- Email: [email protected]
Solidarity, justice and health care priorities
550
Book Reviews
This kind of professional failure is framed by assumptions of commodified help; an asymmetric transaction which leaves you different but myself unchanged. The notion of valued social role invites us to envisage "services" within a context of mutuality, where disabled people are participants rather than objects and are valued for their contribution to other people's lives. Professionals who are unable to recognise the possibility of themselves being changed are unable to value the contribution of disabled people to their lives. Ferguson's personal awareness of this possibility (reflected in the way he speaks of Peter in the Introduction) is not accommodated by the theoretical model which he adopts. Service models developed around the possibility of reciprocity would have implications for wider hierarchies of
competence and privilege in society generally. A paradigm change in services to people who are retarded might provide a beacon for rethinking human relationships at a wider level. This would be a nice reversal.
Solidarity, Justice and Health Care Priorities, edited by Zbigniew Szawarski and Donald Evans. Health Service Studies 8, Link6ping University, Link6ping, Sweden, 1993. 128 pp., U.S.$25.00.
On the basis of the Oregon example, where in 1987 the state stopped public insurance funding for soft-tissue transplants, Norman Daniels discusses in "Justice and limits to care" the reasons for rationing health care services and the current experiences as limits are applied. Disease and disability are seen to restrict the individual's range of opportunities, while health care protects the "normal opportunity range" of each individual. Daniels leaves the reader with quite a few questions which he believes have to be answered before experimenting with approaches to limiting care. How will rationing affect the structure of inequality? Should a special group of people be excluded from special services, or should certain services be reduced across the board? Who will decide on how diseases are ranked; or on the relative importance of medical treatments, and how far should the public participate in all this debate? Responding to Daniels, Donald Evans carefully investigates the deeper aspects of "Limits to care", identifying three areas of concern: practical, conceptual, and moral. How can the term "normal opportunity range" be defined? Such definitions vary not only from individual to individual, but also according to social, ethical, cultural and geographical relativities as well as variables of sex and gender, age and religion. And how can a "normal opportunity range" be defined for the chronic sick, the terminally ill, and the seriously mentally and physically disabled? Evans pleads for modesty in people who devise and employ general models of resource allocation in health care. Henk ten Have considers "Physician's priorities-patients expectations" and convincingly argues that a new phase in an allocation of resources should be characterized by: a new terminology; by a recognition that lack of public awareness is a basic problem; and by an emphasis on the priority setting process rather than on a priority list as a given. Talking of "limits" in health care, as ten Have sees them, bespeaks an external approach both morally inadequate and at any case bound to be unsuccessful. More appropriate is the term "making choices", thus representing the problem with a more positive attitude. Scarcity is not the real problem, but rather that we have not yet learnt to restrict our claims to health care. The idea of a scarcity of health care is bound up in an unfortunate cultural process in which both doctors and patients have taken predominantly consumerist attitudes, and have overvalued the benefits of medical science and technology for human happiness and wellbeing. A new mentality towards health and health care is required. Only with a modified mentality can choices in health care policy priority setting be compatible with equal access and solidarity. Soren Holm explains how the notions of solidarity and justice grew in a specific social structure and history in the
After the Second World War several European states established exemplary welfare systems which included comprehensive health care services designed to be open to everybody in need of them. Rapidly developing natural science and modern technologies created modern "scientific" medicine offering unprecedented possibilities for medical treatment that were potentially beneficial to all members of society. Health care became a social good among others, and came to be perceived as a "right" to health. At present, European welfare states are having to face destabilized economies resulting in a strain upon health services and other social structures. Providing medical treatment to all who have claimed to need it has proved to be beyond the financial resources of many states, and it is the success of biomedicine that has resulted in this. When health services were established, planners expected that improving public health provisions would result in lower costs. On the contrary, complaints of ill health increased. In spite of increasing "commodification" of health care services, questions about alterations are taking place and of course touch upon a sensitive issue. Necessary changes and modifications are bound to come into conflict with the ethical views and moral obligations that gave birth to the welfare state. Solidarity, Justice and Health Care Priorities is for the most part a conference reader which presents modified speeches which were delivered at a meeting sponsored by WHO in Aosta, Italy in 1991. Several new articles are also included. The twelve authors presented discuss the recent developments in health care policies from varying perspectives, dealing with moral and ethical issues as well as economic and juridicial aspects inherent in what is seen as the rationing of health services. The writers review the principles of individual responsibility and social obligation. In "Justice and/or the right to a decent minimum of health care. A moral dilemma in health care policy" Johannes Vang explains the moral and philosophical principles which have guided the health care establishment in European welfare states after the Second World War. It is proffered that two basic principles have dominated health policy (a) the subsidiarity principle placing responsibility at the feet of the individual and the family, and (b) the collective or socialized principle developed in the U.K. and the Scandinavian countries. It is observed, that most states have been oscillating between the two extremes with an increasing tendency to the libertarian view that stresses individual autonomy.
