After the first world war, many industrialised
countries fostered publicly supported sickness insurance, realising that equitable access to
health care could improve the health of their populations. By the early 1970s, universal
health coverage had been achieved in Europe and the developed countries of the former
British Commonwealth.(1) Within the developed world, the United States was a striking
exception, and this anomaly led to comparisons with South Africa, a country riven by racial
policies, which had also turned its back on a national health system in the 1940s.(2)
Since the 1970s the pendulum has swung in many countries towards privatisation and managed
care, no doubt at least in part due to American influence. Interest in universal access to
health care in the United States at the start of the Clinton era was short lived at a time
of resource constraints and was soon eclipsed by a renewed thrust towards managed
care.(3) While the potential impact of managed care remains hotly debated,(1)
(4) the question of what constitutes a just healthcare system has not been adequately
addressed.
Privatisation of health care, seen by many as a panacea in the face of resource
constraints, is usually attacked by critics on two fronts: firstly, as failing to achieve
the benefits invoked to justify it (greater choice for consumers and providers, increased
efficiency, and higher quality of services); and, secondly, as being destructive of the
physician-patient relationship.(5) There is evidence that privatisation of health
insurance is costly, has growing administrative costs, offers less rather than more choice
for consumers and providers, and fails to improve the quality of care.(6)In a masterly
presentation on American health care, Professor Allen Buchanan, professor of philosophy at
the University of Wisconsin and a prominent American bioethicist, goes further than this
evidence in arguing that these defects are magnified by privatisation's failure to foster a
more just system.(5)
He argues that there are nine elements required for a just
healthcare system (see box). The three that constitute the core are based on recommendations
from the United States president's commission on medical ethics(7): these are
universal access, access to an "adequate level" of care, and access without excessive
burdens to patients. While not attempting to define what constitutes an "adequate level"
or "decent minimum" of care, Buchanan suggests that such a definition is possible based on
three considerations. Firstly, the level of care in any society will be less than the best
technically available. Secondly, justice requires preservation of people's freedom to
purchase services that exceed the adequate level of care. Thirdly, that there are moral
limits to what we owe our fellow citizens. The first two considerations are necessary
because society's commitment to ensuring access to health care will be limited by scarce
resources and by the need to provide other socially valuable goods such as education. The
emphasis on avoiding excessive burdens highlights the fact that mere legal entitlement to
services is not sufficient if serious obstacles prevent their use.
| Elements of a just healthcare system |
| Universal access
Access to an "adequate level" of care
Access
without excessive burdens
Fair distribution of the financial costs of ensuring
universal access to an adequate level of health care
Fair distribution of the
burdens of rationing care
Capacity for improvement toward a more just system
Education and training of appropriate numbers and types of healthcare providers
Effective pursuit of high quality biomedical research
Cost effective use of
results of biomedical research |
Buchanan proposes three further necessary elements: that there is a fair distribution of
the financial costs of ensuring universal access to an adequate level of health care, a fair
distribution of the burdens of rationing care, and a capacity for improvement toward a more
just system. These requirements are plausible on the grounds that, in the face of inevitable
rationing, a system could not be considered just if it achieved universal access by imposing
unfair financial burdens on some people or arbitrarily concentrated the burdens of rationing
on some individuals or groups. As it is highly unlikely that a perfectly just healthcare
system will ever be achieved, whatever system is implemented must not "unleash economic and
political forces that will tend to make it less just over time."(5) Even
substantially just but imperfect systems must have the capacity for improvement.
Three
final considerations, which should not be hindered even if privatisation is implemented, are
of particular importance in (but not exclusive to) developing countries: the system should
educate and train appropriate numbers and types of healthcare providers, enable the
effective pursuit of high quality biomedical research, and use cost effectively the results
of biomedical research. These are necessary to prevent the flow of talented staff and
resources away from educational and research facilities into the private sector, and to
ensure that teaching hospitals can retain the broad range of activities required for
providing services and ongoing improvements to health care.
Buchanan explains how
achieving a just healthcare system as a cooperative between the public and private sectors
requires an organisation, such as the state, to act as coordinator and guarantor of
equitable access to care and fair distribution of costs. The division of labour between the
private and public sectors must be coordinated to ensure that rationing is not achieved
through discriminatory or otherwise unfair policies in either sector. Without such control,
gaps in access left by the private insurance market and charity would not be filled, and the
burdens of rationing would not be distributed fairly.
