Complications: The Ethics of the Killing of a Health Insurance CEO (guest post)

NOTE: The author of this post concludes that the killing of Brian Thompson was wrong. (I’ve added this statement because some people sharing the post on social media are making misleading statements about it.) 

The killing of UnitedHealthcare CEO Brian Thompson earlier this month has ignited moral debate around the world.

Many have condemned the killing as they would any other murder. Others, though, have thought that the morality of the killing was less clear. And some people have celebrated it.

Sometimes moral ambiguities and moral disagreements are intractable. But sometimes these things arise from conflicting judgments about what in fact happened, or about what to think about the distinct aspects of what has happened, or about how to bring together what we think about those distinct aspects into an overall judgment. In these kinds of cases, a careful consideration of the relevant facts and moral considerations could help us better understand disagreements, or better identify the sources of ambiguities, and perhaps even help us resolve them, or make some kind of moral progress.

Saba Bazargan-Forward (UCSD) is a philosopher who works primarily in moral philosophy, with an emphasis on topics related to war and coercion. He’s the author of, among other things, Authority, Cooperation, and Accountability (2022).

In the following guest post, Bazargan-Forward discusses the ethics of Thompson’s killing, carefully looking at the factors relevant to our moral assessment of it, and offering us a diagnosis that may help us better understand the varied reactions to it. He concludes that the killing was wrong, arguing for that position by trying to take seriously some of the considerations that might be on the minds of those who disagree with this conclusion.

Complications: The Ethics of the Killing of a Health Insurance CEO
by Saba Bazargan-Forward

• 1 •

On December 4, 2024, UnitedHealthcare (UHC) CEO Brian Thompson was gunned down in New York City while attending an investment conference. He is survived by his wife Paulette Thompson, and their two children. Since news of his death, many individuals on social media have expressed frustration over UHC’s history of denying claims for medically necessary healthcare treatments. Others have gone further, celebrating the death of its CEO.

In what follows, I will attempt to morally evaluate his assassination. The moral evaluation I present here will be preliminary, in two ways. First, I set aside issues pertaining to the state of the healthcare industry in the US more generally; instead, I focus on UHC and Thompson’s role in it specifically. Because the assassination cannot be wholly abstracted from the healthcare industry in the US, or, for that matter, from the growing rampant wealth disparity endemic to the US, what I say here will be incomplete. Second, many of the claims I make depend on empirical facts currently unavailable to me. Hence, what I say here will be conditional. Nonetheless, my hope is that this incomplete, conditional moral evaluation will assist in formulating a more conclusive verdict.

Currently, the chief suspect in Thompson’s slaying is Luigi Mangione. Perhaps we can surmise what his intentions and motivations are, based on a ‘manifesto’ he allegedly wrote. In general, I believe that intentions and motivations can affect the permissibility of what we do. If it turns out that Mangione’s intentions were quite different from what the evidence shows—if, for example, that he killed Thompson solely for looking at him the wrong way—then what he did was impermissible, no matter Thompson’s accountability for his actions as CEO of UHC. Because Mangione’s intentions and motivations have yet to be decisively revealed, I focus not on whether the assassination he committed can be justified, but on whether an assassination can be justified.

I should mention that my areas of specialization, which include the ethics of violence, do not include healthcare ethics. This piece would be best written by someone who does both. I am no such unicorn. I accordingly invite corrections by those who are better versed in that field than I am.

• 2 •

Let’s start with some facts about Brian Thompson and the corporation for which he served as CEO. In 2004, Thompson joined UnitedHealth Group (UHG)—the largest healthcare conglomerate in the country, with over 2,300 different companies. Currently, UHG is ranked fourth in the 2024 Fortune 500 list of the largest companies in the US by revenue. Thompson held a variety of leadership roles in UHG over the course of his career, serving as chief financial officer for several of the company’s businesses and as a director for corporate development. In 2021 he was named CEO of UHC, a division of UHG, which insures more than 46.4 million Americans, and which made $16.4 billion in profit last year with Thompson at the helm.

Thompson’s tenure as CEO marked a period of growth for the company during which profits surged from $12 billion in 2021 to more than $16 billion in 2023. Thompson received an annual compensation package in 2023 valued at $10.2 million, ranking him among the highest-paid executives at UHG. His net worth was approximately $43 million, according to Wallmine. The Daily Mail reported that Thompson’s salary was about $10 million per year.

Under his leadership, UHG was accused of denying claims for medically necessary procedures and medications, and of fraudulently manipulating medical and patient data to maximize profits. In an October 2024 report, “How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care,” the majority on the US Senate Permanent Subcommittee on Investigations (PSI) released a report claiming UHC’s prior authorization denial rate for post-acute care more than doubled between 2020 and 2022. Denial rates for skilled nursing centers “experienced particularly dramatic growth” in that claims were denied nine times more frequently in 2022 compared to 2019.

