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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |        |
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  | *This staff paper was discussed at the November 2007 meeting. It does not represent the official views of the Council or of the U.S. government.*
The Council’s Inquiry into               Health Care: Progress to Date, Key Questions, and Possible Future               Directions Staff Discussion PaperBy Thomas W. Merrill I. Introduction
 This working paper addresses the possibilities and prospects for health care as a topic for this Council, at this time and this place. The question confronting the Council is not, Is health care an important topic and worth discussing? There can be little doubt that it is, especially in light of (but not only because of) this season of presidential campaigns. Rather, our question is, what useful work can we as a council on bioethics do on this topic? As a group we are neither economists nor politicians, and we do not wish to become politicized. And so we ask: what is our place in this national conversation?  The most familiar problem in discussions of health care is the growing number of the uninsured (and under-insured), by most estimates, some 46 or 47 million people. Uninsurance is a complex phenomenon, and one that deserves to be unpacked at some length, although not in this discussion paper. Whatever qualifications we might want to make to that number, it is generally conceded that there is some hard core of Americans who are uninsured for long periods of time; that while they get some emergency care, it tends to be less than ideal both for the individual and for society; that the health of the uninsured is worse than it would otherwise be; and, that this is something about which informed citizens ought to be concerned, both from an ethical and from a policy point of view. 

 Yet the condition of the uninsured is not the only—or perhaps, even in the long term, the most—pressing problem confronting health care in the United States. Another is presented by the rising cost of health care, and its rising share of the GNP. Americans pay more, and pay a larger portion of their income, on health care than they did in the past. Some not insignificant share—though certainly not all—of the uninsured are otherwise financial stable Americans declining to buy insurance, presumably because of its high cost. Scholars of health policy debate a number of plausible causes of this phenomenon: the cost of new and very expensive technologies; overtreatment of patients by doctors and other health care workers; overconsumption of (or excessive demand for) health care on the part of patients, fueled by an unreflective belief in medical progress and abetted by insurance arrangements that insulate patients from the true costs of their treatments; and excessive charges by insurance companies and other 3rd parties, including both administrative costs and profits, among others. Some commentators have suggested that part of our health care problem is a distorted sense of what medicine and medical technology can do and believe this leads to an overemphasis on high tech, high cost therapies to the disadvantage of less intensive kinds of medicine, such as primary, preventative, palliative, and long-term care. In short, beside or behind the coverage question, there is also a question about what kind of care we are getting, and what kind we should be getting.

These practical issues also point to deeper questions about the human significance of health, and to the tension between our proud claims to be wholly self-sufficient and the human reality of vulnerability and neediness. Because the moral heart of medicine is the ability to tend the sick, our reflections on health and health care necessarily lead to more profound questions about the existential significance of our embodied condition, even though our policy debates almost never make such concerns thematic.

 We write here to explore some answers to the question of what we, as a President’s Council on Bioethics, can contribute to this discussion. There is, of course, a vast body of literature, both academic and popular, treating these topics, and there is no need for us to replicate that work. We are also unequipped, and rightly unwilling, to wade into the complex, technical details of health care policy. In a presidential campaign season, information and views about competing policy options are not hard to come by. Even if, however, we are unable to make policy recommendations in this area, there may well be useful work for a council on bioethics to do here. For example, while there is a widespread consensus that the condition of the uninsured is a pressing problem, we believe that there are important differences of opinion about the grounds of that consensus, differences that can and do lead to different preferences concerning solutions to our health care problems. When Norman Daniels argued before the Council that we ought to care about health care reform on the grounds of a larger concern with equality, several Council members disagreed, and suggested that the appropriate approach to this topic should begin with a concern for the genuinely needy and not with any commitment to equality more generally. This is the kind of foundational question that a council like this one might try to clarify, though not, we suspect, settle.

