Health care reform proposals threaten to exacerbate tensions physicians already face in trying to balance traditional duties to individual patients against increasing pressure to serve broader societal and institutional goals. To cope with reform, medical ethics must clarify physicians' moral obligations, change existing ethical codes, and develop an ethics of institutions.

The Catholic Church in the United States provides extensive health care service through its more than 600 health facilities. The Church, on the basis of its moral teaching, sees health care as a basic human right and supports universal coverage. At the same time, the Church considers abortion morally wrong and opposes coverage of abortion as a health service in a national health plan. Mandated coverage of abortion would violate the moral commitments of (...) Catholic hospitals and the consciences of Catholics who would be required to financially support provision of abortion services. Keywords: abortion, Catholic hospitals, Clinton health plan, health care reform CiteULike Connotea Del.icio.us What's this? (shrink)

The paper begins by tracing the historical development of American medicine as practice, profession, and industry from the eighteenth century to the present. This historical outline emphasizes shifting conceptions of physicians and physician ethics. It lays the basis for showing, in the second section, how contemporary controversies about the physician’s role in managed care take root in medicine’s past. In the final two sections, I revisit both the historical analysis and its application to contemporary debates. I argue that historical (...) narratives can function as “master narratives” that suppress or leave out historical facts. I bring to the surface what is covered up by the master narrative approach, and show its relevance to contemporary ethical debates. I conclude by proposing that preserving the integrity of medicine will require modifying the master narratives we tell about physicians. The integrity of medicine also offers new perspectives for thinking about managed care and the broader topic of health care reform. (shrink)

Debates over health care have focused for so long on economics that the proper goals for medicine seem to be taken for granted; yet problems in health care stem as much from a lack of agreement about the goals and priorities of medicine as from the way systems function. This book asks basic questions about the purposes and ends of medicine and shows that the answers have practical implications for future health care delivery, medical (...) research, and the education of medical students. The Hastings Center coordinated teams of physicians, nurses, public health experts, philosophers, theologians, politicians, health care administrators, social workers, and lawyers in fourteen countries to explore these issues. In this volume, they articulate four basic goals of medicine — prevention of disease, relief of suffering, care of the ill, and avoidance of premature death — and examine them in light of the cultural, political, and economic pressures under which medicine functions. In reporting these findings, the contributors touch on a wide range of diverse issues such as genetic technology, Chinese medicine, care of the elderly, and prevention and public health. The Goals of Medicine clearly demonstrates the importance of clarifying the purposes of medicine before attempting to change the economic and organizational systems. It warns that without such examination, any reform efforts may be fruitless. (shrink)

ABSTRACTThe health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance . In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between (...) investing in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives. (shrink)

Health care reform is a perennial issue in elections — partly because of the challenges facing health care and especially because health care is an important issue for the swing voters. Making reform happen is harder. There are deep divisions within each of the parties — not apparent during elections. Bipartisan support — and the willingness to accept the best legislation that can be passed as “good enough”— will be key.

THERE IS WIDESPREAD DISSATISFACTION WITH THE HEALTH CARE SYSTEM in this country. This essay outlines why. It then reviews and evaluates the contributions of the faith community to the discussions of health care reform to assess whether the perspective and contributions of religious actors are distinct from secular approaches. Finally, it proposes different emphases for the religious community's future involvement with health care reform.

Instead of benefitting from open meetings and public discussions, the Clintons drafted their health care plan in private and asked that it be accepted in haste. They advance an ideology that claims we can receive the best care for all without any increase in cost or rationing, and then they use "ethicists" to justify this ideology through a supposedly common morality. However, there is no such common morality. In the context of American pluralism, one must look to (...) the actual consent of the governed and recognize the limits on state authority. The result will be a two tiered system of health care, with a basic tier focusing on cost-effective care for the poor that eliminates suffering rather than equalizing inputs, and a space for collateral private insurance. Keywords: Clinton health plan, egalitarianism of envy, egalitarianism of altrusim, limited democracy, moral pluralism CiteULike Connotea Del.icio.us What's this? (shrink)

Hong Kong is undergoing a public debate on the need to reform and future directions of reforming its health care system. This paper highlights the debates and considerations brought up by the Hospital Authority, the largest provider of public health care in Hong Kong, on the ethical principles and societal values underlying the upcoming reform. It is recognized that the exact meanings behind each ethical principle and value must be debated and clarified during the (...) reform process. In a modern day society like Hong Kong, societal values are likely to be diversified. A health care system also has to fulfil different and often conflicting objectives of equity, efficiency, quality and choice. It would be difficult for a health care system to satisfy these different values and objectives based on a single value parameter. The Hong Kong experience shows that a society may prefer a combination of strategies in addressing different societal values. The re-structuring of the health care system in Hong Kong should therefore be based on a balanced and optimum combination of various financing and delivery strategies. (shrink)

