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North American health care policy in the 1990s
198
Book Reviews / Healh Policy 27 (1994) 193-200
North American Health Care Policy in the 1990s By A. King, T. Hyclak; Ft. Thornton, S. McMahon (Eds.) John Wiley 81 Sons, Chichester 284 pp., 1993, ISBN, 0-471-94003-B.
To a European, one of the most striking features of this book is its title. One never really thinks of North America as having any coherent health care policy, except to the north of the US-Canadian border. My prejudice was not really dampened by the contents of this book. I think this is, in many ways, due to the odd start to the book. There is no real overarching introduction which sets out the issues in much detail and which ties these issues together. The contents of the first chapter, on the morality of efficiency in health care, are familiar, particularly to most Europeans. The chapter does not really outline the issues to be addressed in the remainder of the book, and, in that regard, seemed a bit out of place, despite being well written. Furthermore, many of the forthcoming chapters open with a comparison of US and Canadian systems to provide context. An early chapter containing much of this would have saved repetition. I suspect this problem resulted from the fact that many of the chapters were initially self-standing papers in an issue of the journal Health Economics. Chapter 2 contains a good history of the development of the Canadian health care system and some interesting, and recent, comparisons with that in the US. Comparison of rationing in each country is interesting but lacked reference to some crucial Canadian papers indicating that access to care in that country is based more on need than ability to pay since the inception of universal health care insurance. The scoring of US versus Canadian health care systems at the end of the chapter comes out even if one adds up the scores allocated to each category. This seemed to me to be rather convenient and certainly not what I would have come up with (back to my prejudices again?). I will skip over Chapter 3 on fairness and feasibility in national health care systems, mainly because I found it very confusing. No structure or aim was provided early on which made this worse. Some of the range of aspects of market failure in health care which most other authors seem to accept is challenged in this chapter. The aim seems to be to justify diversity whilst aiming for equity. As with most ‘solutions’ to the US health care dilemma which take this line, the cost of administering the system seems to have been ignored. The fourth chapter goes to the other extreme, examining lessons for the US of experience with long-term care in Canada. Once again, however, many of the arguments are familiar to Europeans; that universal coverage can include long-term care and the case for monopsony power in purchasing services. The chapter on quality assurance was weak in that nothing new was added; we know quality is about establishing best practice, as we do the literature on variations and inappropriateness of practice, guidelines and dissemination. Chapter 6, on management of human resources, is a classic example of many of the articles in this book. The authors took a long time to get round to stating their point. In fact, in this chapter it was difficult to see what the point was. Once again, we start with US-Canada comparisons which are not really used or referred to later on. The chapter is interesting but not much use to anyone outside of Canada. A similar conclusion can be drawn about Chapter 7, on cost savings-quality trade offs in provision of communitybased long-term care. Analyses of mixed economies in such fields of care are old hat and this study did nothing to get over the old flaw of cross-sectional studies in this area (i.e. problems of causality) which makes policy recommendations difficult. The penultimate chapter, on forces for reforming the US health care system, provides useful up-to-date figures on trends in health care costs and access to care. This is a good chapter, but, given its content, should have come earlier as a scene setter. This chapter did tit well with the final chapter, a critical appraisal of proposals to reform the US health care system. The final chapter, however, also contains some material which is a bit out of place. Discussion of paradigms and values and goals of systems should, again, come early in the book. Also, this stuff is not new to Europeans or Canadians who, several years ago, dealt more than adequately with these issues in the literature. The review of proposals for reform is very useful. The authors, however, do not seem to be able to accept the opportunity cost of reform, i.e. that access to care for certain groups will be restricted. The proposals seem to be of two sorts. The
Book Reviews / Healh Policy 27 (1994)
193-200
199
first, to contain costs, gets critic&d for ‘rationing’, as though rationing by price is somehow better. The second, to throw money at the problem, is plainly ridiculous in the US context. The system is paralysed in this Catch-22 with no-one seemingly prepared to grasp the nettle for fear of upsetting some people. In all the surveys that have been done, no-one seems to have put the real choice to the people of the US; what do they think of rationing versus spending more money? Overall, I was not keen on this set of articles when they first appeared in Health Economics. They lacked a beginning, an end, a structure and a common theme then and their production as a book did nothing to correct this. Furthermore, US-Canadian comparisons are becoming boring to Europeans, although it was encouraging to note that even Canadians have problems with waiting lists, measuring quality, reducing acute-care beds and getting community care going. Overall, this book contains pockets of good work but the rest was patchy - a bit like the US health care system! Professor C. Donaldson Deputy Director Health Economics Research Unit University of Aberdeen, UK
Brain Dead, Brain Absent, Brain Donors. Human Subjects or Human Objects By P. McCullauch (Ed.) John Wiley & Sons, Chichester 261 pp., 1993 ISBN O-471-93736-3,
34.96.