 Similarly, recent debates about health care also inevitably raise the question of what kind of medicine and medical care we get and what kind we ought to get. John Wennberg of Dartmouth has presented work to the Council that suggests that some significant portion of medical care in the U.S. does not have positive effects, and Dan Callahan argued to us that the cause of that overtreatment was a deep American commitment to a belief in the goodness of infinite medical progress. Without prejudging the merits of Callahan’s thesis either as an empirical or a moral matter, we can legitimately raise the questions of whether we Americans get the kind and distribution of medicine we ought, and, if not, what are the possible causes of that state of affairs. Is it due to an unreflective belief that everything that can be done should be done, a valetudinarianism deeply embedded in the culture, economic incentives for doctors to do more work regardless of ultimate value to the patient, or something else?

 In short, we think that the current debates about health care reflect deeper questions about the grounds and the ends of medicine that are the legitimate bailiwick of a council on bioethics. In what follows we try to identify some of these issues and to focus the Council discussion on them. This discussion paper proceeds in several parts: a section briefly recapitulating the Council’s inquiries on this issue to date; a section that sketches some questions and topics for reflection that emerge from those inquiries; a section that attempts to lay out some of the alternative views of the moral and political grounds of our thinking about health and health care; and finally a section that raises some questions about our path forward.
II. The Council’s Inquiry to Date
The Council has had two sessions explicitly devoted to questions of health and health care, and the topic has come up spontaneously or indirectly in a number of other sessions as well. Taken as a whole, these sessions and the Council member comments associated with them reveal both the reasons and the concerns that might lead the Council to take an interest in this topic, along with certain objections and problems that, while perhaps not fatal to this work, need to be taken seriously.

 We begin here with what is surely the moral core of any work we might do in this area, our genuine concern for the unmet health needs of many of our fellow citizens. Everyone knows that issues of health care reform are pressing and much debated political and economic questions. This concern was given voice most directly by a number of Council members in the last session of the first day of the September 2007 Council meeting in Chapel Hill. Council members such as Doctors Foster and Rowley, Professors Dresser, Gomez-Lobo, and Schneider all indicated an interest in the President’s Council pursuing this topic. Many members seemed to support for the proposal that the Council at least make a statement indicating that health care is, indeed, a problem in the United States and that something ought to be done about it. But it is fair to say that the shape of a project that goes beyond that statement is unclear, and so, too, are the depth and character of the Council’s interest in pursuing health care as a full-fledged topic in its own right. Do the various sessions that we have already had on health care provide any guidance on what good we might be able to do in this area?

 At the November 2006 meeting, the Council heard from Norman Daniels, Professor at the Harvard School of Public Health and a noted philosopher whose work has explored the topics of justice, health, and health care. Very briefly, Daniels argued that health and health care are proper objects of distributive justice. His argument runs, roughly, as follows: Americans do rightly care about securing a certain equality of opportunity for their fellow citizens; and correctly understood, health ought to be seen as a core element or condition of opportunity; and so health and health care are the sorts of goods that government and society should take an active interest in providing and promoting to all citizens. Daniels suggested that the key premise of this argument, about the importance of equality of opportunity, was widely shared across a number of otherwise differing accounts of justice: Rawls, Sen, and Cohen, as well as a more general, albeit perhaps inchoate, sense among ordinary Americans.

 Daniels also made the important distinction between health and health care. As he presented it, his original concern, visible in the title of his 1985 Just Health Care, was with health care, narrowly conceived. But it turns out that not all, perhaps even not most, of the inequalities in health in a given society are caused by inequalities in access to health care. The model that holds a simple correlation between access to health care and health breaks down. Daniels, therefore, changed his thinking on this topic. If justice leads us to take a strong concern in the health of our fellow citizens, and health care is not the primary determinant of health, then we must turn to the larger set of “social determinants of health”: per capita wealth in a society, social programs beyond access to health care, status of women in a given society, and, perhaps most controversially, the degree of inequality in a society.

