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)

This article explores the ethics and economics of a market in donated kidneys in the United States. With the impending changes in the health care system, the author argues that a full turn to the market for distribution of kidneys is not appropriate. However, he would sanction a regulated market, as outlined in the article.

The truth about health care policy lies between two exaggerated views: a market view in which individuals purchase their own health care from profit maximizing health-care firms and a control view in which costs are controlled by regulations limiting which treatments health insurance will pay for. This essay suggests a way to avoid on the one hand the suffering, unfairness, and abandonment of solidarity entailed by the market view and, on the other hand, (...) to diminish the inflexibility and inefficiency of the control view. It suggests that the way to mitigate these problems is to recognize the malleability of motivation and the range of factors, in addition to financial incentives, that may influence the behavior of patients and especially physicians. (shrink)

In this paper I argue that the free-market provision of health care is both practical and morally sound, and is superior in both respects to its provision by the State. The State provision of health care will be inefficient compared to its free-market alternative. It will thus provide less health care to persons for the same amount of expenditure, and so save fewer lives and alleviate less suffering for two reasons: state actors have no (...) incentive to husband their resources effectively, and that in a non-market setting, special interest groups can capture resources through lobbying, perverting them away from their efficient allocation. Given these considerations of efficiency a utilitarian should morally prefer the free-market provision of health care to its State-based rival. Furthermore, even if one is not a utilitarian, the free-market provision of health care will be more morally sound than its State-based alternative because it will likely better respect the autonomy of persons, and will better refrain from imposing values upon persons. With these points in hand, I address two prominent objections to a free market system of health care. (shrink)

Unlike the managerially oriented reforms that have brought auditing and accounting into such prominence in the UK National Health Service (NHS), and which seem alien to the culture of the caring professions, consumerist reforms may seem to complement moves towards the acceptance of wide definitions of health, and towards increasing patient autonomy. The empowerment favoured by those who support patient autonomy sounds like the sort of empowerment that is sometimes associated with the patient's charter. For this reason moral (...) criticism of recent NHS reforms may stop short of calling consumerism into question. This, however, would be a mistake: consumerism can be objectionable both within and beyond the health care market. (shrink)

Markets have long had a whiff of sulphur about them. Plato condemned innkeepers, whose pursuit of profit he believed led them to take advantage of their customers, Aristotle believed that the pursuit of profit was indicative of moral debasement, and Cicero held that retailers are typically dishonest as this was the only path to gain. And even those who are more favorably disposed towards markets in general are frequently inclined to be suspicious of markets in medical goods (...) and services. For example, Margaret Thatcher supported the legal prohibition of markets in kidneys despite being arguably the most pro-market Prime Minister the United Kingdom saw in the 20th century. (shrink)

The intensity of the opposition to health reform in the United States continues to shock and perplex proponents of the Patient Protection and Affordable Care Act. The emotion and the apocalyptic rhetoric, render civil and evidence-based debate over the implications and alternatives to specific provisions in the law difficult if not problematic. The public debate has largely barreled down two non-parallel yet non-intersecting paths: opponents focus on their fear of government expansion in the future if PPACA is implemented (...) now, while proponents focus on the urgency and specifics of our health care market problems and the limited number of tools we have to address them. Frustration on both sides has led opponents to deny the seriousness of our health system’s problems and proponents to ignore the risk of governmental overreach. These non-intersecting lines of argument are not moving us closer to a desired and necessary resolution. (shrink)

This paper examines the arguments presented by the Roman Catholic Bishops in their 1993 Pastoral Resolution, Comprehensive Health Care Reform: Protecting Human Life, Promoting Human Dignity, Pursuing the Common Good, concerning health care reform. Focusing on the meaning of equality in health care and traditional Roman Catholic doctrine, it is argued that the Bishops fail to grasp the force of the differences among persons, the value of the market, and traditional scholastic arguments concerning obligatory (...) and extraordinary health care. To attempt to equalize the distribution of health care would be ruinous. A more traditional understanding of Christian thought reveals an acceptance of inequality in health care distribution and a bias against using the secular state to coerce a solution to such concerns for social justice. (shrink)