Reification, i.e. the change from subject to object status in an individual is the leitmotiv of McCullagh’s detailed injury on brain death, anencephalic infants, and the use of foetal brain tissue. These topics share in common what the author calls the timing of a subject-to-object transistion: individuals who are diagnosed dead but remain in such a state that their organs are suitable for transplantation. His purpose is to inform current debate regarding the use of human organ sources. ‘The informed nature of any consent [of the community or affected individual/family] to such usage is essential if it is to be regarded as a valid authorisation.’ (p. 3) The first few chapters deal with the generation and evolution of the concept of brain death. A modern approach to define death other than cardiac arrest was first introduced by the Harvard Ad-hoc-committee in 1968. ‘The notation of brain death was not, in the first instance, a contrivance to faciliate the identilication of subjects who would be suitable donors of transplantable organs.’ (p. 8) Of course, latter attitudes towards brain death and the management of affected individuals have been influenced inevitably by the development and rising success of organ transplantation. McCullagh notices considerable differences in the definition of and requirements for brain death between the UK and the USA. The author asks why the brain has been chosen as the organ whose cessation is indicative of death and gives some possible reasons. The most important aspect is, I believe, the occidental attitude towards the brain as the basis of distinct human behavior and consciousness. The difference between diagnosis and prognosis is strongly stated; clinical observations such as the EEG and the brain stem reflexes are reviewed with respect to their conflicts with the brain death concept. McCullagh recognizes that neuropathologic standards are still ill-defined and, considerable difficulties exist in differentiating brain-death abnormalities from postmortem changes. The subsequent chapters focus on ‘brain absence’ -- diagnosis, anatomical, and neurophysiological features of the anencephalic infants and their possible use in transplantation. It is of importance to recognize that the popular term ‘born without brain’ has proven to be incorrect. Immediately after birth both the anencephalic and the non-anencephalic do not mainly differ in terms of neurological examination. It is the lack of capacity for development that gives reason for using anencephalic infants as an organ source. If one considers other forms of highly disabled children in whom the physiological condition is quite similar to that of anencephalics, the question arises of where to place the line. Another section of the book deals with a very intensively discussed issue: the transplantation of foetal
Book Reviews / Healh Policy 27 (1994) 193-200
North American Health Care Policy in the 1990s By A. King, T. Hyclak; Ft. Thornton, S. McMahon (Eds.) John Wiley 81 Sons, Chichester 284 pp., 1993, ISBN, 0-471-94003-B.
To a European, one of the most striking features of this book is its title. One never really thinks of North America as having any coherent health care policy, except to the north of the US-Canadian border. My prejudice was not really dampened by the contents of this book. I think this is, in many ways, due to the odd start to the book. There is no real overarching introduction which sets out the issues in much detail and which ties these issues together. The contents of the first chapter, on the morality of efficiency in health care, are familiar, particularly to most Europeans. The chapter does not really outline the issues to be addressed in the remainder of the book, and, in that regard, seemed a bit out of place, despite being well written. Furthermore, many of the forthcoming chapters open with a comparison of US and Canadian systems to provide context. An early chapter containing much of this would have saved repetition. I suspect this problem resulted from the fact that many of the chapters were initially self-standing papers in an issue of the journal Health Economics. Chapter 2 contains a good history of the development of the Canadian health care system and some interesting, and recent, comparisons with that in the US. Comparison of rationing in each country is interesting but lacked reference to some crucial Canadian papers indicating that access to care in that country is based more on need than ability to pay since the inception of universal health care insurance. The scoring of US versus Canadian health care systems at the end of the chapter comes out even if one adds up the scores allocated to each category. This seemed to me to be rather convenient and certainly not what I would have come up with (back to my prejudices again?). I will skip over Chapter 3 on fairness and feasibility in national health care systems, mainly because I found it very confusing. No structure or aim was provided early on which made this worse. Some of the range of aspects of market failure in health care which most other authors seem to accept is challenged in this chapter. The aim seems to be to justify diversity whilst aiming for equity. As with most ‘solutions’ to the US health care dilemma which take this line, the cost of administering the system seems to have been ignored. The fourth chapter goes to the other extreme, examining lessons for the US of experience with long-term care in Canada. Once again, however, many of the arguments are familiar to Europeans; that universal coverage can include long-term care and the case for monopsony power in purchasing services. The chapter on quality assurance was weak in that nothing new was added; we know quality is about establishing best practice, as we do the literature on variations and inappropriateness of practice, guidelines and dissemination. Chapter 6, on