 In their responses to Daniels, Council members raised some fundamental questions and pointed to genuine controversies. If there was any common thread in those questions, it was that Daniels had gone too quickly from claims about the normative status of equality of opportunity to assertions of a strong obligation to rectify various kinds of inequality both in health and in health care. Some Council members asked questions about how Daniels would respond to fellow citizens with a quite different notion of what justice is and how it applies to health—a libertarian, Robert Nozick-inspired one, for example. One Council member asked whether we ought to think of health and health care as matters of distributive justice at all. Whatever we make of that disagreement, it would certainly seem that a serious controversy is at stake here and that this controversy is a legitimate topic for bioethicists. We discuss this topic at somewhat greater length below.

Be that as it may, some of our speakers on health care at the June 2007 meeting articulated a note of skepticism about treating health care simply as an abstract moral question. Allen Buchanan argued that mere moral theorizing will not provide very much assistance in puzzling through what to do about health care—for example, the appropriate content of a “legal entitlement to health care.” On Buchanan’s account, theories of a “moral right to a decent minimum of health care” (like Daniels’) are defective insofar as they are morally controversial and too abstract to give us very much guidance in specifying the content of that right. Rather than more theorizing, Buchanan suggested, we need a “politically effective societal consensus” that there ought to be a decent minimum, and then we can develop a more determinate sense of to what every American is entitled. Or, as Buchanan put it, “the responsibilities in question” cannot be “discovered”: “in fact they must be created.”

 Buchanan apparently had in mind something like a political movement to create a legal entitlement to health care, followed by a national institution that would hash out what ought to be included in it. But that sounds far more like a political process than a distinctly bioethical one, and one, we suspect, far beyond the ken of this Council. Zeke Emanuel, on the other hand, was skeptical about the usefulness of abstract moral theory for an opposite reason: his objection wasn’t that we lack a political consensus on this topic, but rather that we do, in fact, have one. At a time when Republican governors in Massachusetts and California are leading their states to extend coverage, he argued, there doesn’t seem to be much disagreement on the basic moral question. To be sure, there are many practical disputes over how exactly to accomplish that goal; but those are primarily political and economic questions, not moral or even bioethical ones.

 Daniel Callahan, another speaker at the June 2007 meeting, echoed the ethical concerns that point to universal coverage but also introduced some new and quite interesting angles on this topic. He suggested that certain fixed ideas in the American psyche were the key obstacles to what he regarded as the appropriate objectives for reform: a deepset mistrust of government and attachment to markets, on the one hand, and an “infatuation with medical progress and technological innovation,” on the other. The first is an obstacle to achieving universal coverage, the second the obstacle to controlling costs. Callahan wanted to answer the first with an appeal to solidarity—according to him, the dominant value of European thinking about these matters. Yet it is the second obstacle, on Callahan’s account, that is the root cause of our health care woes. 

 The reason for this, as Callahan explained in part in the 2007 presentation and at greater length in his March 2005 presentation to the Council, is that the rising cost of medicine drives the growing numbers of the uninsured; and, rising costs are driven, in turn (largely but not wholly), by the costs of new medical technologies. Callahan claimed that the deep roots of these rising costs lie in the American attachment to an “infinity model of medical progress,” or the idea that health can and should be improved indefinitely, even to the exclusion of other goods. The root problem for Callahan would seem to be an inability to accept the natural limits of human life; and that inability leads to a whole set of distortions in our priorities for medicine. It gives us “a powerful bias toward cure, rather than care; acute, rather than chronic, disease; length of life rather than quality of life; individual benefit rather than population benefit; technological interventions rather than health promotion, disease, and disease prevention; subspecialty medicine, rather than primary and family care; and increased medicalization of life and social problems.” Not least, the medical costs of technology use up resources that would be better spent in expanding access to health care, on Callahan’s view. Thus, for Callahan, the core problem in American health care is less a dispute over the grounds or extent of our obligations to each other: it is a basic confusion over the appropriate ends of medicine. 
III. The Council and Health Care?
In light of this discussion of the Council’s inquiry to date, two distinctively bioethical issues stand out. One concerns the controversies over the grounds for our concern about health care and finds its practical urgency in the well-known problems of the uninsured. Its jumping off point might be the suggestion made by Leon Kass at the end of the Thursday session of the Council’s September meeting. Kass pointed to the controversies over the kinds of justifications we might give for doing something about the health care problem (or problems) and suggested that the Council might do a useful service to the country by trying to sort out those competing alternatives. One obvious point of entry into that kind of inquiry would the disagreements and questions that came to the fore in the Council session on Norman Daniels’s presentation, although surely we would not want to limit our thinking about these matters to Rawlsian egalitarianism and Nozickian libertarianism. 

