Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.

Because an equitable distribution of health care inevitably requires at least some government regulation, and because government regulations tend to impose rigidity on any system, it is widely believed in the United States (and elsewhere) that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day.

The purpose of this paper is to encourage reflection about the harm that could result if the positive aspects of team-organized health care are compromised during the health care reform process. While other models of health care delivery could replace teamwork and serve patients as well or better, the interdisciplinary health care team (IHCT) probably will not be abandoned. However, one or more disciplines whose members play important roles on various teams may be sacrificed in the hasty effort to define essential health care. Moreover, a significant proportion of the types of IHCTs in existence could be rashly eliminated from health plans. These changes should not take place randomly or by default.

Health care reform that includes universal coverage could lower a major barrier to care for people of color and ethnic minorities—the inability to pay for care. But universal coverage alone, even with comparable fee-for-service payment or appropriately risk-adjusted capitated reimbursement, will not eradicate the racial and ethnic inequities in health care delivery. Restrictive admissions practices, geographic inaccessibility, culture, racial stereotypes, and the failure to employ minority health care professionals will still create barriers to minority health care. In addition to universal financing, health care reform should include new civil rights legislation to address and reduce these noneconomic barriers to minority health care.

As during other eras of American history, both the current debate and attempts to reform the health care system are fraught with vested interests and conflict among policy makers, consumers, the health and medical complex, insurers, and the business community. The process reflects both the strengths and the limitations of our democratic system, and demonstrates the factional battles that must be waged to attain fundamental social change in American society.

Although racial justice is not the dominant issue, the parallels between the present congressional deliberations and polemics and the passage of civil rights legislation in the 1960s are inescapable. For one, a major goal is to codify the basic human right of health care for all, regardless of medical or socioeconomic condition—that is, universal health insurance. Second, although a general feeling exists among the public that considerable change is needed in our health care system, elected representatives cannot agree on an appropriate course of action.

One understanding of health conceives of it as a state of freedom from pathology, achieved by an individual, through the mediation of a doctor. On this view, improvements in health flow from the application of science to specific ills of the body, and access to medical care is the chief determinant of health. This “medicalized” view of health underlies the current debate over medical care payment reform. This is the dominant way of talking about health.

An alternative is the view of health commonly associated with the practice of public health. On this view, health is an attribute of communities in social and physical environments. Health takes its shape in large numbers—in morbidity and mortality statistics—and, ideally, includes not just a high level of well-being for some, but also its even distribution throughout a society. Improvements in health are seen to arise from healthful changes in the environment.

“Big ticket” items in medicine pose a moral puzzle. We can call it the “Coby Howard puzzle,” after the boy whose need for an expensive bone marrow transplant forced Oregonians to reassess their policy of prohibiting this and other expensive “big ticket” procedures in favor of more low-tech, apparently cost-efficient interventions. The Oregon rationing debate was stimulated by the concern that expenditures on “big ticket” medical treatments for life-threatening disease were coming at the expense of low-tech, preventive “basic” care like immunizations, wellbaby clinics, and prenatal care.

Another recent example was the public controversy over expenditures of over $1,800 per day on a project to try to separate Siamese twins conjoined at the heart. The physicians, prior to the procedure, claimed there was a one percent chance of success. It was reported that 50,000 children in Philadelphia could be immunized at the cost of that innovative therapy. Cost-benefit analysis suggests that much greater good would be done in the long run if we ignored the expensive, long-shot, high-risk projects and focused on basic medical needs.

The debate about medical futility is no longer in its infancy. Scholarly literature on this seemingly intractable problem is voluminous. The list of widely publicized cases in which physicians have wanted to discontinue life-sustaining medical treatment that families demand has grown to include not just Helga Wanglie, but also Baby Rena, Baby L, Jane Doe, Joseph Finelli, Baby K, and Teresa Hamilton. A futility case has now been decided at the appellate court level.

Commentators have generated three kinds of proposals for resolving these conflicts. One group contends that the problem can be solved within the physician-patient-family relationship. While some in this group view professional authority broadly enough to warrant unilateral judgments by physicians that interventions desired by the patient or family should not be provided, others contend that physician authority does not extend that far, and that any resolution must be constrained by informed consent requirements.

Spielman’s taxonomy of collective decision making about medical futility is timely and insightful. Her conclusion, that laws are the best reflection we have of collective values, may be accurate. However, a closer look at the six alternatives for collective decisions is necessary before we rely too heavily on the legislature.

The first two alternatives, decisions by professional organizations and by health care facilities, smack of paternalism. Spielman suggests that statements from professional organizations or health care facilities express professional values and lack adequate input from the public. Could it be that some of these statements in fact may be the best reflections of public attitudes?

On March 9, 1993, in the first ruling of its kind, the Maryland Court of Appeals declared that physicians and hospitals may be sued for failing to inform patients of a practitioner’s human immunodeficiency virus (HIV) status. What is more significant, these suits may be pursued even in instances when the physician has followed universal precautions and the patient did not contract the virus that causes acquired immunodeficiency syndrome (AIDS). The Maryland court addressed two central questions in Faya v. Almaraz. First, do HIV-infected physicians have a legal duty to inform their patients of their HIV status? And, second, can patients recover damages for fear induced by a physician’s conduct? While one finds numerous precedents that authorize actions to recover damages based purely on fear of disease and emotional distress, the Faya court’s holdings on the issue significantly expand the scope of potential liability. Moreover, the court’s analysis of the informed consent and HIV-infected physician issue is incomplete, inconsistent, and represents an unjustified and unwise departure from traditional informed consent theory. It, and its progeny, may have widespread and dire repercussions.

Recent court decisions imposing liability on physicians who fail to inform patients that they carry the human immunodeficiency virus (HIV) before performing invasive procedures create an urgent need for the Centers for Disease Control and Prevention (formerly the Centers for Disease Control) to reopen the issuance of guidelines and to address authoritatively the question of the appropriate limits within which HIV-infected health care providers can treat patients.

Public fear of HIV-infected physicians (polls show 80 to 90 percent of patients surveyed want to know if their physicians are HIV-infected) were kindled by reports, beginning in 1990, that Dr. David Acer, an HIV-infected dentist, had infected a number of his patients. However, great skepticism has arisen as to whether Dr. Acer’s patients were infected as a result of procedures conducted in accordance with universal precautions against transmission. Moreover, look back studies have failed to identify even one patient, among the thousands who have undergone procedures administered by HIV-infected physicians, who contracted the virus directly from his/her physician.

On June 20,1991, Dr. Craig Venter, then a molecular biologist at the National Institute of Neurological Disorders and Stroke, a member agency of the National Institutes of Health (NIH), revealed that the NIH was filing an application with the Patent and Trademark Office (PTO) to patent 351 genetic fragments sequenced from brain tissues. The first of many applications filed by the NIH during the next two years, the agency also applied to patent the complete set of genes encompassing each fragment. These applications were filed despite the fact that the full gene sequences, their protein products, and their functions were still unknown (several genetic fragments make up a gene, and these fragments code for protein those products that have physiological functions; an example of such a product is insulin).