Palliative care for the people without medical insurance in Germany: an empirical ethical approach

People without medical insurance often lack access to medical care, increasing their risk of chronic diseases and reducing life expectancy. This disparity likely extends to end-of-life care, when patients are especially vulnerable. The main research question was whether outpatient and inpatient palliative care facilities regularly treat uninsured patients. Based on the results, the study initiated an ethical reflection on the circumstances of uninsured palliative patients in Germany.

The study ran for 15 months from 2024 to 2025 1494 inpatient hospices, outpatient hospice services and specialized outpatient palliative care (SOPC) in Germany were invited to participate in an online questionnaire. The questionnaire contained questions about the care of uninsured patients with palliative care needs. A univariate descriptive analysis was used. Based on the results, ethical reflections on overlapping vulnerability were conducted, focusing especially on how living without medical insurance and its related circumstances interact from an intersectional perspective.

People without medical insurance, usually aged 40-65 years, received care at 41 (45.6%) inpatient hospices, 63 (29.3%) outpatient hospice services, and 29 (48.3%) SOPCs. Social workers usually made the requests. Funding gaps were reported by 10 (24.3%) inpatient hospices, 18 (8.4%) outpatient hospice services, and 55 (60.3%) SOPCs. 49 (54.4%) of inpatient hospices, 133 (61.9%) of outpatient hospice services, and 37 (61.7%) of SOPCs lacked knowledge about care options for uninsured patients ,. Fewer uninsured patients were cared for than had requested care, although there was a high level of willingness to provide palliative care to people without medical insurance.

The findings suggest that palliative care facilities do not regularly treat uninsured patients in Germany. Access to established palliative care institutions seems more difficult for the uninsured. These results indicate major inequalities in the provision of health care in Germany, especially in phases when patients are highly dependent on caregivers and therefore in need of protection. To address these issues, networking between medical services for the uninsured and palliative care services should be further strengthened. Precise legal regulations are ethically necessary alongside measures to ensure low-threshold access to palliative care and targeted training for medical professionals.