Even if it is true that different political and moral philosophies are converging on certain policy reforms, it might still be important to think through the competing accounts of why (or how) we should be concerned about this question. For example, we may think differently about the goals and means of various reforms depending on how we see the underlying ethical issue. Or the convergence may turn out to be more apparent than real. An inquiry (or a report) into this angle of the health care question might take up questions like these. Leon Kass asked us: “how should a decent and prosperous society think about and act for the health care needs of its citizens, in the context also of other important personal, familial, and social goods? What notions of political and moral philosophy are best suited to thinking about this matter?” Is the basis of our concern for health care a larger commitment to equality more generally, or a concern primarily about the needy and vulnerable in society? Should we see health care as a right, whether moral or legal? Should we see it, instead, as a commodity like any other in a market society? Or is health a distinctive good, distinctive in such a way that puts a special burden on society to see that the health care needs of its citizens are met?                The other ethical issue that may be of interest to the Council concerns different notions of the ends of medicine, in particular the place of medical progress and technology in our thinking about what medicine ought to do. The practical concern driving this line of inquiry is the rising costs of medical care and medical insurance. One often hears that the most serious cause of those increases is medical technology; Dan Callahan put it most starkly when he says that technology and the technological mindset—which he calls the “infinity model of medical progress”—“bears a heavy responsibility for rising health care costs and all the pathologies that brings: rapid increases in the number of the uninsured, and more out-of-pocket payments.” We ought not to accept these claims without further investigation. But the Council might do useful work by investigating these kinds of claims and by trying to think about how we should judge them from an ethical point of view. A project along these lines could educate the public about some other aspects of the health care problem beyond the well known facts about the uninsured, and it could easily be seen as continuing the Council’s long-standing interest in the ambivalences of technology, seen now as a socio-political theme and not merely as a clinical or personal one.                An inquiry of this sort might take up questions like these: What are the facts, so far as we can know them, about the contribution of new medical technologies to rising health care costs? Is Callahan correct to say that there is a fundamental clash of values in our thinking about health care between, on the one hand, our commitment to “equitable access to affordable health care for all citizens” and, on the other, “constant medical progress and technological innovation”? Here one avenue that would be worth exploring is the literature on over-treatment.1 It would be very interesting to know what experts think the causes of this phenomenon are: strong patient demand for aggressive treatments, as Callahan might have it; doctors pursuing all possible treatments in order to avoid lawsuits; the insulation of patients from the real costs of treatments; or, some combination of these?

 As we have said, we write here only to sketch possible directions the Council’s inquiry might take, and possible ways in which the Council might add something useful and distinctive to an already much-debated topic. No doubt there are many different angles from which these questions can be seen, and we hope to provoke Council thoughts and critiques about this topic with a view to narrowing down what sorts of questions will be most fruitful for us to pursue. The most obvious topic of disagreement within the Council, however, seems to concern the question about the ethical foundations of health care, and one avenue to a possible Council report (following up the question asked by Leon Kass cited above) would be an investigation of competing accounts of those foundations. In the next section of this working paper we provide a very brief sketch of three leading contenders for ways of thinking about health care.
IV. The Ethical Foundations of Health Care
**A. Health, Health Care, and Distributive Justice**