The unfortunately vast history of paternalism in both medicine and clinical research has resulted in perpetually increasing respect for patient autonomy and free choice in Western health care systems. Beginning with the negative right to informed consent, the principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation. This evolution of patient autonomy has mirrored a more general social attitude of market liberalism where increasing numbers of patients have (...) come to embody the role of the “consumer.” This paper explores this transformation and critiques the current way in which respect for patient autonomy is put into practice. Ultimately, this paper concludes that the consumer view of patient autonomy is dysfunctional. Moreover, this paper argues that, based on the inherent goals of medicine, some form of paternalism is required in any meaningfully therapeutic relationship. (shrink)

When the social relevance of robotic applications is addressed today, the use of assistive technology in care settings is almost always the first example. So-called care robots are presented as a solution to the nursing crisis, despite doubts about their technological readiness and the lack of concrete usage scenarios in everyday nursing practice. We inquire into this interconnection of social robotics and care. We show how both are made available for each other in three arenas: innovation policy, (...) care organization, and robotic engineering. First, we analyze the discursive “logics” of care robotics within European innovation policy, second, we disclose how care robotics is encountering a historically grown conflict within health care organization, and third we show how care scenarios are being used in robotic engineering. From this diagnosis, we derive a threefold critique of robotics in healthcare, which calls attention to the politics, historicity, and social situatedness of care robotics in elderly care. (shrink)

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical (...) question is whether efficiency is the correct criterion, in terms of social justice and individual needs. (shrink)

There is a move away from a market economy in health care in the United States and a move towards such a market in Germany.1 This article tries to make explicit what underlies the moral intuition that there is a tension between a market economy and health care. First, health care is analyzed in terms of the economic theory of the market and incompatibilities are described. The moral problem is identified as the danger of (...) liquefying the distinction between persons and things . The basic moral intuition seems to be the classical social contract: as a functioning market is governed by the principle of commutative justice , free riders have to be kept away, which is achieved by coercion that is not provided by the market; coercion can be justified by a social contract. The special moral problems of a social contract for health care are discussed. It is argued that public coercion in order to collect contributions for essential health care is justified. (shrink)

Health care reform in the United States and United Kingdom has resulted in the cross-fertilization of policy. The “new” health care models adopted by the two jurisdictions utilize free market principles for reasons of quality, efficiency, and cost, but also feature characteristics of a state-run model, through the provision of a safety net for citizens and a buffer against the commodification of health. In this sense, the health care systems of the US and (...) UK are more congruent than they were. Here we identify two distinct narratives that emerge from health care reform undertaken in these jurisdictions. The “revolutionary” narrative views the reforms as fundamental change whilst the “evolutionary” narrative accepts them as natural development. We argue that neither the revolutionary nor the evolutionary narrative adequately characterizes the reforms undertaken in health care because neither takes sufficient account of the broader setting in which reform has occurred. In seeking to examine and explain the jurisdictions' apparent drive to the middle, we propose a distinctive evolutionary narrative, that of “convergence,” which, as well as adopting a less parochial perspective on developments in health care policy and provision, also situates the reforms politically, constitutionally, and comparatively. (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)

Increasingly, physicians are being asked to provide technical services that many believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, (...) I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices. (shrink)

Professional autonomy, as the symbol of the traditional freedom ofdecision-making of medical professionals is criticized. This essayexamines the critique. It analyses the underlying assumption that theautonomy of health professionals is incompatible with the need fororganisation and management in order to control rising health carecosts. It is argued that the concept of professional autonomy should beredefined, not through restricting the decision-making freedom ofindividual health professionals, but through expanding the concept intothe sphere of management, so that managers will take (...) responsibility forpatient care. (shrink)

With the introduction of general management and then of planned markets into the National Health Service (NHS), health care in the UK has gone through a massive amount of change. The effect on those working for the NHS has been ‘challenging’ and often confusing. This paper aims to clarify what is happening by taking an ideological perspective: what ideologies exist, how they are changing and the strategies being used to ensure their survival. Ideologies are basically about (...) power. The relationship between market, managerial and professional ideologies is analysed using charters, codes of conduct and other associated documents. A tentative conclusion is reached that professional ideologies are able to adjust to the overriding market/consumerist ideology. However, the managerial ideology is having difficulty in gaining any real ground against the professional ideology and is having to move strategically by using audit, not just of finance, but also of clinical judgement, to gain power. (shrink)

