, Thomas H., The Hastings Center Report
Deciding whether genetic differences among individuals are morally relevant to health insurance requires us to ask, What kind of good is health care? and, What principles should govern its distribution? There are good reasons to doubt that "actuarial fairness" is an adequate description of genuine fairness in health insurance.
All men are created equal. So reads one of the United States of America's founding political documents. This stirring affirmation of equality was not meant as a claim that all people are equivalent in all respects. Surely the drafters of the Declaration of Independence and the Constitution were as aware then as we are now of the wondrous variety of human-kind. People differ in their appearance, their talents, and their character, among other things, and those differences matter enormously.
The commitment to equality embodied in our political tradition is not a claim that people, in fact, are indistinguishable from one another. Rather it is an assertion that before this government, this system of laws and courts, all persons are to be given equal standing, and all persons must be treated with equal regard.
Human genetics, in contrast, is a science of inequality--a study of human particularity and difference. One of the most difficult challenges facing us in the coming flood tide of genetic information is how to assimilate these evidences of human differences without undermining our commitment to political, legal, and moral equality.
The information about human differences pouring forth from the science of human genetics provides us with a multitude of opportunities to treat people differently according to some aspect of their genetic makeup. Deciding which uses of this information are just and which are unjust will require us to reexamine the ethical significance of a wide variety of human differences and the larger social purposes of a variety of institutions, among them health, life, and other forms of insurance.
Health insurance in the United States has moved from a system based mostly on community rating where, in a given community, all people pay comparable rates, to a system where the cost to the purchasers of insurance is based on the expected claims--a risk- or experienced-based system. This movement has significant ethical as well as economic overtones. Community rating was a system that reflected a notion of community responsibility for providing health care for its members, where the qualifying principle was community membership. Other differences, such as preexisting risks, did not count as morally relevant distinctions. Risk-and experience-based systems presume that it is fair to charge different prices, or to refuse to insure people entirely, if they will need expensive health care. Such systems treat predicted need for care as a morally relevant difference among persons that justifies differential access to health insurance, and through it, to health care. But this presumes precisely what is in question: what are good moral reasons for treating people differently with respect to access to health insurance and health care?
Risk- and experience-rated systems are now dominant in private health insurance in the United States, having largely replaced community rating. This trend, coupled with the rapid growth in the cost of health insurance for employers, creates a situation in which risk-oriented genetic testing could become an important, complicating feature.
We may create a catch-22 so that only people who are unlikely to need health insurance can afford it. Genetic testing may permit a much more complete and refined classification of people into risk categories, and so move us further away from sharing the financial burdens of illness and further in the direction of individualized premiums based on individual risk factors. Genetic risk testing is important because it exposes the logic of a system that provides access to health insurance to those least likely to need it. …