One prominent way of bringing moral and political philosophy to bear on health has been discussed. As we have seen, Norman Daniels and others hold that health and health care are appropriate objects of distributive or social justice: health and access to health care are among the goods that we owe to each other, just by virtue of our shared humanity and shared citizenship. To reiterate, the proponents of this position argue that Americans are rightly committed to securing an equality of opportunity for all citizens, that health is a core component and condition of opportunity, and so that society and government owes its members some sort of access to health care. In making this case, Daniels appeals to the well-known theory of justice articulated by John Rawls, most especially to Rawls’s difference principle, which holds that inequalities are justified only to the extent that they make the least well-off better than they would otherwise be. Some sort of societal provision of universal coverage for health care is thus a moral imperative, because it is one very necessary condition for any other activity (and thus falls under one of Rawls’s “primary goods”) and because it protects and insulates citizens from some undeserved accidents of fortune and chance. A right or entitlement to health care, on this view, stems in a fairly uncomplicated way from the basic social contract, that is, from what rational individuals would agree to when deliberating about the basic structure of society.

 Yet there are some questions and objections that can be raised about this way seeing the matter. Consider Daniels’s shift from seeing the key issue as one of access to health care to one of health itself and the social determinants of health. It must be admitted that this shift makes much intuitive sense, since surely we care about health care only as a means to health, and scholars seem to agree that health care is not the most important determinant of health. Yet once we change our focus from health care to health, we open up a number of extremely thorny and controversial questions about the “social determinants” of health, including what kind of culture Americans ought to have, what the appropriate distribution of income in society ought to be, and so on. The ambition to work toward universal access to coverage is understandable; the ambition to achieve equality in health (as opposed to health care) certainly seems to commit us to some quite radical changes to American society as we know it, changes that may be neither possible nor, depending on your point of view, desirable. At the least, Daniels’ championing of health on the basis of the American commitment to equality of opportunity would have to be weighed against the equally American commitment to limited government. 

**B. Individualism and Health Care**

Another familiar way to think about health and health care is a broadly individualistic one: health is primarily (although perhaps not wholly) the responsibility of the individual. On this view, health is not the sort of thing that can be simply produced from the outside—and thus not something that is, in the first instance, an appropriate object of governmental redistribution. Nor would it be correct to think of health as something that can be demanded as a moral right or as a legal entitlement. To see the matter that way runs the risk of encouraging misguided notions, one, of who is responsible, in the first instance, for an individual’s health and, two, of fostering an unhealthy sense of dependence among citizens. As for health care, proponents of this view might contend that, while we should not put obstacles in the way of obtaining coverage, we are under no obligation to provide health care to each other. They will point to the (fairly significant) fraction of the uninsured who seem to have sufficient income to buy coverage. Given the high cost of insurance, driven in part of oddities of the American tax code, they might say, the decision not to buy insurance might well be an understandable one. There might well be good policy reasons to reform those sorts of problems, but that does not amount to an ethical obligation to give everyone coverage. At the extreme, such a view of health and health care might lead us to see health care as ethically no different from any commodity in a free market.

 Now, the argument just given is usually not the end of the story for the proponents of this position. For they recognize that the world is not a simply just place, and persons may well be buffeted by forces outside of their control, and suffer serious deprivations that are not the result of any lapse of personal responsibility on their part. In those cases, we should stretch out the helping hand, although on grounds of generosity rather than of justice in the strict sense. But unlike those who see health care as primarily a matter of distributive justice, the proponents of this view tend to focus their concern primarily on genuine need and vulnerability, and especially undeserved need. Unmerited suffering or need, rather than a more general commitment to equality, is the core of the concern we ought to show to each other. This difference in moral emphasis bears fruit in a difference over what kind of policies in this area we should prefer: according to the individualism approach, we ought to allow individuals to work these matters out for themselves, and make exceptions only for cases when individuals cannot help themselves.