According to the PSI’s report, soon after Thompson’s was named CEO a UHC committee began exploring the possibility of using AI and machine-learning to predict which instances denying post-acute care would be appealed and which of those appeals would fail. By 2023, the insurance company was served with a class-action lawsuit accusing it of relying on computer algorithms to systematically deny the claims of Medicare beneficiaries in nursing homes. The suit claimed the company illegally deployed “artificial intelligence (AI) in place of real medical professionals to wrongfully deny elderly patients care owed to them under Medicare Advantage Plans by overriding their treating physicians’ determinations as to medically necessary care based on an AI model.” The suit also claimed that UHC knew that this model “has a 90% error rate.”

According to the suit, the insurer “continue[s] to systemically deny claims using their flawed AI model” because they know that only about 0.2% of policyholders will appeal the denied claims. The overwhelming majority will either pay out-of-pocket costs or forgo what remains of their prescribed care. “Defendants bank on the patients’ impaired conditions, lack of knowledge, and lack of resources to appeal the erroneous AI-powered decisions.”

Journalists have also investigated UHC’s denial practices. In January 2023, the health news outlet Stat published a detailed investigation revealing that NaviHealth, a UHC subsidiary, used algorithms to deny care for seniors enrolled in the company’s Medicare advantage plan.

Denying medical coverage is not itself morally wrong. The goal of any insurance company is to collect more in premiums than they pay out in claims. Denying claims is par for the course. The issue, rather, is whether UHC denied medically necessary claims. This is important in part because health insurers agree to cover medically necessary claims. If it fails to cover such a claim, it is in violation of that agreement. Of course, what counts as medically necessary will be subject to dispute. But in such cases, as a matter of law, the insurer makes the final determination; this authority is conferred upon them contractually. Though in the US there might be legal consequences at the federal or state level for denying claims in bad faith, it is not inherently illegal for an insurance company to deny a claim they deem medically unnecessary.

Whether or not it turns out that as a matter of positive law UHC’s conduct is illegal, it clearly should be, if the allegations against them are accurate. These allegations suggest that the insurer operates by intentionally misleading policyholders into believing that UHC will cover claims which they will ultimately deny—claims that by any reasonable standard are medically necessary. For example, when the insurer agrees to cover medically necessary treatments, it seems that by any reasonable standard they have agreed to cover the cost of medication necessary to treat a crippling case of ulcerative colitis—an ailment that caused a student at Penn State to suffer severe arthritis, debilitating diarrhea, numbing fatigue, and life-threatening blood clots. ProPublica reported that UHC refused to cover the cost of medication on the grounds that it was “not medically necessary.” The report uncovered the lengths to which the insurer went to deny the claim, which included burying medical reports and soliciting rubberstamped recommendations from company-paid doctors. If UHC, under Brian Thompson, routinely denied claims for treatments that any reasonable party would deem medically necessary, it routinely defrauds its policyholders by violating its contractual obligations. If the insurer has a contractual obligations to cover an expense that you end up paying out of pocket, then it has defrauded you by precisely that amount. The PSI’s report suggests that this was standard practice, supercharged by AI.

• 3 •

Many of the allegations against UHC are just that. But suppose they are accurate. How wrong is it to systematically defraud policyholders in the way UHC is alleged to have done?

It might be argued that if UHC covered the medically necessary treatments it actually denies, the insurance would be more expensive, it which case it would likely cover fewer people, which would result in more harm. But this reasoning fails to justify UHC’s acts of fraud. There is a general moral prohibition on wronging some to aid others (unless that’s the only way to prevent a moral catastrophe). With a profit of $16 billion and with its parent company at number five on the US Forbes Fortune 500, UHC seems fully capable of providing contractually obligated coverage for medically necessary treatments without pricing out existing policyholders, all while still maintaining a very substantial profit margin. It’s a false dichotomy to suggest that UHC must choose between defrauding its policyholders and raising premiums.

Alternatively, it might be thought that, though defrauding policyholders is wrong, even in the aggregate such acts do not rise to the level warranting assassination. After all, these acts of fraud do not cause the diseases, disorders, or injuries for which UHC denies treatment. Health insurers—when they operate in the way they’re supposed to—fund medical treatments where these treatments prevent harm. It might seem, then, that a health insurer violating its contractual obligations doesn’t cause harm so much as it merely fails to prevent harm.

This is important, since, all things being equal, failing to prevent harm is not as bad as causing harm. By this reasoning, UHC didn’t worsen anyone’s health when it violated its contractual obligations. Instead, it just failed to improve their health. The insurer’s mantra might be: “Yes, we defrauded you—but we didn’t make you sick.” This makes it all the more difficult to justify acts of lethal violence against UHC executives.