Wholistic Health Faculty of Health Sciences Newcastle University Newcastle, N S W 2308 Australia
Thorn Boleyn
Faculty of Health Sciences La Trobe University Bundoora, Victoria 3083 Australia
Da~dLegge
Book Reviews Nordic and North European countries and shows that their health care systems reflect this context. Solidarity as a group concept is defined in various ways in different cultures, nations or social groups. In "Solidarity, justice, and hc:alth care priorities" Holm elaborates that this special cultural, social, political, and historical context also influence health care allocation and the selecting of priorities in health care. "'Guidelines for priority-setting in the Norwegian health care system" by Ole Frithjof Norheim presents the i988 Norwegian legislative guidelines for ranking medical services, and seeks to explain why they were difficult to implement. The three underlying fundamental principles in the guidelines are: equality of access, severity of the disease, and futility. This system is plagued with imprecise definitions for each level of priority making it difficult to identify patients with legitimate claims on their society. A reformulation is required in which minimum standards are stipulated and compared. David Greaves analyses "The ethics of the internal market" which was created in 1991 between constituent parts of the National Health Service (NHS) in Great Britain. The internal market was expected to improve NHS's overall economic efficiency. This modification of the NHS has been debated by the political parties. While some see the inter'hal market just as a reorganization aimed at improving the economic and management arrangements, others see it as a threat to fundamental NHS principles requiring the support rather than competition from the free market. The author sheds light on the background of these disputes, and upon the ethical problems arising from the new orientation to economic efficiency. Discussion of medical ethics looks at the issue of need in Lennart Nordenfelt's article "On the ethical motivation for the medical enterprise: some basic considerations". Norde felt talks about ethical considerations inherent in the concepts of "health" and "health care need". Who ,Jan expect to get priority over others, and what degree ol" ill health determines the right to care? The concept of need is then a completely open question and demands further specification. The author points out, that ironically the idea of mercy, which is strongly anchored in European Christian cultures, has received little attention in the discussion on medical ethics. It is concluded that the highest prio;ity should be given to the most severely ill and disabled. How did the idea of "Personal responsibility for health" emerge, and what do we mean by it? Zbigniew Szawalski concludes that responsibility in health care is not formal because it cannot be seen as a causal. Blaming the individual for his genetic endowment, his natural and social environment, or simply for his bad luck is hardly valid. Even attributing responsibility for a person's lifestyle, which has become quite common in recent years, is only possible to a certain degree. Our idea of personal responsibility in the field of health is determined by underlying philosophical models such as our model of man, his place in nature, and his part in causal relations. Personal responsibility for health can only be seen as a virtue, which we are morally responsible to embody and preserve. "To what extent are individuals responsible for their o~vn health?" is also Povl Riis' question. He argues against 1he
551