 Not surprisingly, this point of view runs into its own problems. Stated most generally, the individualism approach commits itself to distinguishing between things we can be held responsible for and those we cannot. That is not always so easy to do. Consider our current way of handling these matters, which is, in many respects, in accord with the moral intuitions of individualism: the default position is that we expect Americans to get coverage through their own means or through their work places. But we make exceptions for the poor and the elderly, since we think, rightly enough, that it is far less likely that they will be able to provide coverage for themselves. The problem arises at the transition point between poverty and some form of middle class stability (as can be seen in our current controversies over expanding S-CHIP). 

 Arguably, that transition point—where a citizen moves from needing a helping hand to being more self-sufficient—is a particularly important one for the American psyche, and not least for the individualism approach in question here. Yet probably the most ethically troubling part of the uninsurance numbers concerns those Americans who make too much money to qualify for Medicaid but who find it very difficult to obtain insurance through their employers or on their own. For a variety of reasons that bear investigation, those Americans tend to find themselves in a no-man’s-land for health insurance. In that situation, our situation, it easy to see how a reasonable person might choose to stay in poverty and not risk the dangers of going without insurance. That is exactly the kind of “charity trap” that would seem to be morally troublesome for an individualism approach. And there seems to be no simple or easy governmental solution to that problem, since providing more coverage directly tends to lure people who already have private coverage away from that coverage, a phenomenon economists call “crowd-out”—an undesirable outcome from the point of view of the individualism approach.  These sorts of dilemmas appear very likely to arise for an approach that combines a default individualism with the recognition that we ought to help those in need. Whether they pose a fatal objection to its viability is an open question. But it is clear that these problems are the problems of our current arrangements, which correspond, however imperfectly, to the moral intuitions of American individualism. 

**C. Health and the Medical Covenant**

The two approaches just discussed correspond roughly to the egalitarian and the libertarian strains in the American polity. It would be parochial, however, to think that these are the only ways we might think about this question. Another approach begins from a consideration of the medical covenant that is arguably implicit in every doctor-patient encounter. Here we rely, in part, on the writings of former Council member William May.2 According to this view, medicine is best seen as a promise to help made by the doctor to the patient—that is, as a covenant. Concepts of medicine that begin from hypothetical individuals making contracts rationally and with full information sorely miss the existential reality of what it means to be a patient: dependent, frightened, vulnerable. On this view, the appropriate beginning point for an ethical reflection on this topic is the human significance of suffering and the obligation of the fortunate and well off to aid the vulnerable and the sick. 

Neither health nor health care can, therefore, be rightly seen as a commodity: the distinctive character of health implies, on the one hand, that the moral bond between doctor and patient transcends the relationships of the marketplace, and on the other, that health care is an area peculiarly liable to market failure.3 In particular, as an economist might say, there are severe information asymmetries between doctor and patient. Moreover, while not the highest good, health is a necessary condition for all the other goods of life. It is also, on this account, a public, and not merely a private good. To this extent, the “covenant” approach agrees with the emphasis of the distributive justice approach on our social obligation to secure equality of opportunity. Proponents of this view, like May, conclude that health care must be both universal and comprehensive.                Yet someone might raise the following objection to this approach: In taking its inspiration so strongly from the professional obligations or covenant of the physician, does this approach confuse or conflate what doctors owe to their patients and what fellow citizens owe to each other? If so, does the “medical covenant” approach require a more fully fledged political philosophy to make its claims plausible? 

The proponents of this position might respond to this critique as follows. Even if the medical covenant entered into by doctors cannot, on its own, be the basis of a complete account of obligation, notions of covenant might still be a better guide than its competitors to how we think or should think about health care within our polity. A “social covenant,” they might argue, is superior to either an individualistic account or a Rawlsian, egalitarian account, both as a matter of ethics and, arguably, as a matter of how most Americans, in fact, think about their relationships to each other. On this view, individualism fails to articulate the real depth of our obligation to one another, and egalitarianism wrongly puts the emphasis on the rights or entitlements a person might demand from the polity, while we should see this question from the other side, as a matter of what we owe each other. So far from granting that “covenant” is a notion best confined to specific professions like medicine, the proponents of this view turn the criticism around to say: the idea of covenant—accessible to us in the profession of medicine, to be sure, but not only there—is the right beginning point for elaborating an adequate political philosophy. Indeed, one might say that medicine is an arena in which a basic moral truth opposite to the claims of individualism is most manifest: we will all be patients someday, and we will all be dependent on the knowledge and good will of others. 