But this reasoning is flawed. UHC, by violating its contractual obligations, doesn’t merely fail to prevent bodily harm; it does something much worse than that. There are three reasons for thinking this. The first two are not decisive. The third, I believe, is.

First: a contractual obligation to render aid should it be required can be a cause of a need for assistance. A patient suffering from cancer might be uncertain as to whether to undergo chemotherapy. She might ultimately decide to do so given that her insurer has led her to believe—falsely—that they will cover expenses for medically necessary ancillary treatments, such as anti-nausea medication. If the insurer violates its contractual agreement, then it serves as a cause of the harms that the ancillary treatment would have prevented. Cases of this sort, though, are not typical—I mention them only to largely set them aside.

Second: if UHC defrauds a policyholder by denying coverage for medically necessary treatment that an alternatively available insurer would have covered, then UHC might serve as a but-for cause of the bodily harm it failed to prevent. Of course, it might be that the counterfactual insurer would have also denied coverage for the treatment in question. But it seems UHC denies claims at a much higher rate than other insurers do. According to the personal finance platform ValuePenguin, UHC denies 32% of claims compared to the industry average of 16%. Of course, this evidence is not decisive; different insurers might cover different demographics within the US. So, though UHC’s fraud might count as a but-for cause of the harms it fails to prevent, it’s exceedingly difficult to determine how often this is true.

Third, and most importantly: though we all have Samaritan obligations to help one another in times of dire need, those who promise to render such aid, especially in exchange for payment, obviously have a special, stronger duty to render such aid. This partially effaces the moral relevance of the distinction between doing and allowing. Though UHC didn’t cause the harms their defrauded policyholders suffer, their culpable violation of their contractual obligation to fund the prevention of those harms means they are nearly as accountable as they would be if they had. Much more needs to be said here, but if something like this claim is correct—that contractual obligations vitiate the moral relevance of the distinction between doing and allowing—then this helps vindicate accusations that many members of the public seem to be making against healthcare insurers in general and UHC specifically: that they are doing something morally tantamount to causing widespread bodily harm.

• 4 •

Suppose that UHC is indeed engaged in widespread fraud of the sort I’ve described. I take this to be an empirical supposition. And suppose that such fraud, by culpably violating a contractual obligation to provide funds necessary to prevent bodily harm, is as bad or nearly as bad as culpably causing such harm. I take this to be a moral supposition. If these suppositions are both correct, could that justify assassination?

To answer this, we first need to determine whether and to what extent a CEO like Brian Thompson, is accountable for what his corporation does. A CEO’s power is not absolute—they are accountable to the board of directors who represent shareholders. This board has the authority to hire and fire the CEO and must approve major structural corporate decisions. Still, the CEO has unparalleled influence and authority over the direction of the corporation, the strategies it adopts, and oversees major decisions about operations. In this regard, the CEO is not a mere figurehead, but rather a leader with the delegated authority to implement their vision for the corporation. If UHC was systematically defrauding its policyholders in the way I described, it was either because Thompson wanted it or allowed it. Indeed, there is some reason (though not decisive) to believe it was the former: the wrongs detailed in the PSI’s report and the NaviHealth class-action lawsuit—including the use of AI with a 90% error rate to deny claims en masse—all occurred during his tenure in which he was handsomely rewarded. It might be argued that if he hadn’t authorized or allowed these policies, someone else would have in his stead. But even if he is not a but-for cause of UHC’s policies, he is still a cause. Based on this, I believe we can tentatively conclude that Thompson bears significant accountability for the policies UHC adopted.

Supposing Thompson is accountable for these wrongs, what would justify violence against him? Perhaps such violence against those responsible will lead others to think twice about implementing similar policies. Though this might sound like wishful thinking, it’s worth noting that on December 5, the day after Thompson was killed, Anthem Blue Cross Blue Shield—one of the largest health insurers in the US—abruptly reversed its recent decision to cap anesthesia coverage amid widespread backlash. Though we cannot know whether the assassination is what motivated the reversal, it’s hard to believe that it’s mere coincidence.

This might seem like terrorism—in which innocents are targeted with the aim of using their deaths to ultimately affect policy. But it is not clear that Thompson counted as an innocent. He might have been morally liable to be used as a means to deterring others from committing the same wrongs that he has. That is to say, Thompson might have forfeited the right against deprivations instrumental to disincentivizing the kind of wrongful conduct he committed. As I noted, it is wrong to harm one person for the sake of preventing harm to others (unless doing so is necessary to prevent a catastrophe). But if someone has forfeited their rights against being harmed in furtherance of that good, then harming them in that way doesn’t wrong them.

