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Autonomy, Coercion, and Public Healthcare Guarantees: The Uptake of Sofosbuvir in Germany

Published online by Cambridge University Press:  29 December 2020

AFSCHIN GANDJOUR
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Abstract

Health insurance coverage for incarcerated citizens is generally acceptable by Western standards. However, it creates internal tensions with the prevailing justifications for public healthcare. In particular, a conceptualization of medical care as a source of autonomy enhancement does not align with the decreased autonomy of incarceration and the needs-based conceptualization of medical care in cases of imprisonment; and rejecting responsibility as a criterion for assigning medical care conflicts with the use of responsibility as a criterion for assigning punishment. The recent introduction of sofosbuvir in Germany provides a particularly instructive illustration of such tensions. It requires searching for a refined reflective equilibrium regarding the scope, limits, and justifications of publicly guaranteed care.

Keywords

autonomyresponsibilityright to healthcareuniversal coverage
Type
Bioethics Beyond Borders
Information
Cambridge Quarterly of Healthcare Ethics , Volume 30 , Issue 1 , January 2021 , pp. 90 - 102
Copyright
© The Author(s), 2020. Published by Cambridge University Press

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Footnotes

Acknowledgment: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The author would like to thank Hartmut Kliemt for very valuable comments on an earlier draft. The usual disclaimer applies.

References

Notes

1. German Federal Joint Committee. Beschluss des Gemeinsamen Bundesausschusses über eine Änderung der Arzneimittel-Richtlinie (AM-RL): Anlage XII—Beschlüsse über die Nutzenbewertung von Arzneimitteln mit neuen Wirkstoffen nach § 35a SGB V—Sofosbuvir. 17. July 2014.

2. See note 1, German Federal Joint Committee 2014.

3. Zentralinstitut für die kassenärztliche Versorgung in der Bundesrepublik Deutschland. Ausgaben für Arzneimittel gegen Hepatitis C. 2018; available at https://www.zi.de/presse/grafikdesmonats/ (accessed 23 April 2018).

4. See note 3, Zentralinstitut für die kassenärztliche Versorgung in der Bundesrepublik Deutschland 2018.

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6. “The relevant provisions of the Social Code and the regulations made in pursuance thereof shall apply to the type of health examinations and preventive medical services, as well as the extent of these benefits and of the benefits regarding therapeutic treatment, including the supply of medical aids.” (Section 61 of Prison Act).

7. “Prisoners shall be entitled to be supplied with visual and hearing aids, prosthetic appliances, orthopedic and other aids that are necessary in a particular case to ensure the effectiveness of therapeutic treatment or to compensate for a disability, unless this would be unreasonable in view of the short imprisonment term (…).“(Section 59 of Prison Act).

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14. Legal systems that prevent individuals from using their own means for health care reduce those individuals’ autonomy in the name of equality. Although some may deem this desirable, they should be aware that it rests uncomfortably not only with the basic principles of a Western legal order but also with the ethics of care and support for individual autonomy.

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38. See note 5, Robert Koch Institute 2018.

39. See note 17, Gandjour 2015.

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42. Strictly speaking, according to German law, “minor additional benefit” refers to a “moderate” benefit such as a reduction in “non-severe” symptoms (AM-NutzenV §5).