This Colorado doctor studies ethics. He has some thoughts about the UnitedHealthcare shooting.

The killing of UnitedHealthcare CEO Brian Thompson is a tragedy. The weeks since have also shined a light on something people working in patient advocacy know all too well: The tragedies that occur every day when patients struggle to get their health insurers to cover things like medicines or medical devices that they need to live and to thrive.

In this framing of the issue, these delays or denials can also be a form of violence — structural and institutional, instead of vigilante. And that has led in some corners to thinking of this killing as akin to the whacking of a mob boss: Head up a violent business, expect a violent end.

To help make sense of these debates, The Colorado Sun reached out to Dr. Matthew Wynia, an internal medicine specialist who is the director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.

Wynia’s ethical expertise is broad. He helped design the state’s plans during the COVID pandemic for who should get vaccinated first and, more bleakly, for who should get a hospital bed if there aren’t enough to go around. He’s weighed in on debates around artificial intelligence in health care and political involvement in abortion medication decisions. And he has previously examined ideologically motivated violence.

This Q&A has been edited for clarity and brevity.

The Sun: Obviously we don’t know everything about what happened. But when you first heard about the UnitedHealthcare shooting and then as you followed the story, what did you think?

Dr. Matthew Wynia: Probably, like everyone, it was really apparent off the bat that this was a targeted assassination. Just within a day, I think it was clear that this was not a random act of violence. It was an act of political violence.

The idea, of course, that acts of assassination would be a chosen response to frustrations with the health care system is, on the one hand, it’s something doctors have been aware of for a while because we are occasionally targeted. We haven’t seen it where someone targets the entity sort of above the clinician in the health care hierarchy.

It’s terribly disconcerting because, from my perspective, what we know about assassinations is that they rarely end up producing the good effect that people think they’re going to produce. They end up producing more assassinations and more violence.

Sun: I know you’re familiar with some of the frustrations when it comes to dealing with health insurance corporations. I saw you once speak on a panel where you detailed ways that insurers can use artificial intelligence to make their systems even more opaque and challenging to navigate. Given this understanding, was it surprising at all to you that these frustrations could apparently provoke violence?

Wynia: It’s disappointing, but maybe not surprising. The emotions around health care are so intense and often reasonably so, right? We are sometimes talking about life and death issues so they warrant high emotion sometimes.

But anytime you’re talking about things where life is at stake, or you think that life is at stake, that’s a place where it’s possible for people to start thinking, “This is so important that it warrants me doing something really outside what would normally be acceptable.”

Sun: I guess another way to ask this question is: Do you see this as a rational response to injustice in the health care system? Not an acceptable response, but a rational response?

Wynia: I don’t think it is a rational response. It can be justified in ways that make it sound like it’s a rational response. But you don’t have to think very far ahead to realize that assassinating the CEO of a health insurance company is not going to accomplish anything good.

They’re not going to change the way they manage and process claims. They’re not going to change their coverage criteria. They’re not going to change their relationships with employers, who largely set the coverage criteria, which they then implement. There’s no conceivable way in which murdering an executive at a health insurance company is going to make the health care system work better.

Sun: So, murder is obviously a shocking form of violence. But in the wake of this killing, there’s been a lot of critiques of the health insurance system as perpetrating a kind of violence, itself, in how it manages claims and denies coverage. Is that a form of institutional violence?

Wynia: It is because the definition of structural violence, or institutional violence, is quite broad. By the definitions that people now use to describe harms that are attributable to policies and structures that make it hard to get things, then, yes, this meets that definition.

Of course, there’s a reason why people in public health have developed those terms to describe policies that are harmful. It’s to try and create more of a sense of crisis and more of a sense that this is an injustice that needs to be remedied.

It’s a successful rhetorical strategy to call something structural violence, so I understand why people want to do it. They want to ramp up the pressure to change a system they see as fundamentally unjust.

Sun: Am I getting the sense that you don’t necessarily agree with that approach?

Wynia: Well, I think it has some potential downsides, including that it makes a policy dispute into a moral dispute. And moral disputes tend to have higher emotional valence, right? They tend to gin people up and make them willing to do things that they might not normally do.