Even supposing this is all correct, is extra-judicial killing warranted? At first, it seems like the answer has to be ‘no’. Imagine the ideal civil and criminal justice system. Imagine further that in that system, Thompson is tried before a criminal court and found guilty, in his own person, for authorizing policies systemically defrauding policyholders at UHC. Presumably, execution would not be appropriate punishment for those crimes. If it’s wrong for the government to execute Thompson—even in a world where, as a matter of positive law, it is pellucidly clear that his activities were illegal—then surely it is wrong for a private citizen to execute Thompson in this world. It’s one thing for a private citizen to take the law into his own hands. But it is another for a private citizen to do what even the government would not be permitted to do. Or so it might be argued.

Importantly, though, it would be wrong for the government to execute Thompson because the government would have another, less harmful option at its disposal: it could imprison him. Given that this mode of punishment would sufficiently deter others from engaging in similar misconduct, there would be no need to resort to execution. But a private citizen doesn’t have this option. What is permissible for you to do depends on the menu of options available to you—given that imprisonment is an option, execution will often be impermissible. But remove that option, and execution might indeed be warranted.

To see this, imagine again the ideal civil and criminal justice system—except this time, imagine that for whatever reason the government is unable to incarcerate Thompson or those like him. He has to be either executed or let free to continue his activities. Under these circumstances, it’s far less obvious that execution is impermissible. The upshot is that (given all the suppositions I’ve detailed so far), a private citizen committing an extra-judicial assassination is doing what a government would be permitted to do—provided we imagine that the government, like the private citizen, is incapable of incarcerating the offender. The suggestion here is that the government violates the constraint of necessity should it execute Thompson, whereas perhaps a private citizen does not.

Against this, it might be asked: couldn’t have the private citizen merely wounded Thompson? Perhaps that would still have had a sufficient deterrent effect. If so, this suggests killing violates the necessity constraint after all. For that matter, one might worry that killing violates the proportionality constraint—death might be too severe a harm relative to the harms that the death prevents. Thompson’s, culpability, though, affects the stringency of the proportionality constraint.

This entire discussion of Thompson’s liability, though of academic interest, seems to neglect an important issue: the law.

• 5 •

Even if there is some sense in which Brian Thompson is morally liable to be used as a means in the way I have indicated, the law forbids private citizens from taking action of that sort. As private citizens in a legitimate state, we are prohibited from acting unilaterally in this way against one another. On an influential Lockean view of a democratic state, each of us vests in the state the authority to discharge vicariously the rights we have against one another, which is what prohibits us from acting unilaterally in our own person. On some versions of this view, the reasons we have to abide by laws prohibiting killing are not merely very strong reasons outweighing competing reasons to dispense justice privately. Rather, the reasons to abide by such laws are exclusionary in that they typically silence competing reasons which ought to carry no weight at all in our deliberations. This is all very rough, of course. But the point is that, according to this influential family of views, Thompson’s assassin acted immorally even if all of his unilateral judgments about the CEO were correct. Thompson’s moral liability to be used as a means is, in a sense, irrelevant to what private citizens are permitted to do to him, not just legally but morally—presuming a legitimate state.

This is to say nothing of the risk that condoning the assassination would have on social stability, which is itself a valuable good. Already in New York City “Wanted” posters have appeared, targeting healthcare executives. It might be thought that some instability is warranted given the systemic wrongdoings healthcare insurers are committing. But I personally do not trust armed Americans, acting privately, to determine which CEOs should be killed and which should be allowed to live, especially in a social environment where misinformation is rampant. It is not hard to imagine a future in which private citizens begin assassinating academics they view as a danger to society.

We are, then, at an impasse. But in a way, it is a felicitous one. I tentatively suggested that:

a. UHC systematically defrauded its policyholders by refusing to cover contractually obligated medically necessary treatments,

b. failing to prevent harms resulting from refusing to cover medically necessary treatments is as or almost as wrong as causing those harms, and

c. Brian Thompson as CEO of UHC is accountable for authorizing or allowing policies that systematically defrauded its policyholders.

By harming Thompson as a means to deter others of his ilk from authorizing or allowing similar policies, a private citizen is doing the sort of thing the government should be doing (provided that he has the right sort of intentions and that the proportionality and necessity constraints are met). Yet this private citizen’s actions are still not morally justified, because he lacks the requisite authority to act unilaterally in that way. This two-step reflects the ambivalence some might feel about the assassination.

I have suggested that Thompson and those like him are morally liable to be used by the government, but not by a private citizen. This, though, can change. Assume something like the Lockean picture is correct, in which our rights are vouchsafed by the government. A government that consistently and systematically reneges on its duties to protect rights within a particular domain, thereby weakens the exclusionary power of the reasons private citizens have to refrain from acting unilaterally within that domain. In such a case, the government loses legitimacy within that domain. With respect to health insurers, we are still, I believe, in early days; for example, the use of AI is a relatively new phenomenon for which regulations have yet to appear. But we may yet get to the point where it becomes clear that the government will never be willing or able to regulate these industries in the ways that morality requires and that the people demand.