This chapter contains section titled: I Equality of Resources II Justice in Health Care III Why Universal Access Requires In‐kind Transfers IV Conclusion Acknowledgement.

This article discusses cosmopolitanism as the moral foundation for access to health care for migrants. The focus is on countries with sufficiently adequate universal health care for their citizens. The article argues for equal access to this kind of health care for citizens and migrants alike—including migrants at special risk such as asylum seekers or undocumented migrants. Several objections against equal access are raised, such as the cosmopolitan approach being too (...) restrictive or too permissive, or the consequences being undesirable; but the objections are largely refuted. Some special cases in which a restriction of equal access to health care might be justified are described: humanitarian crisis, short term tourism, and the case of a migrant or refugee who will stay only very briefly on a state's territory. (shrink)

A universal entitlement to health care can be grounded in the liberty principle. A detailed examination of Rawls's discussion of health care in Justice as Fairness shows that Rawls himself recognized that illness is a threat to the basic liberties, yet failed to recognize the implications of this fact for health resource allocation. The problem is that one cannot know how to allocate health care dollars until one knows which basic liberties one (...) seeks to protect, and yet one cannot know which basic liberties to protect until one knows how health care dollars will be allocated. The solution is to design the list of basic liberties and the health care system in tandem so as to fit each other, such that every citizen is guaranteed a set of basic liberties and access to the health services needed to secure them. (shrink)

Menzel and Light have argued that the conservative principle of self-sufficiency gives good reasons to strive for universal health coverage. This paper gives further reasons for connecting universal health care with self-sufficiency and continues Menzel’s and Light’s project in four more ways. First, a more extended analysis of a conservative conception of government shows how a general opposition to welfare programs is consistent with guaranteeing universal basic health care. Second, common fears about (...) the abuse of health care when universal access is guaranteed are unfounded. Third, worldwide experience shows that the most effective way to bring high quality health care to a population is through a government mandate, not the free market. Fourth, while socioeconomic status is an important determinant of health independent of the accessibility of health care itself, this does not undermine the case for universal health care based on a minimal, conservative conception of equality of opportunity. (shrink)

This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, (...) and freedom–where freedom is understood as independence and self-determination–justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and–although this is arguable–government action to guarantee access to health care does not itself undermine freedom. (shrink)

The most ambitious effort in many years to reform the U.S. health insurance system was signed into law earlier this year in Massachusetts. In the essay below, a health economist who advised the state on the reform describes the plan and how it unfolded. Five commentaries weigh its odds of success and ask whether it can provide a model for the nation.

Many societies, and nearly all wealthy, developed countries, provide universal access to a broad range of public health and personal medical services. Is such access to health care a requirement of social justice, or is it simply a matter of social policy that some countries adopt and others do not? If it is a requirement of social justice, we should be clear about what kinds of care we owe people and how we determine (...) what care is owed if we cannot possibly meet every health need, as arguably no society can. We should be clear about what constitutes appropriate access to that care, given that there are diverse barriers to access. We must also be able to say why we owe these things as a matter of justice, and, of course, different accounts of social justice will bake and serve this cake in different ways. (shrink)

Catholics have been at the forefront of efforts over many years to secure universal access to health care in the United States. These efforts suf­fered a serious setback when the federal government enacted the Affordable Care Act and then quickly used it to assault rights of conscience. This assault has brought into serious question the once promising hope that a partnership might be forged between church and state to benefit those at the margins of society. (...) Given recent events, Catholics and others are compelled to reassess their willingness to trust the power of government to carry out this aim in a manner that respects fundamental human rights, including the rights of religious believers. The words of our founders and framers, who warned against the dangers of an overbearing government, merit renewed attention. (shrink)

Among political philosophers - and indeed public officials - it is generally believed that some sort of general principle of distributional equality can provide solid moral foundations for universal access to health care. In fact, this belief is so widely received that even among those who are very critical of egalitarianism, few have expressed doubts about the prospects for an egalitarian defense of universal access to health care. The purpose of this paper (...) is to put pressure on this received view. (shrink)

Universal access to health care has historically faced strident opposition from political conservatives in the United States, although it has long been accepted by most conservatives in the rest of the industrialized world. Now, in a global economy where American business is crippled by the rising cost of market-based health care, the time may be ripe for change. The key to fostering a new mindset among American conservatives is to show why universal (...) class='Hi'>access fulfills many of the basic values that all conservatives hold. (shrink)

Paul Menzel and Donald Light ("A Conservative Case for Universal Access to Health Care," Jul-Aug 2006) tell a story that is plausible. However, based on my twenty-five years of experience as a policy analyst interested in access to health care, I find it inaccurate for a number of reasons.