application of an oversimplifying dichotomy between the right to autonomy and paternalism. He sees individual freedom as largely determined by genetic and fixed social conditions. Man is somewhere in between determinism and indeterminism. According to the author, the large amount of new data on human genetic information strengthens the determinist view and suggests that we should identify genetically vulnerable groups in order to apply target-oriented prevention in certain risk groups. In any case, people working in the health sector need to accept that both deterministic and indeterministic factors influence citizens' health. Sheila McLean describes the difficulties of agreeing on useful moral principles encountered in achieving the WHO goal Health for All as well as problems that emerge in using legislation as a mechanism for attaining this goal. McLean discusses "'Law versus morality", pointing out that both are perceived differently according to the respective culture. Health for All is a very comprehensive concept and the notions of health and health care provision seem to be poorly demarcated. Providing health care is only one way of maintaining or enhancing health standards, and the law must then take a moral position on access to it. The law reflects morality as it represents what a specific community believes to be good and moral, and so it reflects only one of the possible views of morality as evidenced in differences internationally. Equity can also be defined in a number of ways. If we accept the limitations of law, the greatest challenge lies in defining a morality which can become a basis for national and global health care politics. If we succeed in finding this foundation, the law can be a valuable weapon in achieving health care provision. In "International justice and health care" Onora O'Neill comments on health care in the broader context of internationally accepted and applied Human Rights and in a new, more just international economic order. She reviews the best known theoretical approaches to international justice, and argues neither for a moral cosmopolitanism, nor for a radically particularist position, paying special attention to the ethical significance of state boundaries, which often represent sharp economic demarcations. Immigration opportunities have to create conduits, through which skills and money can make their way from poorer to richer states. At first sight, Solidarity, Justice and Health Care Priorities seems to deal with very "'European" problems and ways of thinking. But as the contribution by Onora O'Neill especially shows, the subject is by no means a national or regional one. This book offers access to an ongoing and crucial debate in Europe over recent years; one that will continue in the coming decade. The articles by Henk ten Have and Zbigniew Szawarski are worthy of particular attention because they point to our need to concentrate much more on the philosophical and moral implications of our concepts of health, health care and the mechanical health paradigm.
lnstitut .[fir Ethnologie University of Hamburg D-20148 Hamburg Germany
Christine Tuschinsky
Book Reviews
This kind of professional failure is framed by assumptions of commodified help; an asymmetric transaction which leaves you different but myself unchanged. The notion of valued social role invites us to envisage "services" within a context of mutuality, where disabled people are participants rather than objects and are valued for their contribution to other people's lives. Professionals who are unable to recognise the possibility of themselves being changed are unable to value the contribution of disabled people to their lives. Ferguson's personal awareness of this possibility (reflected in the way he speaks of Peter in the Introduction) is not accommodated by the theoretical model which he adopts. Service models developed around the possibility of reciprocity would have implications for wider hierarchies of
competence and privilege in society generally. A paradigm change in services to people who are retarded might provide a beacon for rethinking human relationships at a wider level. This would be a nice reversal.
Solidarity, Justice and Health Care Priorities, edited by Zbigniew Szawarski and Donald Evans. Health Service Studies 8, Link6ping University, Link6ping, Sweden, 1993. 128 pp., U.S.$25.00.
