Ethical and moral issues are inseparable from health care and are usually addressed by employers' health insurance plans, government agencies, and national and state lawmakers. Through the delibera­tions of their elected representatives, Americans will define and refine the laws concerning abortion, medical care at the end of life, and such other com­plex and difficult topics as the use of genetic infor­mation, embryonic stem cell research, the use of fetal tissue, and the legitimacy of physician-assisted sui­cide. Public debate on biomedical ethical issues is necessary and should not be confined to experts. Every American has a stake in these issues, which involve tax dollars as well as private dollars for health insurance and medical care.

Primacy of Conscience. Regardless of how health policy issues are resolved legally, Americans must retain their individual right not only to dis­sent from existing public policies, but also to make personal health care decisions-including how money is spent for health benefits, medical treat­ments, and procedures-according to the dictates of their consciences. This is why, regardless of their differing views on many controversial health issues, all Americans should work together to protect patients' freedom of conscience in health care. Recent debates on the rights of conscience have focused on providers, not patients, but freedom of conscience for every person should be the rule in health care, which is emerging as the central arena of new and profoundly serious scientific and ethi­cal issues. Americans should have the option to control their health care dollars and to participate in plans that respect their values and deliver medi­cal benefits that are consistent with those values.

But most Americans, as a practical matter, do not have that kind of control. Third-party payers- administrators of government and private health insurance plans-generally set the rules for cover­age: which plans are offered, what benefits are included, and how they are funded. Many Ameri­cans are rightly concerned that they are progres­sively losing control over the key decisions that affect their health care.

Biomedical Advances. The fruits of biomedical research will be incorporated rapidly into advanced medical treatments and procedures. Once a proce­dure is covered by a health insurance plan, its financing is spread among all participants in the plan. In the case of publicly funded insurance, that includes all taxpayers.

Because many emerging treatments and proce­dures will have serious ethical ramifications, poli­cymakers should enact major reforms that would allow health care in America to function more as a genuine consumer-driven and values-driven mar­ket functions. Freedom of conscience is merely an abstraction unless individuals and families can act on it, especially when spending their own money on insurance premiums, medical providers, and medical procedures. In this way, individuals and families could "vote with their feet," freely choosing which health benefit plans, packages, and medical procedures they wish to support.

Emerging Ethical Challenges. Abortion and related issues are flashpoints at the busy intersec­tion of health care policy, medical ethics, and per­sonal morality. Meanwhile, embryonic stem cell research, therapeutic cloning, pre-birth genetic screening to identify "unwanted" children, thera­pies or treatments for genetic enhancement, and growing social acceptance of physician-assisted suicide will create new ethical challenges. Individ­uals and families cannot assume that employers, third-party administrators, or government officials will resolve these sensitive issues in a manner con­sistent with their personal beliefs.

Creating a New Environment for Personal Freedom. Most individuals and families have little control over the terms or conditions of their health insurance contracts or the payment of premiums to doctors and other providers. Most Americans get what they are given and pay what they are told to pay. Personal choice is limited, and this limitation on personal freedom is a central defect of America's health care system. Policymakers can correct this deficiency by returning control to individuals and families in four major ways:

Allow all Americans to choose their own health plans. In addition to conventional and employer-sponsored health plans, Americans should be allowed to choose plans sponsored by professional associations, employee organi­zations, unions, and faith-based and religious groups. Individuals and families could then secure coverage through health plans that are compatible with their ethical and moral values.

Eliminate discrimination in the tax code. To make personal choice a reality, the federal and state tax codes should treat all types of plans equally. The best way to accomplish this is to give every person a refundable, individual health care tax credit to purchase the plan of his or her choosing, regardless of place of work. This change could foster the development of new kinds of plans, including plans sponsored by religious organizations and church consortia.

Open up health insurance markets. Health insurance is governed by state law and, to a lesser extent, federal law. State officials could open up current markets by replacing the bal­kanized, highly regulated state health insurance markets with a single statewide market, or insurance exchange. Through the exchange, employers could contribute a defined amount to the health plans designated by their employ­ees, and plans would compete directly with each other for consumers' dollars. Congress could allow Americans to purchase health insurance across state lines, just as they buy many other goods and services, including other types of insurance.

Allow values-driven health plans to partici­pate in public programs. Health plans spon­sored by religious and other organizations should be allowed to participate in Medicare, Medicaid, and the State Children's Health Insur­ance Program, just as they already do in the Fed­eral Employees Health Benefits Program.

Conclusion. Individuals and families should be free to control the flow of dollars in their health care plans and to make the decisions that will affect their medical treatment and health care coverage, including ethical decisions.

Robert E. Moffit, Ph.D., is Director of the Center for Health Policy Studies, Jennifer A. Marshall is Direc­tor of Domestic Policy Studies, and Grace V. Smith is a Research Assistant in Domestic Policy Studies at The Heritage Foundation.