• Abstract and Figures
• Public Full-text

Where Civic Republicanism and Deliberative Democracy Meet Author(s): Ezekiel J. Emanuel Source: The Hastings Center Report, Vol. 26, No. 6, In Search of the Good Society: The Work of Daniel Callahan (Nov. - Dec., 1996), pp. 12-14 Published by: The Hastings Center Stable URL: http://www.jstor.org/stable/3528746 Accessed: 20/07/2009 13:30 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=hastings. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit organization founded in 1995 to build trusted digital archives for scholarship. We work with the scholarly community to preserve their work and the materials they rely upon, and to build a common research platform that promotes the discovery and use of these resources. For more information about JSTOR, please contact [email protected]. The Hastings Center is collaborating with JSTOR to digitize, preserve and extend access to The Hastings Center Report. http://www.jstor.org Hastings Center Report, November-December1996 does not, however,yield an account the proportion of the GNP going to health care of we can Is fine-grainedprinciples use and/or reduces the range of services covered as part in rationing contexts. of basic medical services. these 4. See "The Goals of Medicine: Despite connections, Tustice these three levels are distinct. -Justie Towarda SustainableFuture," (draft conceptually of February,1996). The fundamental challenge to theories of dis- tributive for health care is to a Enough?? 5. See John Rawls, PoliticalLiber- justice develop prin- alism (New York:Columbia Univer- cipled mechanism for defining what fragment of the sity Press, 1993), esp. lecture 6; vast universe of technically available,effective medi- Joshua Cohen, "Deliberation and cal care services is basic and will be guaranteed so- Democratic Legitimacy,"in The GoodPolity, ed. Alan Ham- cially and what services are discretionary and will lin and Phillip Petit (Oxford: Blackwells,1989), pp. 17-34; not be guaranteed socially. Such an approach ac- Cass Sunstein, The Partial Constitution(Cambridge: Har- a two-tieredhealth citizens will vard cepts system-some UniversityPress, 1993), esp. chaps. 1 and 6. receive basic services while others will receive 6. Norman Daniels, "Growth Hormone for only Therapy both basic and some health services. Short Stature: Can We Support the Treatment/Enhance- discretionary ment Distinction?" Growth,Genetics, & Hormones8 (1992, Within the discretionary tier, some citizens will re- Supplement 1): 46-48; James E. Sabin and Norman ceive few discretionaryservices, other richer citizens Daniels, "Determining 'Medical Necessity' in Mental will receive almost all available services, creating a Health Practice," Hasting CenterReport 24, no. 6 (1994): multiple-tiered system. 5-13. m Underlying the repeated failure of attempts to provide universalhealth care coverage in the United States is the failure to develop a principled mecha- nism for characterizingbasic health services.Ameri- cans fear that if society guarantees certain services as "basic,"the range of services guaranteed will ex- pand to include all-or almost all-available ser- Ezekiel J. Emanuel vices (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every Where Civic medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in Republicanism which the well insured receive a wide range of medi- and cal services with some apparently basic services un- Deliberative covered; Medicare beneficiaries receive fewer ser- Democracy Meet vices with some discretionary services covered and some services that intuitivelyseem basic uncovered; Medicaid beneficiaries and uninsured persons re- Is there a relationship between defects in ceive far fewer services. our medical ethics and the reason the On this view, the reason the United States has United States has repeatedly failed to enact failed to enact universal health coverage is not pri- universal health coverage? I will begin to suggest an marily political or economic; the real reason is ethi- answer to this question by clarifying the locus of cal-it is a failure to provide a philosophically de- decisions. The allocating allocation of health care fensible and practical mechanism to distinguish ba- resources can occur on three levels. The social or, sic from discretionary health care services. What is in the economist's language, the macro level entails the reason for this failure of medical ethics? the of the proportion gross national product (GNP) There are two opposing explanations. One ex- allocated to health care. The patient, or micro, level planation points to the inherent limits of ethics. entails which determining individual patients will re- Some philosophers, such as Amy Gutmann and Nor- ceive medical specific services; that is, whether Mrs. man Daniels, argue that we lack sufficientlydetailed White should receive this available liver for trans- ethical intuitions and principles to establish priori- plantation. Finally, there is an intermediate level ties among the vast array of health care services. called the service or medical level that entails de- Every time we try to define basic services our intui- termining what health care services will be guaran- tions "run out." As Gutmann once wrote: teed to each citizen. These socially guaranteed ser- vices have been called "basic"or "essential"medical I suspect that no philosophical argument can provide us with a which we services or what the President's Commission desig- cogent principle by nated as "adequate health care."Clearly, these three can draw a line within the enormous group of levels are connected. A larger proportion of the goods that can improve health or extend life GNP going to health care permits coverage of more prospects of individuals . The remaining services. Similarly,as demonstrated by the end-stage question of establishing a precise level of priori- renal disease program, providing specific services to ties among health care and other goods is ap- left to a wider range of patients causes upward pressure on propriately democratic decision-making.' 12 Hastings Center Report, November-December1996 Taken at face value, this moral skepticism is ex- cies regarding opportunities, wealth, and matters of tremely dangerous; it suggests that there can be no the common good can only be justified by appeal principled mechanism to define basic health care to a particularconception of the good. As Rawlshas services and, therefore, that the efforts to ensure put it: universal access will founder on the fear that always Public reason does not apply to all political guaranteeing any health care to all citizens means questions but only to those involving what we guaranteeing all available services. It suggests we may call "constitutionalessentials."3 should just give up on a just allocation of health care resources because we can never succeed. More expansively,Brian Barry has written: The second holds that the explanation problem Examples of issues that fall outside [the princi- with basic health services is not a defining general ple of neutrality include] two distinct kinds of of but a of liberal lapse ethics, specific lapse political items. One set of items (tax and property laws) that informs our in- philosophy political discourse, contains matters that are in principle within the the allocation of health care resources. The cluding realm of "justiceas fairness"but are subject to is that health care services problem priorities among reasonable disagreement about the implications can be established only by invoking a conception of of justice ... The other set... contains issues the good, but this is not possible within the frame- that in the nature of the case cannot be resolved work of liberal Liberalism di- political philosophy. without giving priorityto one conception of the vides moral issues into three the spheres: political, good over others . There is no room for a and domestic. It then holds that within the social, complaint of discrimination simply on the laws and cannot be political sphere, policies justified ground that the policy by its nature suits those to the To laws by appeals good. justify by appealing with one conception of the good more than it to the good would violate the principle of neutrality suits those with some different one. This is un- and be coercive, imposing one conception of the avoidable.4 good on citizens who do not necessarily affirm that conception of the good. But without appealing to Thus, it seems there is a growing agreement be- a conception of the good, it is argued, we can never tween liberals, communitarians, and others that establish priorities among health care services and many political matters, including matters of jus- define basic medical services. This is Dan Callahan's tice-and specifically, the just allocation of health view with which I agree:2 care resources--can be addressed only by invoking a particular conception of the good. .. there can be no full discussion of equality We may go even further. Without overstating it in health care without an full discussion equally (and without fully defending it) not only is there a of the substantive and that medi- goods goals consensus about the need for a conception of the cine and health care should ..

Load more

  4

Copy Link