USING QUALITATIVE INTERVIEWS AT CATHOLIC AND JEWISH HOSPITAL organizations, this essay contrasts the market-driven reforms of consumer-directed health care and physician entrepreneurship with the mission-driven structures of religious nonprofits. A structural analysis of values in health care makes a convoluted system more transparent. It also demonstrates the limitations of market reforms to the extent that they erode organizational structures of solidarity, which are needed to pool risks, shift costs, and maintain safety nets in a complex and (...) expensive health economy. (shrink)

This paper uses the recent history of marketization and privatization in the UK National Health Service as a case study through which to explore the relationship between health-care organization and health-care goods. Phases and processes of marketization are briefly reviewed in order to show that, although the scope of both marketization and privatization reforms have, until recently, been very heavily circumscribed (and can only be understood in the context of the rise of managerialism), they have (...) nonetheless had a major impact on the “value field” of UK health services. The second half of the paper draws upon the concerns of the critics of market-style reforms to set out and explore the ways in which organizational reform and the shifts in institutional norms consequent upon it construct health-care goods and argues that the investigation of this organization-goods axis ought to have a central place in health-care ethics. (shrink)

The current health care system is not operating with a properly functioning market. Health care costs are hidden and often shifted, consumers and providers are insulated from the economic consequences of their decisions, and costs therefore go up dramatically. Instead of attacking both the structural deficiencies and the consequent inequities of the current employer based insurance system, the Clinton Plan simply expands them, and adds a heavier level of government regulation. The ultimate choice for the public (...) is between a health care system based on consumer choice or a government controlled system. In pursuing a market based health care reform that enhances personal freedom and responsibility, two ethical principles are served. First, American consumers will be made aware of the true costs of health care services, and market forces will thus introduce incentives on the part of providers to control costs. Second, justice will be served; for not only will providers of medical services receive their due, but public policy makers can target relief more effectively to those who need it most. Keywords: Clinton health plan, free market, freedom, responsibility CiteULike Connotea Del.icio.us What's this? (shrink)

Many Western countries have introduced market principles in healthcare. The newly introduced financial instrument of “care-intensity packages” in the Dutch long-term care sector fit this development since they have some characteristics of a market device. However, policy makers and care providers positioned these instruments as explicitly not belonging to the general trend of marketisation in healthcare. Using a qualitative case study approach, we study the work that the two providers have done to fit these instruments to their (...) organisations and how that enables and legitimatises market development. Both providers have done various types of work that could be classified as market development, including creating accounting systems suitable for markets, redefining public values in the context of markets, and starting commercial initiatives. Paradoxically, denying the existence of markets for long-term care and thus avoiding ideological debates on the marketisation of healthcare has made the use of market devices all the more likely. Making the market invisible seems to be an operative element in making the market work. Our findings suggest that Dutch long-term care reform points to the need to study the ‘making’ rather than the ‘liberalising’ of markets and that the study of healthcare markets should not be confined to those practices that explicitly label themselves as such. (shrink)

Artificial Intelligence (AI), especially of the machine learning (ML) variety, is used by health care organizations to assist with a number of tasks, including diagnosing patients and optimizing operational workflows. AI products already proliferate the health care market, with usage increasing as the technology matures. Although AI may potentially revolutionize health care, the use of AI in health settings also leads to risks ranging from violating patient privacy to implementing a biased algorithm. This (...) chapter begins with a broad overview of health care AI and how it is currently used. We then adopt a “lifecycle” approach to discussing issues with health care AI. We start by discussing the legal and ethical issues pertaining to how data to build AI are gathered in health care settings, focusing on privacy. Next, we turn to issues in algorithm development, especially algorithmic bias. We then discuss AI deployment to treat patients, focusing on informed consent. Finally, we will discuss existing oversight mechanisms for health AI in the United States: liability and regulation. (shrink)

Trust in the nurse—patient relationship is maintained not by how professionals perceive their actions but rather by how the public perceives them. However, little is known about the public's view of nurses and other health care professionals who participate in pharmaceutical marketing. Our study describes public perceptions of health care providers' role in pharmaceutical marketing and compares their responses with those of a random sample of licensed family nurse practitioners. The family nurse practitioners perceived their participation (...) in marketing activities as significantly more ethically appropriate than did the public responders. Further research is warranted before conclusions can be drawn, but these early findings suggest that nurse practitioners should consider a conservative approach to participating in pharmaceutical marketing. (shrink)

