We pose the question: Is consumer sovereignty in the healthcare market fact or fiction? Consumer sovereignty in healthcare implies that society benefits at large when healthcare organizations compete to develop high quality healthcare products while reducing the cost of doing business (reflected in low prices), and when consumers choose wisely among healthcare products by purchasing those high quality products at low prices. We develop a theoretical model that encourages systematic empirical research to investigate whether consumer sovereignty in healthcare is fact (...) or fiction. In doing so, we develop a series of theoretical propositions that may demonstrate that consumer sovereignty is more fiction than fact. Specifically, healthcare consumers lack the ability, motivation, and opportunity to choose healthcare products that are high in quality and low in price. Similarly, healthcare firms lack the ability, motivation, and opportunity to compete in ways to develop and market higher quality products at lower prices. (shrink)

Many leading health economists hold misconceived ideas about central components of their work. In particular, they assume that their methods are in principle valueneutral. This belief is demonstrably false. Health economic investigations incorporate mainly unexpressed theories of health. Unless this fact is recognised health economics will shortly reach a conceptual and practical dead end. The way to avoid this dead end is to express implicit theories of health, and explicitly to base philosophically and economically justifiable policy proposals on them.

Competent patients who refuse life saving medical treatment present a dilemma for healthcare professionals. On one hand, respect for autonomy and liberty demand that physicians respect a patient’s decision to refuse treatment. However, it is often apparent that such patients are not fully competent. They may not adequately comprehend the benefits of medical care, be overly anxious about pain, or discount the value of their future state of health. Although most bioethicists are convinced that partial autonomy or marginal competence of (...) this kind demands the same respect as full autonomy, Israeli legislators created a mechanism to allow ethics committees to override patients’ informed refusal and treat them against their will. To do so, three conditions must be satisfied: physicians must make every effort to ensure the patient understands the risks of non-treatment, the treatment physicians propose must offer a realistic chance of significant improvement, and there are reasonable expectations that the patient will consent retroactively. Although not all of these conditions are equally cogent, they offer a way forward to assure care for certain classes of competent patients without abandoning the principle of autonomy altogether. These concerns reach past Israel and should engage healthcare professionals wary that respect for autonomy may sometimes cause avoidable harm. (shrink)

We live in an age of great scientific and technological innovation, and what seemed out of the question or at least very doubtful only a few years ago, today lies almost within our grasp. In no area is this more true than that of human health care, where lifesaving and life-enhancing technologies have given, or have the enormous potential in the not so distant future to give, relief from some of the most terrible human illnesses. On two fronts in particular, (...) xenograft or cross-species transplantation and genetic engineering of animals on behalf of gene therapy in humans, such relief appears very promising, if not actually on the horizon. Certainly, extensive research work on both fronts is underway both in the United States and abroad. (shrink)

It is widely accepted that one of the main objectives of government expenditure on health care is to generate health. Since health is a function of both length of life and quality of life, the quality-adjusted life-year (QALY) has been developed in an attempt to combine the value of these attributes into a single index number. The QALY approach - and particularly the decision rule that healthcare resources should be allocated so as to maximise the number of QALYs generated - (...) has often been equated with the utilitarian philosophy of maximising `the greatest happiness of the greatest number'. This paper considers the extent to which the measurement and aggregation of QALYs really is utilitarian by developing a new taxonomy in order to classify utilitarianism and the different aspects of the QALY approach. It is shown that the measurement of QALYs is consistent with a number of different moral positions and that QALYs do not have to be aggregated according to the maximisation rule. Therefore it is inappropriate to necessarily equate QALYs with utilitarianism. It is shown that much turns on what in principle the QALY represents and how in practice it can be operationalised. The paper highlights the category confusion that is often present here and suggests possible avenues for future theoretical and empirical research. (shrink)

The first question I discuss in this paper is whether we have a duty of rescue to make our organs available for transplantation after our death, a duty we owe to patients suffering from organ failure. The second question is whether political obligations, in particular the obligation to obey the law, can be derived from natural duties, possibly duties of beneficence. Such duties are normally seen as merely imperfect duties, not owed to anyone. The duty of rescue, however, is a (...) perfect one, mainly because it applies to us when we are in a unique position to provide urgent help to a person in need. The basic idea of a natural duty account of political obligation is that such unique positions can be artificially created by institutionalized coordination schemes. The remaining problem is how any particular coordination scheme could claim our allegiance rather than any other. This problem can be solved in different ways in the organ donation case, and in respect to a limited set of political obligations, mainly negative ones. A natural duty account is best seen as a constitutive part of a multiple principle theory of political obligation. (shrink)

It has been proposed that an old and ill person may have a ‘duty to die’, i.e. to refuse life-saving treatment or to end her own life, when she is dependent on the care of intimates and the burdens of care are becoming too heavy for them. In this paper I argue for three contentions: You cannot have a strict duty to die, correlating to a claim-right of your relatives, because if they reach the point at which the burdens of (...) care are larger than you can reasonably expect them to take, the natural conclusion is that their duty ends. They may be prepared, however, to go on caring for you beyond that point. In that case your responsibility for their wellbeing may require you to refuse this care, even if this results in a situation for you in which death will be preferable to continued life. If this is the correct understanding of your responsibilities, the objection that in the context of family life the burdens of care attached to one family member’s valued existence can never be ‘too heavy’, fails. It postulates unlimited concern on one side and a total lack of concern on the other. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)