The need for change in the system of health care delivery in the United States has finally emerged as a political issue alongside continuing budget deficits, a growing national debt, declining educational outcomes, and decreased competitiveness of American business in the global economy. The two most pressing health care problems at the present time are rapidly increasing costs and lack of access to the system. A more distant but potentially more recalcitrant problem is the ageing of (...) our population. This paper outlines and discusses some of the options for reform which are currently under consideration in the United States. (shrink)

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law. ACA aims to improve access to care and health outcomes through a number of mechanisms, including requiring most individuals to carry health insurance, prohibiting insurers from denying health insurance coverage based on pre-existing conditions, and creating exchanges through which individuals and families not eligible for employer- or government-sponsored health insurance may purchase coverage. While the Act is aimed primarily (...) at improving individual health by increasing access to health insurance, it also contains a number of provisions targeted directly at improving health at the population level. Most of these provisions, which encompass a variety of disease prevention and access-to-care initiatives, are found in ACA Title IV. (shrink)

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law. ACA aims to improve access to care and health outcomes through a number of mechanisms, including requiring most individuals to carry health insurance, prohibiting insurers from denying health insurance coverage based on pre-existing conditions, and creating exchanges through which individuals and families not eligible for employer- or government-sponsored health insurance may purchase coverage. While the Act is aimed primarily (...) at improving individual health by increasing access to health insurance, it also contains a number of provisions targeted directly at improving health at the population level. Most of these provisions, which encompass a variety of disease prevention and access-to-care initiatives, are found in ACA Title IV. (shrink)

According to Congressional Budget Office projections, the Patient Protection and Affordable Care Act — assuming it survives the pending legal challenges and is fully implemented — will provide health insurance to 34 million additional Americans by 2021. This will increase the percentage of non-elderly Americans with health insurance from the current rate of 83 percent to 95 percent. Although enactment of the Affordable Care Act constitutes a historic step forward in the nearly century-long effort to ensure (...) universal health insurance coverage, relatively little in the Act focused on the potentially transformative impact of public health efforts that prevent disease. Chronic diseases such as heart disease, cancer, stroke, and diabetes are now responsible for more than 75 percent of health care costs, and reducing the incidence of these diseases — which are often entirely preventable — could dramatically improve the nation’s physical and fiscal health. (shrink)

The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of solidarity, (...) which has been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups—that is, what people need at different stages of life. (shrink)

We are well into the political season that guarantees the election of a new president. Actually, this season, the election cycle began in November 2006, as soon as the off-year election ended. Not surprisingly, health care and reforming health care are major issues for the election — although somewhat less important than they were before late 2007.I use the phrase “not surprisingly” because there are easily understandable reasons why health care tends to be an (...) election issue whenever we are electing a new president. One obvious reason is that, for several decades, we have been plagued by sizeable numbers of people without health insurance and even more importantly, by unsustainable increases in health care spending and substantial numbers of people experiencing patient safety and clinical appropriateness problems. I regard the unsustainable spending and safety and quality problems as especially important because they affect all of us — not just the 15% of the population that is without health insurance. (shrink)

Even when turning its attention to public health topics such as preventive care and workplace wellness, the Affordable Care Act law embodies a highly individualistic paradigm of health. The provisions of the law implicitly assign the primary responsibility for prevention to individuals, who should be urged to make more responsible and healthier choices about what they consume and how they live. Relatively little in the law reflects the “population perspective” set forth in public health scholarship (...) that focuses on environmental and social determinants of health. This article explores the cultural and economic factors that led Congress to embrace a highly individualist conception of public health, and it suggests how public health advocates and legal scholars might seek to reframe the public discourse surrounding preventive health issues. (shrink)

Now might be the time, if the proposal is crafted right.

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government (...) regulations tend to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government (...) regulations tend to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

We have just completed an exhausting nine‐month debate on the future of the Affordable Care Act. I see this debate as having ended—as of this writing—in a draw. After months of repeal efforts, Republicans in the House barely passed in early May, with a 217‐to‐213 margin, the American Health Care Act, which would have significantly amended the ACA. Republicans in the Senate spent the summer trying to arrive at amendments to the AHCA that could attract fifty of (...) their fifty‐two votes, but in the end, the clock ran out on their opportunity to enact an amendment without Democratic input. With this legislative failure, we appear to be in a stalemate. The Affordable Care Act remains in place as the law of the land, but the Trump administration seems committed to at best condemning the ACA to malign neglect and at worst actively undermining it at every opportunity. Given the political stalemate, the time is right to reassess the deeper issues at stake and ponder the prospects for a considered compromise on health reform. (shrink)