Although the impact of market reforms in Swedish health care stands out as not very far-reaching in an international comparison, it represents a route away from the features and basic values normally associated with the Swedish or Scandinavian model. Summarizing the development over the last decades, we may identify signs of sustainability as well as change. Popular support for public provision and a robust institutional structure make far-reaching alterations of existing structures less feasible, although most visible changes this (...) far—incremental though they may be—represent a change in which the normative foundations of the Swedish model are challenged. (shrink)

It is generally agreed that the current methods of providing health care in the West need to be reformed. Such reforms must operate within the practical limitations to which any future system of health care will be subject. These limitations include an increase in the demand for costly end-of-life health care coupled with a reduction in the proportion of the population who are working taxpayers (and hence a reduction in the proportionate amount of (...) class='Hi'>health care funding that can be secured through taxation) and the fact that the imposition of bureaucratic regulations on health care systems is costly. Recognizing these limitations should naturally lead one to consider market-based reforms. Yet despite the practical impetus for such reforms, there is still widespread concern that market-based health care is unethical. The purpose of this paper is to address this concern and, in so doing, to pave the way for the market-based reform of health care to proceed. (shrink)

The emergence of Covid‐19 in the United States has revealed a critical weakness in the health care system in the United States. The majority of people in the nation receive health care via employment‐based health insurance from providers in a competitive market. However, neither employment‐based health care nor a competitive health care market can adequately provide treatment during a global pandemic. Employment‐based health care will fail to provide care (...) for a large number of people in any destabilizing economic event, including a pandemic. Competitive for‐profit health care systems distribute limited goods based on markets rather than health care needs. If a global pandemic results in unusually high demand for specific medical supplies, then these will be distributed suboptimally. The combined risk of suboptimal distribution of needed goods and a significant drop in health care access in a global pandemic indicates that the U.S. health care system has serious vulnerabilities that need to be addressed. (shrink)

This article reviews recent developments in health care law, focusing on controversy at the intersection of health care law and culture. The article addresses: emerging issues in federal regulatory oversight of the rapidly developing market in direct-to-consumer genetic testing, including questions about the role of government oversight and professional mediation of consumer choice; continuing controversies surrounding stem cell research and therapies and the implications of these controversies for healthcare institutions; a controversy in India arising at the (...) intersection of abortion law and the rights of the disabled but implicating a broader set of cross-cultural issues; and the education of U.S. health care providers and lawyers in the theory and practice of cultural competency. (shrink)

This article addresses the role of science and science advisory bodies in modeling practices for the support of policy-making procedures in the Netherlands in the field of health care. The authors show, based on a detailed investigation of a prestigious interdisciplinary modeling project in which an economic care model was developed for governmental use, that science advisory bodies are entangled with the policy actors they advise in what we call boundary configurations. Boundary configurations are strongly situated interconnections (...) between science advisory institutes and policy institutions that share a specific approach to problem definitions and methods and that are embedded in specific social, discursive, and material elements. Importantly, as the case study shows, such boundary configurations shape the kind of science, and related, the kind of social and political theories about the world, that is effectuated in modeling practices. In this case study, the boundary configuration in which economic experts and policy makers participated contributed to the articulation of health care in terms of a market-based policy program for the health care sector. (shrink)

In order to reflect on the morality of the health care market this paper critiques some of H. T. Engelhardt's presuppositions. Engelhardt has created the vivid term ‘moral stranger’ and suggested that there can be a ‘morality of moral strangers’. However his position relies either on certain necessary presuppositions which he leaves unmentioned or on presuppositions that are—in a strict sense—not moral ones. Engelhardt advocates the market economy as the guiding principle of health care, and claims (...) that the market needs no moral presuppositions. But when the preconditions of a functioning market are examined it turns out that a functioning market requires property and ownership, and that property and ownership are moral institutions. Therefore the application of the idea of the market to health care undoubtedly has morally serious consequences: most important, the difference between commodities and human beings is obscured. (shrink)

This essay begins by summarizing the reasons why unregulated health-care markets are inefficient. The inefficiencies stem from the asymmetries of information among providers, patients and payers, which give rise to moral hazard and adverse selection. Attempts to ameliorate these inefficiencies by means of risk-adjusted insurance and monetary incentives such as co-pays and deductibles lessen the inefficiencies at the cost of increasing inequalities. Another possibility is to rely on non-monetary incentives, including ordeals. While not a magic bullet, these (...) are feasible methods for addressing the inadequacies of market provision of health care, such as moral hazard. (shrink)

