Meet Ezekiel Emanuel.. The Future of our Health Care!

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Ezekiel J. Emanuel, 1996
 
Where Civic Republicanism and Deliberative Democracy meet  is there a relationship between defects in our medical ethics and the reason the United States has repeatedly failed to enact universal health coverage?  I will begin to suggest an answer to this question by clarifying the locus of allocating decisions.  The allocation of health care resources can occur on three levels.  The social or, in the economist’s language, the macro level entails the proportion of the gross national product (GNP) allocated to health care.  The patient, or micro, level entails determining which individual patients will receive specific medical services; that is, whether Mrs. White should receive this available liver for transplantation.  Finally, there is an intermediate level called the service or medical level that entails determining what health care services will be guaranteed to each citizen.  These socially guaranteed services have been called “basic” or “essential” medical services or what the President’s Commission designated as “adequate health care.” Clearly, these three levels are connected.  A larger proportion of the GNP going to health care permits coverage of more services. Similarly, as demonstrated by the end-stage renal disease program, providing specific services to a wider range of patients causes upward pressure on the proportion of the GNP going to health care and/or reduces the range of services covered as part of basic medical services.  Despite these connections, these three levels are conceptually distinct.  The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially.  Such an approach accepts a two-tiered health system some citizens will receive only basic services while others will receive both basic and some discretionary health services.  Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all available services, creating a multiple-tiered system.  Underlying the repeated failure of attempts to provide universal health care coverage in the United States is the failure to develop a principled mechanism for characterizing basic health services.  Americans fear that if society guarantees certain services as “basic,” the range of services guaranteed will expand to include all or almost all available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective).  So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services uncovered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.  On this view, the reason the United States has failed to enact universal health coverage is not primarily political or economic; the real reason is ethical it is a failure to provide a philosophically defensible and practical mechanism to distinguish basic from discretionary health care services.  What is the reason for this failure of medical ethics?  There are two opposing explanations. One explanation points to the inherent limits of ethics.  Some philosophers, such as Amy Gutmann and Norman Daniels, argue that we lack sufficiently detailed ethical intuitions and principles to establish priorities among the vast array of health care services.  Every time we try to define basic services our intuitions “run out.”  As Gutmann once wrote: I suspect that no philosophical argument can provide us with a cogent principle by which we can draw a line within the enormous group of goods that can improve health or extend life prospects of individuals . . . The remaining question of establishing a precise level of priorities among health care and other goods is appropriately left to democratic decision making. 
 
Taken at face value, this moral skepticism is extremely dangerous; it suggests that there can be no principled mechanism to define basic health care services and, therefore, that the efforts to ensure universal access will always founder on the fear that guaranteeing any health care to all citizens means guaranteeing all available services.  It suggests we should just give up on a just allocation of health care resources because we can never succeed. The second explanation holds that the problem with defining basic health services is not a general lapse of ethics, but a specific lapse of liberal political philosophy that informs our political discourse, including the allocation of health care resources. The problem is that priorities among health care services can be established only by invoking a conception of the good, but this is not possible within the frame work of liberal political philosophy.  Liberalism divides moral issues into three spheres: the political, social, and domestic.  It then holds that within the political sphere, laws and policies cannot be justified by appeals to the good.  To justify laws by appealing to the good would violate the principle of neutrality and be coercive, imposing one conception of the good on citizens who do not necessarily affirm that conception of the good.  But without appealing to a conception of the good, it is argued, we can never establish priorities among health care services and define basic medical services.  This is Dan Callahan’s view with which I agree: . .. there can be no full discussion of equality in health care without an equally full discussion of the substantive goods and goals that medicine and health care should pursue … Unless there can be a discussion of the goals of medicine in the future as rich as that of justice and health has been, the latter problem will simply not admit of any meaningful solution.  Fortunately, many, including many liberals, have come to view as mistaken a liberalism with such a strong principle of neutrality and avoidance of public discussion of the good.  Some think the change a result of the critique provided by communitarianism; others see it as a clarification of basic liberal philosophy.  Regardless, a refined view has emerged that begins to create an overlap between liberalism and communitarianism.  This overlap inspires hope for making progress on the just allocation of health care resources.  This refined view distinguishes issues within the political sphere into four types: issues related to constitutional rights and liberties;  issues related to opportunities, including health care and education; issues related to the distribution of wealth such as tax policies; and other political matters that may not be matters of justice but are matters of the common good, such as environmental policies and defense policies.  While there still may be disagreement about the need for a neutral justification for rights and liberties, there is consensus between communitarians and liberals that policies regarding opportunities, wealth, and matters of the common good can only be justified by appeal to a particular conception of the good.  As Rawls has put it: Public reason does not apply to all political questions but only to those involving what we may call “constitutional essentials.” More expansively, Brian Barry has written: Examples of issues that fall outside [the principle of neutrality include] two distinct kinds of items.  One set of items (tax and property laws) contains matters that are in principle within the realm of “justice as fairness” but are subject to reasonable disagreement about the implications of justice … The other set… contains issues that in the nature of the case cannot be resolved without giving priority to one conception of the good over others . . . There is no room for a complaint of discrimination simply on the ground that the policy by its nature suits those with one conception of the good more than it suits those with some different one.  This is unavoidable.  Thus, it seems there is a growing agreement between liberals, communitarians, and others that many political matters, including matters of justice and specifically, the just allocation of health care resources–can be addressed only by invoking a particular conception of the good.  We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues.  Communitarians endorse civic republicanism and a growing number of liberals endorse some version of deliberative democracy.  Both envision a need for citizens who are independent and responsibile and for public forums that present citizens with opportunities to enter into public deliberations on social policies.  This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources.  Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic.  Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed.  An obvious example is not guaranteeing health services to patients with dementia.  A less obvious example is guaranteeing neuropsycho- logical services to ensure children with learning disabilities can read and learn to reason.  Clearly, more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services. Perhaps using this progress in political philosophy we can begin to address Dan’s challenge, begin to discuss the goods and goals of medicine.
 
 
 
OH MY GOD, WELCOME TO OBAMACARE!  IT’S TIME TO ORDER THE BACK UP GENERATOR FOR GRANDMA! 
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