Approximately one in six persons in the U.S. lacks medical insurance. Legislation permits only physicians to prescribe many common medicines. This state of affairs is unjust. A just society cannot have it both ways: legislation cannot say that the expertise of physicians is so precious that only they can prescribe medicine and that not everyone is guaranteed reasonable access to their services. If there is no guarantee of reasonable access, then physicians should not have a monopoly on writing (...) prescriptions, and if there is a monopoly on writing prescriptions then people should have reasonable access to their services. To remedy this situation we must ensure that all citizens have reasonable access to medical services, or allow the uninsured to self-medicate. (shrink)

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the conceptual specification (...) of health system boundaries and on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries. (shrink)

The availability of free health care to all citizens has been regarded as a great achievement of the Soviet society. In recent decades, however, decreased funding of the state-run health care system has led to a deterioration in the quality and quantity of available medical equipment and services. More than 50 percent of the Russian population is dissatisfied with the health care system and the attitudes and moral standards of their health care (...) providers. This article discusses the degree, nature, and some of the causes of the public's dissatisfaction and concludes with a preliminary look toward the future of the Russian health care system. (shrink)

Health care reform that includes universal coverage could lower a major barrier to care for people of color and ethnic minorities—the inability to pay for care. But universal coverage alone, even with comparable fee-for-service payment or appropriately risk-adjusted capitated reimbursement, will not eradicate the racial and ethnic inequities in health care delivery. Restrictive admissions practices, geographic inaccessibility, culture, racial stereotypes, and the failure to employ minority health care professionals will still (...) create barriers to minority health care. In addition to universal financing, health care reform should include new civil rights legislation to address and reduce these noneconomic barriers to minority health care. (shrink)

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and (...) to purchase medication; and, primary care is free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing. (shrink)

In the United States, amid the fractious politics of attempting to achieve something close to universal access to basic health care, two impressions are likely to feed skepticism about the status of a right to universal access: the moral principles that underlie any right to universal access may seem incredibly "ideal," not well rooted in the society's actual fabric, and the necessary practical and political attempts to limit the scope of universally accessible (...) care to make its achievement realistic may seem marked less by moral rhyme and reason than by the pull of conflicting interests. I try to directly dispel the first of these impressions and to obliquely question the second. The immense political barriers to .. (shrink)

One widely accepted way of justifying universal access to health care is to argue that access to health care is necessary to ensure health, which is necessary to provide equality of opportunity. But the evidence on the social determinants of health undermines this argument.

Health care reform that includes universal coverage could lower a major barrier to care for people of color and ethnic minorities—the inability to pay for care. But universal coverage alone, even with comparable fee-for-service payment or appropriately risk-adjusted capitated reimbursement, will not eradicate the racial and ethnic inequities in health care delivery. Restrictive admissions practices, geographic inaccessibility, culture, racial stereotypes, and the failure to employ minority health care professionals will still (...) create barriers to minority health care. In addition to universal financing, health care reform should include new civil rights legislation to address and reduce these noneconomic barriers to minority health care. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another (...) commodity to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

In addressing issues of access to health care and rationing, Jewish and Roman Catholic writers identify similar guiding values and specific concerns. Moral thinkers in each tradition tend to support the guarantee of universal access to at least a basic level of health care for all members of society, based on such values as human dignity, justice, and healing. Catholic writers are more likely to frame their arguments in terms of the common good (...) and to be more accepting of rationing that denies beneficial and needed health care to some persons. Jewish writers are more likely to consider individual responsibility for illness in allocation decisions and to accept differences in the health care that different members of society receive. The article considers the relevance of both shared and complementary perspectives for deliberations in nations such as the United States. (shrink)