On the basis of the Oregon example, where in 1987 the state stopped public insurance funding for soft-tissue transplants, Norman Daniels discusses in "Justice and limits to care" the reasons for rationing health care services and the current experiences as limits are applied. Disease and disability are seen to restrict the individual's range of opportunities, while health care protects the "normal opportunity range" of each individual. Daniels leaves the reader with quite a few questions which he believes have to be answered before experimenting with approaches to limiting care. How will rationing affect the structure of inequality? Should a special group of people be excluded from special services, or should certain services be reduced across the board? Who will decide on how diseases are ranked; or on the relative importance of medical treatments, and how far should the public participate in all this debate? Responding to Daniels, Donald Evans carefully investigates the deeper aspects of "Limits to care", identifying three areas of concern: practical, conceptual, and moral. How can the term "normal opportunity range" be defined? Such definitions vary not only from individual to individual, but also according to social, ethical, cultural and geographical relativities as well as variables of sex and gender, age and religion. And how can a "normal opportunity range" be defined for the chronic sick, the terminally ill, and the seriously mentally and physically disabled? Evans pleads for modesty in people who devise and employ general models of resource allocation in health care. Henk ten Have considers "Physician's priorities-patients expectations" and convincingly argues that a new phase in an allocation of resources should be characterized by: a new terminology; by a recognition that lack of public awareness is a basic problem; and by an emphasis on the priority setting process rather than on a priority list as a given. Talking of "limits" in health care, as ten Have sees them, bespeaks an external approach both morally inadequate and at any case bound to be unsuccessful. More appropriate is the term "making choices", thus representing the problem with a more positive attitude. Scarcity is not the real problem, but rather that we have not yet learnt to restrict our claims to health care. The idea of a scarcity of health care is bound up in an unfortunate cultural process in which both doctors and patients have taken predominantly consumerist attitudes, and have overvalued the benefits of medical science and technology for human happiness and wellbeing. A new mentality towards health and health care is required. Only with a modified mentality can choices in health care policy priority setting be compatible with equal access and solidarity. Soren Holm explains how the notions of solidarity and justice grew in a specific social structure and history in the
After the Second World War several European states established exemplary welfare systems which included comprehensive health care services designed to be open to everybody in need of them. Rapidly developing natural science and modern technologies created modern "scientific" medicine offering unprecedented possibilities for medical treatment that were potentially beneficial to all members of society. Health care became a social good among others, and came to be perceived as a "right" to health. At present, European welfare states are having to face destabilized economies resulting in a strain upon health services and other social structures. Providing medical treatment to all who have claimed to need it has proved to be beyond the financial resources of many states, and it is the success of biomedicine that has resulted in this. When health services were established, planners expected that improving public health provisions would result in lower costs. On the contrary, complaints of ill health increased. In spite of increasing "commodification" of health care services, questions about alterations are taking place and of course touch upon a sensitive issue. Necessary changes and modifications are bound to come into conflict with the ethical views and moral obligations that gave birth to the welfare state. Solidarity, Justice and Health Care Priorities is for the most part a conference reader which presents modified speeches which were delivered at a meeting sponsored by WHO in Aosta, Italy in 1991. Several new articles are also included. The twelve authors presented discuss the recent developments in health care policies from varying perspectives, dealing with moral and ethical issues as well as economic and juridicial aspects inherent in what is seen as the rationing of health services. The writers review the principles of individual responsibility and social obligation. In "Justice and/or the right to a decent minimum of health care. A moral dilemma in health care policy" Johannes Vang explains the moral and philosophical principles which have guided the health care establishment in European welfare states after the Second World War. It is proffered that two basic principles have dominated health policy (a) the subsidiarity principle placing responsibility at the feet of the individual and the family, and (b) the collective or socialized principle developed in the U.K. and the Scandinavian countries. It is observed, that most states have been oscillating between the two extremes with an increasing tendency to the libertarian view that stresses individual autonomy.