Commodification of health care is a central tenet of managed care as it functions in the United States. As a result, price, cost, quality, availability, and distribution of health care are increasingly left to the workings of the competitive marketplace. This essay examines the conceptual, ethical, and practical implications of commodification, particularly as it affects the healing relationship between health professionals and their patients. It concludes that health care is not a commodity, (...) that treating it as such is deleterious to the ethics of patient care, and that health is a human good that a good society has an obligation to protect from the market ethos. (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)

This essay focuses on the challenge European states have imposed on themselves, namely, to provide state-of-the-art health care equally to all and for less than market price. Continued endorsement of that challenge in these states hinges on their character as media democracies: the public is moved by a supposed morally warranted expectation that all should receive adequate health care at no significant personal cost. The structural and economic constraints that hamper such forms of healthcare delivery result (...) in systems that are financially inefficient and fail to provide the quality of treatment patients are led to expect. This essay examines the tension between secular moral claims to social solidarity and the actual limits of accessibility to healthcare services. Its critical focus addresses both the difficulties that result from politicians invoking high moral ideals while framing their decisions around short-term political advantage, and the transformation of the Enlightenment’s secular aspirations into a political ideology that distorts such moral ideals. This essay concludes that the commitments to very particular notions of equality and human dignity, which frame contemporary Europe’s provision of publicly subsidized health care, have given rise to a governance that is morally incoherent and unsustainable. This failure of public health care in Europe can thus be read as one more belated manifestation of the epistemological and moral failure of the Enlightenment’s secularizing project, a failure which should invite contemporary Europeans to honestly face the moral challenge of postmodernity. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that (...) a complete theory of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating (...) scarce health care resources.The market in health care has increased administration, fragmented services, eroded local accountability, and decreased choice.This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need.The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly.The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care. (shrink)

A recently published book, 'The Economics of Health Reconsidered' by Tom Rice, provides a strong critique of the role of markets in health care. Many of the issues of 'market failure' raised by Rice, however, have been, to varying extents, recognised previously in the health economics literature (at least outside the U.S.). What perhaps sets Rice's book apart from previous attempts to document such issues is its elegance and the methodical manner in which this critique (...) is delivered. Significantly the critique is based solely on conventional economic arguments. There has, however, been an emerging strand of the health economics literature not acknowledged in Rice's book which has approached some of these issues of market failure from a different perspective. Notably this research has involved, in part, borrowing from the ideas and methodological traditions of other disciplines. The emphasis in this work has been to expand the scope and the concerns of economic analysis in health care. (shrink)

Some see health care as primarily an individual responsibility. Others see it as a public responsibility. Behind these approaches are strong conflicting beliefs about ethical matters, specifically about the kind of good that health care is. On the one side the underlying belief is that health care is no more than an individual good and hence calls for a distributive policy based on the market. On the other side the underlying belief is that it (...) is a public good and hence calls for a distributive policy based on widespread agreement.' There will be intermediate approaches which try with varying success to justify themselves by piecing together beliefs from both sides. I shall explain what is involved in calling something a public good. Then I shall try to show that, if health care is to satisfy some rather plausible criteria, it must have the character of a public good. (shrink)

The free market theory has as its basis the assumption of equity. This equity is ascribed to both purchasers and providers in a perfectly balanced system so that there are seen to be no 'winners' or 'losers' in the market-place. The health system that is developing in the UK is structured as a managed market, but agency relationships between GPs and health authorities buffer the costing process of goods and therefore may be described as distorting the price. This (...) could also be distorting the ability of the users, who are the real purchasers, from exercising their economic freedom. They may also lose the autonomy to choose goods that suit their particular needs, and equally not to choose those services that they do not want or wish to pay for vicariously (i.e. that the common good is respected by both providers and purchasers). This assumes that users of the service know the level of choice that they have and that not only are providers protected at present by the practices of the purchasers but also entry into the market for new providers is severely curtailed. The exercise of true freedom of the market in economic terms is one of moral obliga tion to provide services that not only have a market value that is affordable and a require ment of the 'common good' but also are historically acceptable for social requirements (i.e. that the services are valued as fundamental tenets of the rights of individuals in soci ety). The expression of this need will therefore be utilitarian (i.e. the users of the services should benefit from them rather than the providers). (shrink)