Henry Shue’s model of basic rights and their correlative duties provides an excellent framework for analysing the requirements of global distributive justice, and for theorising about the minimum acceptable standards of human entitlement and wellbeing. Shue bases his model on the claim that certain ‘basic’ rights are of universal instrumental value, and are necessary for the enjoyment of any other rights, and of any ‘decent life’. Shue’s model provides a comprehensive argument about the importance of certain fundamental goods for (...) all human lives, though he does not consider health or health care in any significant detail. Adopting Shue’s model, I argue that access to health care is of sufficient importance to the enjoyment of any other rights that it qualifies as what Shue describes as a ‘basic’ right. I also argue that the basic right to health care is compatible with the basic rights model, and is required by it in order to for it to achieve its goal of enabling right holders to enjoy any decent life. In making this claim I also explore the requirements of the basic right to health care in terms of Shue’s triumvirate of duties and with reference to several key examples. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another (...) commodity to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

This article makes a moral argument for universal access to health care and for the legitimate function of government to guarantee that access. Constructed as a reply to the libertarian argument against universal access, this article utilizes the moral and political theory of John Locke, favored by libertarianism, to develop a Lockean argument for a view contrary to the libertarian philosophy. In particular, the argument here shows how libertarianism’s neglect of a crucial element (...) of the natural-law tradition, to which Locke adhered, not only undercuts the libertarian objection to universal access to health care but also underwrites an alternative argument in favor of such. (shrink)

Health systems that provide for universal patient access through a scheme of prepayments—whether through taxes, social insurance, or a combination of the two—need to make decisions on the scope of coverage that they secure. Such decisions are inherently controversial, implying, as they do, that some patients will receive less than comprehensive health care, or less than complete protection from the financial consequences of ill-heath, even when there is a clinically effective therapy to which they might (...) have access.Controversial decisions of this sort call for a public justification for covering or not covering a given treatment. Priority-setting agencies play a key role in providing such a justification. A recent... (shrink)

There is a vast amount of evidence across countries that the use of health care services (including hospitalizations, physician services, and clinical preventive services) is positively associated with income, education and other markers of socioeconomic position. In some analyses, lower socioeconomic status (SES) is associated with greater physician and hospital use, although it appears that these findings are primarily driven by higher rates of poor health status or medical need in socioeconomically disadvantaged populations. Three general sets of (...) explanations have been investigated to explain SES differences in health care use: (1) financial access or affordability differences (e.g. the poor use fewer services because they have fewer financial means); (2) knowledge, attitudinal and cultural differences in seeking care (e.g. the poor use fewer services because they value and/or understand the benefits of health care less than other people); and (3) health care system factors (e.g. the poor use fewer services because of ways in which the health care system is organized). The empirical evidence from a number of countries suggests that health care system variables, especially non-financial components of access, offer the greatest explanatory power regarding SES differences in utilization. The policy implications of such findings are important, for they suggests that providing universal coverage or offering free health services to the poor is not a panacea for reducing social inequalities in health care utilization. Research across countries also suggests that, although SES differences in the use of health care services may contribute to some portion of observed SES disparities in health status, the contribution here is likely to be small. Social inequalities in health status are driven by myriad factors other than access to and use of personal health services. (shrink)

Background There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto (...) Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds. Discussion The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill. Summary Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge. (shrink)

Proposed solutions to the problems of this country's health care system range along a spectrum from central planning to free market. Central planners and free market advocates provide various ethical justifications for the policies they propose. The crucial flaw in the philosophical rationale of central planning is failure to distinguish between normative and metanormative principles, which leads to mistaken understanding of the nature of rights. Natural rights, based on the principle of noninterference, provide the link between individual morality (...) and social order. Free markets, the practical expression of natural rights, are uniquely capable of achieving the goals that central planners seek but find beyond their grasp. The history of this country's health care system and the experiences of other nations provide evidence of the superiority of free markets in reaching for the goals of universal access, control of costs, and sustaining the quality of health care. (shrink)

BackgroundThere are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint (...) Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds.DiscussionThe top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill.SummaryAlthough many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge. (shrink)

