Equity in health and health care is animportant issue. It has been proposed that thepursuit of equity in health care is beinghampered by the dominance of individualism inhealth care practices. This paper explores theway in which communitarian ideals and practicesmight lend themselves to the pursuit of equity.Communitarians acknowledge, respect and fosterthe bonds that unite and identify communities.The paper argues that, to achieve equity inhealth care, these bonds need to be recognisedand harnessed rather than ignored. The notionof individual autonomy in the (...) context of thecommunity is examined. Alternative concepts ofautonomy – social autonomy and communityautonomy – are seen to be more respectful andnurturing of both the individual and thecommunity. Moreover, these concepts appeardesirable for the pursuit of health care equitygoals. The paper concludes with some thoughtsabout how equity in Australia's health caresystem can reasonably progress within acommunitarian vision. Disadvantaged communitiesare discussed throughout, in particular,Australian Aboriginal communities. (shrink)

Most of the debate surrounding standards in medical care, issues of medical audit and what constitutes benefit from health care assumes that what is obtained from health care is health and only that. This is an assumption which most health economists at least implicitly appear to endorse. This paper questions that assumption. There are various outcomes beyond health and there are various processes involved in health care about which patients are not indifferent. This paper calls for a fuller investigation as (...) to what it is that patients want from their health services and the adoption of a more pluralistic conception of health care benefits. It is further argued that the objectives of health care systems are those in which citizensqua citizens also have interests and which may be different from those of patients. It is yet less likely that citizens’ interests in health care will be restricted to health. (shrink)

The issue of assessing priorities is one that has become the subject of much debate in the National Health Service particularly in the wake of various documents on priorities from central Government. It has become even more so with the prospect of real cuts in expenditure. Economists claim that their science, or perhaps more accurately art can assist in determining not only how best to achieve various ends but also whether and to what extent competing objectives should be pursued. Such (...) choices cannot be made in the absence of some ethical considerations and it is important that health service decision makers (and in particular the medical profession) are aware if the relationship between economics (and especially cost-benefit analysis) and medical ethics. (shrink)

This study is part of a programme to elicit and examine community preferences for health care in different contexts. Data were obtained from a group of predominantly Australian health care decision-makers. A short questionnaire contained six valuation questions and four demographic questions. The six valuation questions posed choices where equal health gains were to be allocated to different population groups based upon: age; sex; current health; socio-economic status; across time; and across different numbers of individuals. The results provide some evidence (...) that respondents were prepared to discriminate between health gains derived in different contexts especially where health gains were to be allocated between groups of different health status and over time. Further research is planned and the possible implications for health policy, and in particular for resource allocation in health care, are briefly discussed. (shrink)

This book comprises an attempt to examine how we might set about an- swering the question: How much is society prepared to pay to reduce mortality: Or more brutally, what is the value of human life? The justification for attempting to answer such questions lies in the de- sirability of injecting increased explicitness and rationality into decision-making in those areas of the public sector which are con- cerned with life saving. Given that resources are already being de- ployed to such (...) activities as crash-barriers on motorways, helicopters for air-sea rescue, kidney machines and other life-saving measures - although such activities result only in a reduction in risk of death, not itsillimination, in the policy fields affected - this means that already at the present time, at least by implication, values are be- ing placed by decision-makers on the saving of life. (shrink)

John Rawles's criticism of QALYs are seen as being both imprecise and largely unhelpful. This paper accepts that there are problems in both QALYs themselves and in the current decision-making processes with which they seek to help. The QALY pliers tend to play down the former and the QALY knockers the latter. It is suggested that theories (regret theory and prospect theory) other than expected utility theory, which is normally seen as the basis for QALYs, may provide better approaches to (...) measuring health service outputs. Thus equity, information and decision-making per se are not handled as well in the expected utility QALYs as they could be. Developing better QALYs, with qualifications, is the goal. (shrink)

This paper introduces this mini-series on vertical equity in health care. It reflects on the fact that by and large equity policies in health care have failed and that there is a need for positive discriminationto promote equity better in future. This positive discrimination is examined under the heading of`vertical equity'. The paper considers Varian's notion of 'envy' as a basis for equity in health care but concludes that this is not a helpful route to go down. Better it would (...) seem to pursue the idea from Sen of 'freedoms' and 'communitarian claims' (as raised previously by this author). While it is argued that procedural justice is to be preferred in the longer run as a basis for equity there are gains in adopting a short run goal of promoting distributive justice. Some preliminary evidence is presented on the weighting of health gains to reflect such vertical equity concerns. (shrink)

This paper argues that there is a need to move yet further than has already been suggested by some from the individual to the collective as a base for public health. A communitarian approach is one way to achieve this. This has the advantage of allowing not only the community’s voice to have a say in setting the values for public health but also more formally the development of a constitution on which public health might then be built. It also (...) sees public health as a social institution which can be valued in its own right. (shrink)

Providing health care in the most cost-effective way has become a priority in recent years. This book tackles the important issue of the potential conflict between economic expediency and the welfare of individual patients. Contributors examine different attitudes to this complex problem, along with a variety of legal and historical perspectives. The book addresses particular aspects of health care, such as medical expert systems, general practice, medical education, and clinical decision-making where the direct involvement of doctors in allocating scarce and (...) expensive resources is perhaps most obvious. (shrink)

There is frequently an appearance of conflict between medicine and economics. This arises first because the nature of health and health care requires the doctor to make decisions on behalf of the patient and thus serves to explain why medical ethics exist. But secondly it is due to the relative lack of acceptance of the ethics of the common good within medical ethics. As a result while economics in the field of health has as an objective the maximisation of the (...) health of the community, subject to resource constraints, medical ethics pushes individual doctors to try to maximise the health of their patients. There is no reason to believe that the latter will sum to the former. To make the maximisation of health of the community the goal of the medical profession requires institutional changes, particularly with regard to budgeting, which will cajole and if necessary coerce doctors to adopt the good of the community as their objective. (shrink)

Effectiveness, efficiency and equity in health care are discussed in this article against the background of concerns that cost containment may lead to reductions in quality of care. It is suggested that effectiveness is best seen from the patient's point of view and that it relates to more than simply improved health status. Efficiency and equity are better viewed from a societal stance.The paper discusses the role of the medical profession in effectiveness, efficiency and equity and argues that the role (...) of medical doctors needs to be constrained. (shrink)

Most of the debate surrounding standards in medical care, issues of medical audit and what constitutes benefit from health care assumes that what is obtained from health care is health and only that. This is an assumption which most health economists at least implicitly appear to endorse. This paper questions that assumption. There are various outcomes beyond health and there are various processes involved in health care about which patients are not indifferent. This paper calls for a fuller investigation as (...) to what it is that patients want from their health services and the adoption of a more pluralistic conception of health care benefits. It is further argued that the objectives of health care systems are those in which citizensqua citizens also have interests and which may be different from those of patients. It is yet less likely that citizens’ interests in health care will be restricted to health. (shrink)

This book addresses an intruiging question: What do we mean by justice in health care? It concentrates on the social level of decision-making rather than the individual decisions which are more commonly the subject of medical ethics.