This paper aims to provide an argument for saying that a publicly funded health care system, available to all free at the point of delivery, is morally superior to a market system, and to provide a framework for deciding questions about which forms of health care should be included in such a public system. The argument presents health care as a ‘head’, in the sense of something to which human beings are morally entitled as (...) a necessary condition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Daniels and Buchanan, are critically examined and rejected. (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)

One of the arguments that is often advanced in defence of the public health care system in Canada appeals to the idea that medical care should not be treated as a “commodity.” The recent Romanow Report on the Future of Health Care in Canada, for instance, says that, “Canadians view medicare as a moral enterprise, not a business venture.”1 Public provision is then urged on the grounds that this is the only mode of delivery compatible (...) with this constraint. This argument has received surprisingly little scrutiny, despite the important role that it plays in structuring the recommendations of the report, not to mention the broader public debate. This is unfortunate, since not only is it, in my view, a bad argument, but it is one that actually obscures the rationale for the current public system. It encourages the widely shared misperception that health care is a pure public good in our society (financed through taxation, then provided “for free” to all citizens). Provincial governments in Canada do not, for the most part, deliver health care services directly to the population. What they provide instead is health insurance. They rely primarily upon the private sector to deliver care. Thus the Canadian health care system more closely resembles what is often described as a quasi-market, or a “public market.” The justification for the role of the public sector in health care can be traced back to market failure in the insurance sector, and not in the market for health care services. (shrink)

The history of drug/vaccine development has included major advances guided primarily by risk/benefit analyses concerning the innovative agent, not by evidence-based clinical trials (Phase I–IV). Because the approval for new drugs is hindered under the present process, the system requires restructuring. The Phase I/II study period should be more flexible, using the “environment of knowledge” about the new agent, plus risk/benefit assessments. Phase III, as presently constructed, does not add new adverse events data, it provides a narrower profile of drug (...) efficacy than properly done Phase II studies, and placebo-controlled trials continue to raise unresolved ethical and social issues. Phase III studies should be abandoned for most drugs, and substituted with properly powered Phase II doseranging studies plus careful post-marketing surveillance. Phase III should be a penalty for poor drug development, not a regulatory requirement. (shrink)

ABSTRACTThe health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance . In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing (...) in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives. (shrink)

'Trade in Health is a timely reflection on the interface of economics with the ethics and public policy facets of the international movement of patients. Health issues such as these are at the forefront of modern political economy."National" health is increasingly less so. Reisman's previous scholarship in this area is brought to bear in an insightful and eminently readable and engaging fashion. In an area where uncovering the facts is more difficult than "decyphering the Dead Sea Scrolls", (...) such a reflective work on the critical aspects of political economy helps to fill a void in considering whether such trade is likely to be in the interests of patients, nations and the global community. In addition to the rosy picture of healthy and wealthy tourists having a sojourn for medical care during a vacation, Reisman is not afraid to tackle the thorny issues concerning trade in organs, eggs and even death, in this sobering and comprehensive volume. It is a rare skill to bring the luminaries of Smith, Marshall, Mill and Confucius to bear on such a contemporary tale! International travel by patients is at the nexus of a revolution in global health. It is driving and affecting aspects of foreign investment, health worker migration and e-health provision. Reisman skilfully links these foundations of health care, and as such provides critical text for consideration by those seeking to build and strengthen future health systems. Trade in Health is an excellent overview. It provides critical insights for those new to the area as well as new information and challenges for those of us involved for a number of years.' - Richard Smith, Professor of Health Ssytem Economics and Dean of Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK. Once exports and imports meant agriculture and industry. In the global economy and the electronic age, trade is also expanding into the service sector. This timely book closely examines trade in health. It documents the growth of a cross-national service that in the past was mainly consumed at home. Following from his highly successful book Health Tourism, Professor David Reisman offers a comprehensive and searching multidisciplinary account of the way in which medical services, patients, capital and professionals are making up a global healthcare economy that crosses borders. He reflects on their pursuit of lower prices, better quality and a differentiated product, and suggests that public policy is essential if the ethical capital of interdependent societies is not to be eroded by the international market in health and care. Written in a concise and lucid form, this original book will be of great interest to all people interested in the internationalization of health care. Combining theory and empirical evidence from economics, tourism and medical care, scholars involved in health policy and social administration will find much of significance in this authoritative study. (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)