Scientific progress in the areas of health and biological science is phenomenal. Still, current health policies limit optimal benefit for our peoples. Our present system costs too much, delivers too little, is not comprehensive, coherent, or cost-effective, does not allow choice, is not equitable, and is not universal. We must overcome many crises if we are to create a healthy people fro the twenty-first century in the US. We will need to use multiple strategies to achieve the (...) nation's goals of Healthy People 2010, which are to: 1) increase the quality and years of healthy live; 2) eliminate health disparities; 3) provide access to primary preventive care for all citizens. We are the richest country in the world and the only industrialized country that does not provide health care for its entire people. Health care costs are escalating and insurance is out of reach for many. Public policy changes are necessary to provide universal access to basic health care. We have advances in sciences; now we need the science delivered to our people in an equitable way. Politicians will respond proportionately to the insistence of the people. Healthcare professionals and scientists should lead the way. (shrink)

When the President’s Commission of 1983 concluded that there is an “ethical obligation” to secure universal access to a decent minimum of health care, some hoped that this standard would be achieved in the United States within a few years. Nearly 30 years later, when we began work on this issue of the Journal of Medicine and Philosophy (JMP), that standard had yet to be achieved, although the bills that would later become the Affordable Care (...) Act (ACA) were then working their way through Congress. Now, the ACA has been passed and signed into law. The provisions of that bill aim at achieving universal access to an “essential health benefits (EHBs) package". (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Developing Health Care in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences of health care providers working in resource-poor settings, with stories written by those on the frontlines of global health. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of global health practitioners (...) within the frameworks of sociology and medical anthropology respectively.The burgeoning interest in global health among students, health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantial moral claims. People working in global health often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to quality health care services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among global health equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basic health services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducing health disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes of health inequity.We believe that global health must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of global health as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by global health leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of global health work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic and moral—involved in this work. The profound scarcity of resources available to health providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and other health care workers, who make difficult choices every day about what to do with the few resources they have. These are the ethical dilemmas of mortal dramas at their most dire. Global health work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of global health practitioners. They highlight the translation of the moral and programmatic challenges of health care delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-up care. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)

Distributive justice on the income and on the service aspects is the most vexing modern day problem for the creation and maintenance of an all inclusive health care system. A pervasive problem of all current schemes is the lack of effective cost control, which continues to result in increasing burdens for all public and private stakeholders. This proposal posits that the responsibility and financial obligation to achieve an ideal outcome of equal and affordable access and benefits for (...) all citizens is misplaced. The Good Samaritan demonstrated basic ethical principles, which are revisited, elaborated and integrated into a new approach to health care. The participants are limited to individual contributors and beneficiaries and organized as a citizen carried, closed, independent, and self-sufficient self-governing cooperative for their own and the benefit of a minority of disadvantaged health care consumers. The government assumes oversight, provides arbitration, enforces democratic decision making, a scheme of progressive taxation, a separate and transparent accounting system, and a balance between income and reinvestment in health care. The results are a fair distribution of cost, its effective control, and increased individual motivation to take on responsibility for personal health as a private good and a sharpened focus towards community health. At the sociopolitical level the government as well as employers are released from the inappropriate burden of catering to individual health. (shrink)

Recent developments in organ procurement have revived the much-debated role of markets in our health care system. The unique American health care system, with its presumption of universality alongside private health insurance and relatively limited federal and state programs, is in many ways consumer-driven today. We certainly tolerate more broad disparities in availability of care and in outcomes of care largely based on socioeconomic status than do many other developed countries, where notions of (...) universal access are supported by broader public financing. (shrink)

Two narratives have emerged to describe recent health care reforms in the United States of America and the United Kingdom. One narrative speaks of revolution, that the adoptions of the Affordable Care Act 2010 in the US, and the Health and Social Care Act 2012 in the UK, have resulted in fundamental, large-scale philosophical, political and legal change in the jurisdictions’ respective health care systems. The other narrative evokes evolution, identifying each new legislative (...) scheme as a natural development of existing governance structures. Policymakers in both the US and UK face the problem of a health care system which, as traditionally envisaged, cannot offer universal access to health care at a reasonable, or politically acceptable, price. (shrink)