To the extent that they cause people to write letters and show up in Congress and go to protests and make their voices heard, then those are all productive. To the extent that they make someone feel like, “Well, I’ve been the victim of violence, so I get to exact violence in return,” that’s counterproductive.

Sun: Let’s move past this debate about what constitutes violence and turn toward the ethical responsibilities of individuals. If you are an individual working within an unjust system, to what extent do you individually bear the responsibility for that injustice?

Wynia: That’s such a great question because it gets at some of the defenses of United that have arisen in the wake of this. Basically saying: “Look, we are all in this terrible system together, and we all think it ought to be changed. We’re going to have disagreements about how it ought to be changed, but killing each other is not the way to do this. How about if we find ways to make it more functional together.”

And I think it’s easy and often justified to take that from a health insurance executive and say, “Yeah, well, it’s dysfunctional in ways that tremendously benefit you. You are obviously not trying to fix the parts that continue to benefit you.”

So I understand and I’m very sympathetic to that cynicism. But I still fall back on the pragmatics of this, which is that killing an executive is not going to change that system. If you are a rational actor, you’re going to try and figure it out. How do I change the system in ways that help people like me?

Sun: Is it ever OK to focus on the actions of individuals within the system? Murder is bad, obviously. But can you stand outside their house at 3 a.m. with a bullhorn? Systems can feel huge and impenetrable. People are individuals you can confront, for better or for worse.

Wynia: This is why I think it’s so dangerous for doctors to say anything that condones this kind of targeted violence. Because the people who are most likely to be the recipients of targeted violence in the health care system are health care workers, doctors and nurses. We are the ones who bear the brunt of most of the violence that occurs in health care, including murders. They just don’t get the coverage that this got.

So I think it’s a terrible idea for us to even whisper a condoning of this kind of targeted violence in response to a dysfunctional system. And I do think that the appropriate strategies are strategies that actually have a chance of making a difference, both either for yourself or for the system as a whole.

Sun: That’s a great point about violence against health care workers — that they often stand in, unfairly, as the faces of a dysfunctional system. And we know that a lot of people who work in the health care industry are passionate about making it work better and more fairly for patients. But how do you distinguish between people struggling with the issue versus people who are …

Wynia: Capitalizing?

Sun: Exactly.

Wynia: I don’t think it’s a clear line. I think it’s a very fuzzy line. And one reason I think that is because doctors are often on both sides of it, right? So there are doctors who get paid enormous amounts of money for taking care of sick people. And the only reason they get away with that is because they have a monopoly on a service and people will pay whatever it takes.

That is taking money out of a system that is struggling to pay for basic services for everyone else. Does that mean the doctor is wrong to do that? Well, that is the system that we have set up. The doctor is operating within the rules that we have established. So you’re not wrong to play by the rules.

It is a systems problem. It’s not necessarily attributable to any one individual. Individuals tend to play by the rules, and we have picked these rules. We’ve picked them in a political process through which, you know, doctors have a lot of power.

Sun: Well, so going back to the question of individual responsibility, is there ever a point where you as an individual within this system have a moral obligation to stand up and say it’s too much? “I don’t want to be a part of this. I’m going to talk to our board about steering us away from this profit-focused model. I’m going to, as a doctor, decide that I don’t want to charge as much as the market would bear for my services.”

Wynia: Absolutely, yes. We all should be operating under a code of ethics in health care, and that code of ethics ought to apply whether you are a doctor or a nurse or a health insurance executive. The ethics of medicine are an ethics of altruism, right? They are an ethics of putting the patient’s needs above one’s own. And that certainly means putting the patient’s needs above the needs of, you know, nebulous stockholders.

We do not have such a uniform code of ethics that covers health insurance executives. We do have such a code of ethics that covers doctors. And you can argue about the extent to which doctors always live up to it, but often they do, right? I just made the opposite case for doctors sort of gouging the system to some extent. But there are a lot of doctors who do not gouge the system, who provide more services than they are paid for, who provide services to people who never pay them at all.

So there are plenty of people out there in the health care system who really do try their best to abide by their code of ethics despite the dysfunctional system and not trying to take advantage of it. And I think there is a great deal of promise in the possibility of expanding that pool of like-minded people because we get a new batch of them every year in medical school.

They come in wanting to change the world and make medical care better and make the system better. And one of these generations, they’re actually going to make some progress.