The United States government could
use Medicare and Medicaid (the state health insurance for elderly and for poor and disabled
people respectively)to fill in the gaps left by the private sector. Or it could regulate the
behaviour of the private sector to stimulate it to provide wider access than it would do if
it were responding only to market incentives. This second approach is likely to be more
effective, but only if the public sector were dominant, as the state's role would be
diametrically opposed to the competitive behaviour of the market.
Buchanan illustrates
the naivety of imagining (as the World Bank does) that professional altruism and duty can be
relied on to fill the gaps in the regulatory infrastructure-not turning away the sick who
cannot pay and fighting for universal access to health care. He also shows, through
reference to the current status of health care in the United States (where privatised
insurance is most developed and has failed), that a predominantly private system is likely
to generate economic and political forces that will make movement towards justice more
difficult. The even worse failures of developing countries that attempt to emulate the
American pattern illustrate both the symbolic power of the United States as an exemplar, and
the potential global importance of its implementing a more just healthcare system.
Buchanan acknowledges that his suggestions would require politicians to mount heroic
resistance to pressures from their most powerful constituents. But he also emphasises that
moving towards a just healthcare system will require the public to trust government
bureaucrats at least as much as they seem to trust the private bureaucrats and highly paid
chief executive officers of managed care systems.(8) Individual and population health
would surely be better served in social democracies, where individual rights are
supplemented by some community solidarity and where accountable leaders and bureaucrats can
be voted in and out of power, than in highly individualistic societies where almost
anarchical power can be accumulated by entrepreneurial organisations driven predominantly by
self interest.
Rational arguments, such as those offered by Buchanan(5) and
Dworkin,(9) best reflect the concern for social justice that characterises healthcare
systems in, for example, Britain and Canada. They also reflect the concern for political
accountability in these countries' reform towards mixed private and public healthcare
systems under conditions of constrained resources. If market forces are allowed to
predominate in health care, "fear, bias, and greed" may impede the rational efforts needed
to answer important public health questions.(10)
The effort required by the
American public to overcome these impediments will need to be matched by the willingness of
medical professionals to overcome their resistance to the transformation of the American
healthcare system.(11) This will require a broadening of professional ethics to
include considerations of the public interest and the common good.(12) Buchanan has
shown that legitimate retrospective moral judgements can be mounted against those involved
in radiation experiments on humans in recent years.(13) Similarly, failing to drive
American health care in the direction of greater justice could make the present generation
of American politicians and professionals vulnerable to legitimate retrospective moral
judgements.
Solomon R Benatar
Professor Department of Medicine
and Bioethics Center,
University of Cape Town and Groote Schuur Hospital,
Observatory 7925,
Cape, South Africa
References:
1 R Williams, ed.
International developments in health care. London: Royal College of Physicians, 1995.
2 Benatar S R. A unitary health service for South Africa. S Afr Med J
1990;77:441-7.
3 Angell M, Kassirer J P. Quality and the medical marketplace:
following elephants. N Engl J Med 1996;335:883-5.
4 Hunter D. Managing
medicine: a response to the `crisis'. Soc Sci Med 1991;32:441-9.
5
Buchanan A. Privatization and just health care. Bioethics 1995;9:220-39.
6 Himmelstein D, Woolhandler S. Cost without benefit: administrative waste in the US
health care system. N Engl J Med 1986;314:441-5.
7 United States
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioural Research. Securing access to health care. Washington DC:US Government
Printing Office,1983.vols I and II.
8 Woolhandler S, Himmelstein D. Extreme risk - the
new corporate position for physicians. N Engl J Med 1995;325:1706-8.
9
Dworkin R. Will Clinton's plan be fair? New York Review 1994 Jan 13: 20-5.
10
Angell M. Evaluating the health risks of breast implants: the interplay of medical science,
the law and public opinion. N Engl J Med 1996;334:1513-8.
11 Botelho RJ.
Overcoming the prejudice against establishing a national health care system Arch Intern
Med 1991;151:863-9.
12 Wolf S. Health care reform and the future of
physician ethics. Hastings Centre Report 1994;24:28-41.
13 Buchanan A.
Judging the past: the case of the human radiation experiments. Hastings Centre Report
1996;26:25-30.