Wholistic Health Faculty of Health Sciences Newcastle University Newcastle, N S W 2308 Australia
Thorn Boleyn
Faculty of Health Sciences La Trobe University Bundoora, Victoria 3083 Australia
Da~dLegge
Book Reviews Nordic and North European countries and shows that their health care systems reflect this context. Solidarity as a group concept is defined in various ways in different cultures, nations or social groups. In "Solidarity, justice, and hc:alth care priorities" Holm elaborates that this special cultural, social, political, and historical context also influence health care allocation and the selecting of priorities in health care. "'Guidelines for priority-setting in the Norwegian health care system" by Ole Frithjof Norheim presents the i988 Norwegian legislative guidelines for ranking medical services, and seeks to explain why they were difficult to implement. The three underlying fundamental principles in the guidelines are: equality of access, severity of the disease, and futility. This system is plagued with imprecise definitions for each level of priority making it difficult to identify patients with legitimate claims on their society. A reformulation is required in which minimum standards are stipulated and compared. David Greaves analyses "The ethics of the internal market" which was created in 1991 between constituent parts of the National Health Service (NHS) in Great Britain. The internal market was expected to improve NHS's overall economic efficiency. This modification of the NHS has been debated by the political parties. While some see the inter'hal market just as a reorganization aimed at improving the economic and management arrangements, others see it as a threat to fundamental NHS principles requiring the support rather than competition from the free market. The author sheds light on the background of these disputes, and upon the ethical problems arising from the new orientation to economic efficiency. Discussion of medical ethics looks at the issue of need in Lennart Nordenfelt's article "On the ethical motivation for the medical enterprise: some basic considerations". Norde felt talks about ethical considerations inherent in the concepts of "health" and "health care need". Who ,Jan expect to get priority over others, and what degree ol" ill health determines the right to care? The concept of need is then a completely open question and demands further specification. The author points out, that ironically the idea of mercy, which is strongly anchored in European Christian cultures, has received little attention in the discussion on medical ethics. It is concluded that the highest prio;ity should be given to the most severely ill and disabled. How did the idea of "Personal responsibility for health" emerge, and what do we mean by it? Zbigniew Szawalski concludes that responsibility in health care is not formal because it cannot be seen as a causal. Blaming the individual for his genetic endowment, his natural and social environment, or simply for his bad luck is hardly valid. Even attributing responsibility for a person's lifestyle, which has become quite common in recent years, is only possible to a certain degree. Our idea of personal responsibility in the field of health is determined by underlying philosophical models such as our model of man, his place in nature, and his part in causal relations. Personal responsibility for health can only be seen as a virtue, which we are morally responsible to embody and preserve. "To what extent are individuals responsible for their o~vn health?" is also Povl Riis' question. He argues against 1he
551
application of an oversimplifying dichotomy between the right to autonomy and paternalism. He sees individual freedom as largely determined by genetic and fixed social conditions. Man is somewhere in between determinism and indeterminism. According to the author, the large amount of new data on human genetic information strengthens the determinist view and suggests that we should identify genetically vulnerable groups in order to apply target-oriented prevention in certain risk groups. In any case, people working in the health sector need to accept that both deterministic and indeterministic factors influence citizens' health. Sheila McLean describes the difficulties of agreeing on useful moral principles encountered in achieving the WHO goal Health for All as well as problems that emerge in using legislation as a mechanism for attaining this goal. McLean discusses "'Law versus morality", pointing out that both are perceived differently according to the respective culture. Health for All is a very comprehensive concept and the notions of health and health care provision seem to be poorly demarcated. Providing health care is only one way of maintaining or enhancing health standards, and the law must then take a moral position on access to it. The law reflects morality as it represents what a specific community believes to be good and moral, and so it reflects only one of the possible views of morality as evidenced in differences internationally. Equity can also be defined in a number of ways. If we accept the limitations of law, the greatest challenge lies in defining a morality which can become a basis for national and global health care politics. If we succeed in finding this foundation, the law can be a valuable weapon in achieving health care provision. In "International justice and health care" Onora O'Neill comments on health care in the broader context of internationally accepted and applied Human Rights and in a new, more just international economic order. She reviews the best known theoretical approaches to international justice, and argues neither for a moral cosmopolitanism, nor for a radically particularist position, paying special attention to the ethical significance of state boundaries, which often represent sharp economic demarcations. Immigration opportunities have to create conduits, through which skills and money can make their way from poorer to richer states. At first sight, Solidarity, Justice and Health Care Priorities seems to deal with very "'European" problems and ways of thinking. But as the contribution by Onora O'Neill especially shows, the subject is by no means a national or regional one. This book offers access to an ongoing and crucial debate in Europe over recent years; one that will continue in the coming decade. The articles by Henk ten Have and Zbigniew Szawarski are worthy of particular attention because they point to our need to concentrate much more on the philosophical and moral implications of our concepts of health, health care and the mechanical health paradigm.
lnstitut .[fir Ethnologie University of Hamburg D-20148 Hamburg Germany
Christine Tuschinsky