It is generally agreed that the current methods of providing health care in the West need to be reformed. Such reforms must operate within the practical limitations to which any future system of health care will be subject. These limitations include an increase in the demand for costly end-of-life health care coupled with a reduction in the proportion of the population who are working taxpayers (and hence a reduction in the proportionate amount of (...) class='Hi'>health care funding that can be secured through taxation) and the fact that the imposition of bureaucratic regulations on health care systems is costly. Recognizing these limitations should naturally lead one to consider market-based reforms. Yet despite the practical impetus for such reforms, there is still widespread concern that market-based health care is unethical. The purpose of this paper is to address this concern and, in so doing, to pave the way for the market-based reform of health care to proceed. (shrink)

The Clinton Administration stated that the list of values and moral principles generated by the Ethics group reflects "fundamental national beliefs about community, equality, and liberty" and that "these convictions anchor health reform in shared moral traditions." However, these statements are difficult to justify. There is not a moral consensus in America that would justify thorough-going health care reform. In such a context of pluralism, ethicists should seek to move society in the direction of solidarity. (...) The participation of ethicists on the Clinton Task Force was valuable because it showed that health reform is an exercise in social ethics, disseminated the work of ethicists to the entire Task Force, and expanded the experience of the ethicists involved. It may also have accelerated the moral transformation of Americans, which is needed before radical reform can take place. Keywords: American values, Clinton health plan, health care reform CiteULike Connotea Del.icio.us What's this? (shrink)

In this essay, I explore John Stuart Mill’s theory of government and its application to the issue of health care reform. In particular, I ask whether Mill’s theory of government would justify or condemn the creation of a public health-insurance option. Although Mill’s deep distrust of governmental authority would seem to align him with Republicans, Tea Partiers, libertarians, and others, who cast the public option as a “government takeover” of “our” health care system, I (...) argue that Mill offers good reasons for seriously considering some form of government-operated health insurance. For Mill theorizes government as having a positive as well as a negative role to play in people’s lives, and he explicitly endorses “public options” in different areas of life. According to his theory of government, a public health-insurance option would be just as long as it would meet the following two conditions: (1) it would not invade the “reserved territory” of individual liberty; and (2) “the case of expediency is strong.” I argue that a public option would in fact meet both of these conditions, and that Mill would have likely endorsed it as an effective solution to the current health care crisis in the United States. (shrink)

The normally staid topics of judicial ethics and the standards for judicial recusal have become the focus of political debates, editorials and letter writing campaigns. Most of the recent focus falls on conservative justices of the US Supreme Court and in particular on their anticipated participation in what is expected to be an important ruling on the constitutionality of the heath care reforms championed by President Obama and the Democratic Party. But the issue is not simply about partisan politics. (...) It's also about the structure of the US federal judiciary and the need to think about the impact of two-career couples on the judicial recusal rules. (shrink)

The Harvard Report, published in April 1999 for public consultation in Hong Kong, proposed a fundamental restructuring in its health care delivery and financing systems. The Report claims to be evidence-based in its approach (Hsiao et al., 1999a). While 'evidence' has been widely collected by the consultancy team through surveys, consultations and focus groups, the recommendations put forth are not value-free. They carry clear ideological preferences. The value assumptions and ethical presuppositions underlying the report are discussed in this (...) paper. The Harvard consultancy study is in favor of a positive government role in regulation and control, a single central body to administer compulsory health insurance for all citizens, and a purchaser-provider split to induce competition. Such preference is based on pre-existing ideology and generic health care management concepts, which are still in the experimental phase internationally. While value and ideology are inevitable factors in any policy choice, the challenge is to lay these values open for reflection and public debate. For Hong Kong, the challenge is also to take on local substantive issues in health care and deal with them head-on, rather than putting hope in a universal, generic solution. (shrink)

Using interviews with activists and Lisa Sowle Cahill's concept of participatory discourse, this article examines how the Greater Boston Interfaith Organization (GBIO) built solidarity for the 2006 Massachusetts health care reform law. The analysis explores the morally formative connections between GBIO's activist strategies and its public liturgy for reform. The solidarity generated through this interfaith coalition's activities and religious arguments contrasts with two standard types of policy discourse, economics and liberalism. Arguments for health care (...) reform based on economic efficiency or positive rights are hampered by the lack of solidarity in U.S. political culture. GBIO's congregation-based organizing offers a performative model of public argumentation for religious groups committed to achieving affordable, quality health care for all Americans. (shrink)

Book reviewed in this article: Seeking Fair Treatment: From the AIDS Epidemic to National Health Care Reform. By Norman Daniels.