American health care reformers face a number of ethical issues, including familiar debates over the merits of a single-payer system and publicly provided universal health insurance. No matter how these debates are resolved, a further ethical question must be addressed. Both universal coverage and a single-payer system are compatible with permitting some patients to pay more for faster, better, or more health care choices. Should the United States continue to have a two-tier (...) class='Hi'>health care system in which wealth grants some patients access to medical services that others with the same needs cannot obtain? Critical evaluation of both principled objections to inequalities and practical objections to anticipated social and medical consequences of a two-tier health care system are needed. (shrink)

Background Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns.Reflections Parks, like health services, are embedded in their local landscape, (...) serving their communities, but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there.Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be ‘in the moment’, to take personal risks and to draw energy and inspiration from the participants. Hence ‘audiences’ are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co-constructed experience.Conclusions Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients ‘co-producers’ of their own health and ‘co-shapers’ of their health services. (shrink)

This article examines the consequences of the politicization of health care in the United Kingdom following the creation of the National Health Service (NHS) in 1948. The NHS is founded on the principle of universal access to health care free at the point of use but in reality charges exist for some services and other services are rationed. Not to charge and/or ration would create a common-pool resource with no means of conserving scarce (...) resources. Taking rationing decisions in the political realm means that the values and priorities of individual patients are marginalized and the preferences of powerful organized groups able to capture the political process dominate. The key lesson for international health care reform is that the politicization of health care via the NHS has not led to the realization of egalitarian ends but rather has empowered vested and organized interests at the expense of individual patients. (shrink)

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness (...) of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing. Keywords: principles, health care reform, rationing, universal access CiteULike Connotea Del.icio.us What's this? (shrink)

Environmental pollution and greenhouse gas emissions that contribute to climate change have adverse impacts on global health. Somewhat paradoxically, health care systems that aim to prevent and cure disease are themselves major emitters and polluters. In this paper we develop a justification for the claim that solidaristic health care systems should include sustainability as one of the criteria for determining which health interventions are made available or reimbursed – and which not. There is however (...) a complication: most adverse health effects due to climate change do occur elsewhere in the world. If solidarity would commit us to take care of everyone’s health, worldwide, it might imply that solidaristic health system cannot justifiably restrict universal access to their own national populations. In response we explain health solidarity is to be considered as a moral ideal. Such an ideal does not specify what societies owe to whom, but it does have moral implications. We argue that ignoring sustainability in political decision making about what health care is to be offered, would amount to betrayal of the ideal of solidarity. (shrink)

Under the impact of cultural, economic and legislative forces the traditional role of the university health center is changing. The academic health center is rapidly evolving from a relatively undifferentiated general hospital, primarily responsible for the education of undergraduate students of medicine, into a center of clinical research, caring for very specialized mixes of patients, and having as its primary educational mission the training of subspecialists. The nature of the forces responsible for this change are analyzed, and some (...) of its possible consequences for the definition of quality health care, for the shape of medical practice and medical education, and for the allocation of resources for health care are explored. This exploration suggests that the functional separation of the medical school from the highly technical, clinical research center is inevitable. This in turn may exacerbate tensions within medicine between the physician as scientist and as healer, between curative and preventive practice and between personal and public health. Although the effects of this separation on medical education remain obscure, it has already occasioned the most comprehensive review of the medical curriculum since the time of Flexner. Out of this is likely to develop a more generalist view of the education of future physicians. (shrink)

