O'Neill O
Newnham College, Cambridge, UK.
Philos Trans R Soc Lond B Biol Sci. 1997 Aug 29;352(1357):1087-93. doi: 10.1098/rstb.1997.0089.
Life is risky, and insurance provides one of the best developed ways of controlling risks. By pooling, and so transferring risks, those who turn out to suffer antecedently uncertain harms can be assured in advance that they will be helped if those harms arise; they can then plan their lives and activities with confidence that they are less at the mercy of ill fortune. Both publicly organized and commercial insurance can organize the pooling of risk in ways that are beneficial for all concerned. They provide standard ways of securing fundamental ethical values such as solidarity and mutuality. Although policy holders do not know or contract with one another, each benefits from the contribution of others to a shared scheme for pooling and so controlling risk. Although there is a limit to the degree to which commercially-based insurance, where premiums depend on risk level, can go beyond mutuality towards solidarity, in practice it too often achieves a measure of solidarity by taking a broad brush approach to pooling risk. However, the ordinary practices of insurance, and in particular of commercial insurance, also raise ethical questions. These may be put in simple terms by contrasting the way in which an insurance market discriminates between different people, on the basis of characteristics that (supposedly) determine their risk level, and our frequent abhorrence of discrimination, in particular on the basis on religious, racial and gender characteristics. Are the discriminations on which insurance practice relies upon as standard acceptable or not? The increasing availability of genetic information, which testing (of individuals) and screening (of populations) may provide, could lend urgency to these questions. Genetic information may provide a way of obtaining more accurate assessment of individual risks to health and life. This information could be used to discriminate more finely between the risk levels of different individuals, and then to alter the availability and the costs of health, life and unemployment insurance to them. Since all of these forms of insurance bear very directly on the way most people live, it will matter to them how (if at all) insurers take account of genetic information. Will use of this information improve or damage the capacity of insurance to provide confidence in the face of uncertain harms, and help if they happen? Will it discriminate in acceptable or in unacceptable ways? Will it support or damage the sorts of mutuality and solidarity various sorts of insurance schemes have successfully institutionalized?
生活充满风险，而保险提供了一种最为成熟的风险控制方式。通过集中风险并进行转移，那些可能遭受先前不确定伤害的人能够预先得到保障，即如果这些伤害发生，他们将获得帮助；这样他们就能自信地规划自己的生活和活动，因为他们不太会受厄运摆布。公共组织的保险和商业保险都能够以对所有相关方有益的方式组织风险集中。它们提供了保障诸如团结和互助等基本道德价值观的标准方式。尽管保单持有人彼此不认识也未签订合同，但每个人都能从他人对共同风险集中和控制计划的贡献中受益。虽然基于商业的保险（其保费取决于风险水平）在超越互助走向团结方面存在一定限度，但实际上它常常通过广泛的风险集中方式实现某种程度的团结。然而，保险的常规做法，尤其是商业保险的做法，也引发了伦理问题。通过对比保险市场基于（据称）决定不同人风险水平的特征对他们进行区分的方式，以及我们对歧视（尤其是基于宗教、种族和性别特征的歧视）的普遍厌恶，这些问题可以简单地表述出来。保险实践所依赖的这种作为标准的区分是否可接受？个人检测和群体筛查所提供的基因信息越来越容易获取，这可能会使这些问题变得更加紧迫。基因信息可能提供一种更准确评估个人健康和生命风险的方法。这些信息可用于更精确地区分不同个人的风险水平，进而改变他们获得健康、人寿和失业保险的可能性及成本。由于所有这些保险形式都与大多数人的生活方式直接相关，保险公司如何（如果考虑的话）考虑基因信息对他们来说至关重要。使用这些信息会提高还是损害保险在面对不确定伤害时提供信心并在伤害发生时提供帮助的能力？它会以可接受还是不可接受的方式进行区分？它会支持还是损害各类保险计划成功制度化的那种互助和团结？
