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Getting Philosophical about Health Insurance

Spring 2014 | By Nick Rogers. Photo by ©Eduard Gurevich/Shutterstock.com.

It’s not every day that assistant professor Tina Rulli’s work sweeps across the blogosphere or gets picked up in the health news digest on the Los Angeles Times website. But that’s exactly what happened when she weighed in on a hot-button U.S. political issue with a unique, partisan-free argument.

Photo of Tina Rulli 
Tina Rulli 

The media flurry was a response to “The Moral Duty to Buy Health Insurance”—a paper Rulli co-authored* in 2012 during her postdoctoral fellowship in bioethics at the Clinical Center at the National Institutes of Health. “It’s usually just a small audience of people reading my work, so [the press] was pretty neat,” says Rulli, who joined the Department of Philosophy in 2013.

Published in the Journal of the American Medical Association and presented at the American Society for Bioethics and Humanities conference, the paper argues that an individual’s moral duty to take rescue precautions creates sufficient grounds to justify the insurance mandate provision of the Patient Protection and Affordable Care Act.

Before and after the act was signed in 2010, it served as a well-scorched political lightning rod. Among the continuing points of contention is its mandate that U.S. citizens must have health insurance or face financial penalty.

Regardless of a patient’s insurance status, physicians and hospitals are federally mandated to provide rescue through acute or emergency care. In 2008, care for the uninsured cost an estimated $56 billion—an expensive burden of rescue that causes costs to rise across the board.

Rulli and her co-authors eschewed partisan views and focused on the widely accepted idea of an individual’s “duty to rescue”—a research specialty for Rulli and a theory that suggests we are morally obligated to help others when there’s no significant cost to do so.

The paper asserts, then, that potential rescuees (i.e., medical patients) have a corresponding duty to ease this burden to rescuers (i.e., physicians and hospitals) by taking precautions to reduce these treacherous rescue conditions. In this case, that means purchasing health insurance to cover costs of acute and emergency care.

“In a compassionate society, we can’t imagine doctors turning people away,” Rulli says. “Well, if we want to have this practice, and it’s what a moral society does, there are reciprocal duties for the rest of us to use that charity.”

An individual’s requirement to reduce rescue burdens is not limitless; Rulli and her co-authors suggest a mandatory moral minimum of insurance. The paper also examines how benevolence and compassion at the core of medical practice demand emergency intervention even if an individual has waived his or her right to care (e.g., a physician can’t allow crash victims to bleed to death even if they have forgone healthcare rights).

From a perspective of enforcing this healthcare reform, Rulli cites mandatory hurricane-zone evacuation laws that protect would-be rescuers as legal precedent for requiring people not to pose a substantial burden on others. And from an economic viewpoint, Rulli cites research that suggests a reasonable percentage of uninsured Americans can afford insurance without hardship through out-of-pocket payments or federal subsidy.

After presenting the paper at the bioethics conference, Rulli reports, “We received a lot of letters from people who thanked us for bringing clarity to the issue or for using philosophical machinery to tighten up what they had been thinking.”

She is currently working on “The Duty to Take Rescue Precautions,” a follow-up paper that will expand on the concept through more work in normative ethics (the study of right and wrong) and examine objections to the theory.

“Philosophy really shows us the power of a reasoned argument, and it’s important to apply it to various social issues,” Rulli says. “I think analytical philosophy is fundamentally iconoclastic. We’re always questioning whether the social practices and norms we follow are the right ones, and that’s a good thing.”

* The paper’s co-authors were: Ezekiel J. Emanuel, former chief of the NIH Clinical Center’s bioethics department, now head of the medical ethics and health policy department at the University of Pennsylvania and special advisor for health policy to the Office of Management and Budget; and David Wendler, head of the unit on vulnerable populations in the NIH Clinical Center’s bioethics department.


I enjoyed reading about Rulli's interesting and thought-provoking work. My question to her is whether a society based on capitalism (with greed as its basis) can also be a "moral society"?

Dave Price

From the editor

I shared your question with assistant professor Tina Rulli, and she responded.

I can't offer here a full argument about whether any capitalist arrangement could be morally justified. But regardless, the current system cannot be plausibly defended as fully just. Even so, we can choose moral improvements to non-ideal economic arrangements over doing nothing at all. So it seems that among those societies based on capitalist values, we can choose more or less just versions.

Tina Rulli

It is frustrating that so few understand the extent to which mandatory care for the uninsured contributes to rising health care costs. It is a moral duty to help "ease this burden" if one is financially able to do so. My hope is that Dr. Rulli's audience grows and Americans take time to consider her non-partisan view.


"The paper asserts, then, that potential rescuees (i.e., medical patients) have a corresponding duty to ease this burden to rescuers (i.e., physicians and hospitals) by taking precautions to reduce these treacherous rescue conditions. In this case, that means purchasing health insurance to cover costs of acute and emergency care." This is true if each rescuee is required to ease this burden on the basis of how much burden they, as individuals, place on the rescuers. Under the new system, individuals are not charged for lifestyle choices or exposures, except for smoking. In order for this to work, there have to be enough people enroll who will not use the plan to subsidize the people that will use it. Moral or immoral, there won't be enough "healthy" rescuees enrolled to subsidize the "non-healthy" rescuees. That will be a tough sell. The cost of the program has to have upfront risk acceptance by each individual, followed up by catastrophic insurance-based products with the bulk of the cost shifted to the individuals that will use the program the most. Currently, the penalty/tax for younger/healthier citizens is less than the annual premium they will pay if they enroll. There are no pre-existing conditions to worry about anymore, except for smoking. Therefore, the younger/healthier citizens will pay the lower cost option until they actually get sick. They will then buy coverage during the next open enrollment period. Obamacare is classic adverse selection underwriting. The young, health-conscious citizens will have to pay more so that the unhealthy, older constituency can pay less. Except, the young and healthy can pay the penalty and wait until they get sick before enrolling, and pay no more than they would if they had enrolled when they were healthy. Therefore, why do so until they are forced? Unfortunately, it is virtually impossible to legislate and enforce morality. I'm sure this program was developed with the best of intentions. But, like most entitlement programs, it will be very difficult to generate enough revenue to cover the cost.

David A. Rocchio

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