The 1988 Brazilian Constitution establishes a right to health in two of its provisions. The first provision provides a relatively long list of social rights, which includes not only the right to health, but also the right to the determinants of health such as education, food, employment, and shelter. The second provision recognizes the two components of the right to health, namely: factors that are likely to affect a person’s health, such as access to (...) clean water, sanitation and nutrition; and medical care or health services. This second provision establishes that the right to health “shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and by the universal and equal access to actions and services for its promotion, protection and recovery.” It also enumerates state obligations, the first and most important one being the duty of the Brazilian state to guarantee the right to health to every citizen. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working on the Clinton Administration's Health Care Reform Task ForceNancy Neveloff Dubler (bio)This narrative is based on my understanding of the elements of the Health Security Act that may have ethical implications. I have reconstructed these elements from my experience on the Health Care Reform Task Force and they are part of the health care plan that the President presented to Congress. (...) (At the time this article went to press, the actual legislation, which should answer my remaining specific questions more clearly, had not yet been released.) I perceive the most important features of the plan to be:• The legislation will create a "right" to health care for all citizens—access to care will be universal;• The plan will involve some form of managed competition in which groups of providers (called Approved or Accredited Health Plans (AHPs)) will offer comparable benefit packages at slightly (or widely) different costs;• The AHPs will negotiate with the Health Alliance (HA) to determine the price that they will charge their consumer-patients;• There will be open enrollment with no barriers to coverage, such as exclusions for pre-existing conditions;• Community rating will be in effect in different localities and enrolled persons in any AHP will pay the same premium;• The coverage for any enrolled person will be portable;• The overall structure will be a cooperative federal/state enterprise in which the states will have quite extensive abilities to fashion variations of the basic plan to meet their particular needs;• Primary care will be encouraged and incentives for physicians to train in primary care specialties provided;• Non-physician providers will be central to the functioning of the health care plans;• Efforts will be made to develop a "person power" pool so that people with an abstract "right" to health care will have real access to providers, in their localities, who can fulfill the promise that the right creates; [End Page 421]• The goal of cost containment will be central to the organization and regulation of the system;• Administrative simplicity and quality protections will be central.Co-chairing the Bioethics Working Group (BWG) of the White House Task Force on Health Care Reform was a unique experience. Approximately 40 Task Force working groups were established by Hillary Rodham Clinton, the President, and the senior Task Force staff. Various members of the President's office and other knowledgeable members of the Executive Branch selected the participants. In our group, appointments were made largely on the recommendations of the co-chairs. The BWG, among the last of the groups formed, carried the official name "The Working Group on the Ethical Foundations of the New System" and was jointly led by me and Marion Gray Secundy, a Professor of Bioethics at Howard University. The fact that the leadership of the Task Force saw fit to establish such a group, thereby confirming that bioethics is a player in the arena of health care policy, was in itself significant and was made no less so by the lack of clarity regarding the group's aims and goals.The working groups of the Task Force were organized into clusters, determined by the relatedness of the somewhat distinct, but always overlapping, content of their investigations. Separate clusters and working groups, for example, looked at mental health, long term care, and the benefit package and coverage for low-income and non-working families. On this last issue there was also a working group that explored health policy initiatives for underserved populations. This multiple focus on related issues proved to be an excellent method for ensuring that the complexity of these topics was sufficiently explored. There was a published schedule for when these groups met together, and members of other groups who had similar or overlapping concerns were invited to attend and to participate.Every week or so, all of the working groups reported to the Task Force leadership, under the direction of Ira Magaziner, in a process called a "tollgate." Prior to the tollgate, the working groups were required to submit formal written analyses of the problems they had most recently been considering. Copies of these documents were placed in a special room so that those who were interested could review... (shrink)

Context is a pivotal concept for social scientists in their attempt to weave singularities or universals to moral codes and political orders. However, in this, social scientists might be neglecting the ways in which individuals or groups who are excluded from the collective production of knowledge want to politicize their concerns also by claiming their uniqueness and singularity. In this article, drawing on the public controversy about access to dementia drugs on the U.K. National Health Service and on (...) the work of pioneering sociologist Helen McGill Hughes on “human interest stories,” the author argues that the “politics of singularities” can be articulated in two related ways within technical controversies. First, it expresses the unraveling of sociotechnical ties caused by institutional failure to take concerns into account. Second, it expresses the concrete uniqueness of persons caught by standardized, “universal” and impersonal implements and/or policies. Both these effects are underpinned by resourcing to allegorical expression, a literary form that while fostering political imagination in technological democracies might weaken Science and Technology Studies' ambitions to influence decision making. (shrink)

This essay argues that Hume's theory of justice can be useful in framing a more persuasive case for universal access in health care. Theories of justice derived from a Rawlsian social contract tradition tend to make the conditions for deliberation on justice remote from the lives of most persons, while religiously-inspired views require superhuman levels of benevolence. By contrast, Hume's theory derives justice from the prudent reflections of socially-encumbered selves. This provides a more accessible moral theory (...) and a more realistic path to the establishment of universal access. (shrink)

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article (...) evaluates the impact of the ACA on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities. (shrink)