management of human resources, is a classic example of many of the articles in this book. The authors took a long time to get round to stating their point. In fact, in this chapter it was difficult to see what the point was. Once again, we start with US-Canada comparisons which are not really used or referred to later on. The chapter is interesting but not much use to anyone outside of Canada. A similar conclusion can be drawn about Chapter 7, on cost savings-quality trade offs in provision of communitybased long-term care. Analyses of mixed economies in such fields of care are old hat and this study did nothing to get over the old flaw of cross-sectional studies in this area (i.e. problems of causality) which makes policy recommendations difficult. The penultimate chapter, on forces for reforming the US health care system, provides useful up-to-date figures on trends in health care costs and access to care. This is a good chapter, but, given its content, should have come earlier as a scene setter. This chapter did tit well with the final chapter, a critical appraisal of proposals to reform the US health care system. The final chapter, however, also contains some material which is a bit out of place. Discussion of paradigms and values and goals of systems should, again, come early in the book. Also, this stuff is not new to Europeans or Canadians who, several years ago, dealt more than adequately with these issues in the literature. The review of proposals for reform is very useful. The authors, however, do not seem to be able to accept the opportunity cost of reform, i.e. that access to care for certain groups will be restricted. The proposals seem to be of two sorts. The
Book Reviews / Healh Policy 27 (1994)
193-200
199
first, to contain costs, gets critic&d for ‘rationing’, as though rationing by price is somehow better. The second, to throw money at the problem, is plainly ridiculous in the US context. The system is paralysed in this Catch-22 with no-one seemingly prepared to grasp the nettle for fear of upsetting some people. In all the surveys that have been done, no-one seems to have put the real choice to the people of the US; what do they think of rationing versus spending more money? Overall, I was not keen on this set of articles when they first appeared in Health Economics. They lacked a beginning, an end, a structure and a common theme then and their production as a book did nothing to correct this. Furthermore, US-Canadian comparisons are becoming boring to Europeans, although it was encouraging to note that even Canadians have problems with waiting lists, measuring quality, reducing acute-care beds and getting community care going. Overall, this book contains pockets of good work but the rest was patchy - a bit like the US health care system! Professor C. Donaldson Deputy Director Health Economics Research Unit University of Aberdeen, UK
Brain Dead, Brain Absent, Brain Donors. Human Subjects or Human Objects By P. McCullauch (Ed.) John Wiley & Sons, Chichester 261 pp., 1993 ISBN O-471-93736-3,
34.96.
Reification, i.e. the change from subject to object status in an individual is the leitmotiv of McCullagh’s detailed injury on brain death, anencephalic infants, and the use of foetal brain tissue. These topics share in common what the author calls the timing of a subject-to-object transistion: individuals who are diagnosed dead but remain in such a state that their organs are suitable for transplantation. His purpose is to inform current debate regarding the use of human organ sources. ‘The informed nature of any consent [of the community or affected individual/family] to such usage is essential if it is to be regarded as a valid authorisation.’ (p. 3) The first few chapters deal with the generation and evolution of the concept of brain death. A modern approach to define death other than cardiac arrest was first introduced by the Harvard Ad-hoc-committee in 1968. ‘The notation of brain death was not, in the first instance, a contrivance to faciliate the identilication of subjects who would be suitable donors of transplantable organs.’ (p. 8) Of course, latter attitudes towards brain death and the management of affected individuals have been influenced inevitably by the development and rising success of organ transplantation. McCullagh notices considerable differences in the definition of and requirements for brain death between the UK and the USA. The author asks why the brain has been chosen as the organ whose cessation is indicative of death and gives some possible reasons. The most important aspect is, I believe, the occidental attitude towards the brain as the basis of distinct human behavior and consciousness. The difference between diagnosis and prognosis is strongly stated; clinical observations such as the EEG and the brain stem reflexes are reviewed with respect to their conflicts with the brain death concept. McCullagh recognizes that neuropathologic standards are still ill-defined and, considerable difficulties exist in differentiating brain-death abnormalities from postmortem changes. The subsequent chapters focus on ‘brain absence’ -- diagnosis, anatomical, and neurophysiological features of the anencephalic infants and their possible use in transplantation. It is of importance to recognize that the popular term ‘born without brain’ has proven to be incorrect. Immediately after birth both the anencephalic and the non-anencephalic do not mainly differ in terms of neurological examination. It is the lack of capacity for development that gives reason for using anencephalic infants as an organ source. If one considers other forms of highly disabled children in whom the physiological condition is quite similar to that of anencephalics, the question arises of where to place the line. Another section of the book deals with a very intensively discussed issue: the transplantation of foetal