THE WHIRLWIND pace of proposed changes in the social status quo is embodied in the current iteration of the lively debate surrounding US healthcare system reform. A recent Economist.com article1 outlines one comparative example of the need for reform--life expectancy as compared with gross domestic product percentage for healthcare across the United States, European Union, and Japan, where the United States is spending one-half to one-third greater gross domestic product percentage on healthcare and boasts the lowest average life expectancy. Examples of other comparative statistics are available elsewhere.2

Indeed, there is significant political momentum for change, as noted in a recent congressional briefing, held June 2, 2009, in the Judiciary Committee room of the US House of Representatives (S. S. Bush, personal communication, June 8, 2009). The purpose was to provide legislators or their assistants with information regarding the impact of psychological practice upon the current healthcare system. Importantly, the meeting organizers announced the intent of the legislature to pass a healthcare reform act in summer of 2009. The varied themes of the proposed bills currently under consideration included extending private insurance to the uninsured (sponsor: Baccus), a private/public option based largely upon the Medicare model (Kennedy), a single payer system (Conyers), and a public/private partnership (Obama). Goals of such legislation are the following: leaving no citizen without health insurance, promoting greater interdisciplinary integration and collaboration in provision of healthcare services, and cost containment (making healthcare record-keeping more efficient--electronic records, decreasing health service overutilization, etc). While these are certainly laudable goals, it remains to be seen if the Congress can muster the necessary votes across both houses to pass some form of sorely needed healthcare reform legislation.

Notably absent in most of the political discussions surrounding this vital topic is mention of ethics providing essential guidelines for policy-making decisions. This absence is not due to healthcare ethicists having been silent on the matter.3-6 Unfortunately, ethics in public media is most frequently portrayed in its narrow role of professional ethics committees prescribing sanctions in response to morally unacceptable public behavior.

We7 have argued for a broader utilization of ethical principles and concepts in an aspirational sense but applied directly to healthcare practice. Beauchamp and Childress3 have provided ample ethical guidelines to assist in formulating healthcare policy. The American Psychological Association8 Code of Ethics also employs core principles that drill down to specified applications (Standards) regarding professional practice. Adhering to fundamental ethical principles during the policy development process ensures a balanced approach to finding an adaptive blend of healthcare system components.

As an example of the applicability of ethical principles and concepts to healthcare planning, respect for autonomy addresses the right to choose and informed consent regarding service provision. Beneficence ensures that effective and beneficial services are not only available but provided. This principle further urges specification (in the form of defined criteria) of the process of determining "medical necessity" for treatment authorization.9 Nonmaleficence protects both individuals and populations with healthcare needs from harm due to inaccessible care and treatment, and in managing risk associated with these services. Justice aims to reinforce the concept of equity in allocating resources, access to services, defining financial responsibility for service delivery, and in effective provision of care at the point of service to those in need. The ethical concept of duty to care obligates healthcare providers to meet the legitimate healthcare needs of those who seek their services and highlights the responsibilities of healthcare organizations to facilitate adequate access to such services. Precautions regarding conflict of interest attempt to safeguard resource allocation decisions from being substantially governed by financial considerations. Finally, guidelines specifying moral status give structure to criteria for inclusion of vulnerable populations (in our case, individuals with cognitive processing compromise secondary to vagaries of development and onset of illness or trauma) in allocation of healthcare resources.3

We must be mindful that approximately 47 million American citizens currently lack adequate access to healthcare services. Furthermore, socially responsible healthcare providers and organizations are rendering uncompensated care--a situation of increasing financial jeopardy in times of economic contraction. Healthcare and long-term support services for individuals with cognitive impairment have traditionally varied significantly across states, calling into question the concept that "best practices" are willingly and universally adopted solely upon the premise that their effectiveness and efficiency have been demonstrated. Finally, the economic crisis has significantly reduced state budgetary allotments for basic healthcare services, in addition to cuts in long-term supportive services for those with disabling conditions. This is certainly a time for change.

The current state of the US economy not only has induced significant distress across our social fabric but also offers a social stimulus to rectify problems within the healthcare system. Fortunately, we do not have to reinvent the wheel. As we have noted, there exist models of integrated healthcare systems among other industrialized nations from which we can sample the most desirable components. In addition, we must also acknowledge the valuable lessons learned from the limited universal healthcare systems that have been created in our country. The active military health system and Veterans Administration healthcare system offer a broad continuum of health services for all those individuals who meet their eligibility criteria. The US Public Health Service provides preventive and limited intervention services to identified disadvantaged segments of the population. Finally, the myriad providers of charity care have developed workable methods of allocating limited resources to those financially disadvantaged. While there are operational challenges within these existing models of healthcare delivery, there are also efficiencies that have evolved across time that should be utilized (integrated electronic medical record, centralized and distributed care provision within tight budgetary constraints, proven highly efficient trauma care delivery models, etc).

In the absence of a constitutionally guaranteed right to healthcare, utilizing aspirational ethical principles and concepts as guideposts in devising a revised health system adds socially valued parameters to proposed healthcare models. Adhering to ethical principles and concepts, any proposed model of the US health system would bear certain responsibilities. An ethically sound healthcare model should preserve the individual's right to choose and to be adequately informed about care and treatment benefits, risks, and alternatives. Furthermore, the individual should receive care and treatment of proven benefit. In addition, the individual should be protected from harmful care and/or treatment practices, along with protections regarding financial jeopardy as a direct result of receiving needed care and treatment.

All American citizens should have unfettered and equal access to needed healthcare services, without exclusion. Simultaneously, oversight of healthcare should be uniform, require a minimum of administrative cost, and have clearly defined decisional criteria that are applied equally across all segments of the population. Individuals should contribute in an equitable manner to the financial viability of the healthcare system. As trained healthcare professionals, psychologists and other rehabilitation professionals have a duty to provide services to those individuals with legitimate needs. Psychologists and other rehabilitation professionals should be folded into an integrated healthcare system, based upon value added. Finally, the financial status of an integrated healthcare system should be monitored, and fiscal controls adjusted to meet the evolving needs of persons served and of providers.

Maintaining the political and social momentum to craft a workable, accessible, inclusive, and integrated healthcare plan in the face of inevitable objections, caveats, and territorial claims is a challenge we must face, not only as a profession but as a nation also. Rehabilitation and mental health professionals of all persuasions are challenged to unify under the banner of healthcare quality with broad healthcare provider inclusion. At this critical juncture, advocacy with the lawmakers tasked with accomplishing this laudable goal is urged.

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