 These proponents thus articulate a position that begins from quite different moral intuitions than either of its competitors. We might still ask, however, whether the “covenant” approach has discovered a true “third way” between the familiar alternatives of American moral discourse. Or will the competing moral considerations behind egalitarianism and individualism spring up anew and require another weighing?
V. Conclusion: Questions for Council Members
 We conclude with some speculations on what a Council report on this topic might look like and some questions for Council members. One way of approaching a possible Council report would be to pursue the suggestions made by Leon Kass at the September Council meeting. In other words, the Council would seek to develop and publish a report whose stated goal is to articulate various ways of justifying and thinking about health care reform—or what we have been calling here the grounds of our public and ethical concern for health and health care. The final document would be written primarily with a view to public education, not advocacy of any particular program of reform. Such a report might well include a dispassionate discussion of the problems facing American health care, including discussions of both the problems of the uninsured and the issues surrounding the rising cost of care. This part of the project might take one chapter or a series of chapters in the report, but the idea would be to do something roughly similar to the first chapter of Taking Care. The dramatic heart of the report, however, would be a thoughtful consideration of the alternative ways of conceiving the moral and political issue, including the ones we have discussed here and any others the Council thinks worthy of consideration.

 The other path to a Council report might be a thoughtful and informed inquiry into the question raised above about medical technology and the rising cost of medicine. Such a report would investigate both the factual and the moral claims made by commentators like Dan Callahan, although certainly not only him. Without an extensive survey of the literature on this topic, it is premature to speculate on what we might say, although it seems clear that such a report would be at most for the sake of public education, and again not in the service of any preferred solution. But it should be said, on behalf of this option, that this topic is both interesting and important; that it examines a important theme of the Council’s previous work from a new angle; and that providing an explication of a side of the health care debate very often overlooked might do some real good in fostering informed public debate on this topic. It is also conceivable that this topic might serve as the basis for a chapter in a Council report more along the lines of the first option above.

We offer these alternatives only as possibilities, and we welcome comments and criticism about them, as well as thoughts about other ways of proceeding on this topic. But we conclude by raising some questions Council members will need to answer for themselves. First, in your view, have the pressing objections to our moving forward in this area been adequately met? Here we think in particular of the objection (articulated to the Council by Zeke Emanuel among others) that the moral question is either uncontroversial or effectively irrelevant for the actual policy decisions before the country. We would ask: is it really true that it makes no difference whether we think about this topic from the perspective of distributive justice, individualism, or a “medical covenant”? And can the Council do good work in clarifying, perhaps to some extent adjudicating, between these alternatives? Second, if we move forward, should the main burden of the report be the questions concerning the ethical foundations of health care, technology and the ends of medicine, or something else? 

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FOOTNOTES-   On this topic one might look to the work of John Wennberg, who also spoke to the Council at the March 2005 meeting. For example, according to one recent paper published by Wennberg and colleagues, almost 20% of Medicare spending seems to bring no benefit in terms of survival. See �The Efficiency of          Medicare,� Jonathan Skinner, Elliot Fisher, and John Wennberg, NBER Working Paper No. 8395, available at  www.nber.org . 
-   See William F. May,  Testing the Medical Covenant: Active Euthanasia and Health Care Reform   (Wipf & Stock: Eugene, Oregon, 2003 [1996]), especially �Keeping Covenant and Health Care Reform.� 
-   For further critique of the commodification of health care, see E. D. Pellegrino, �The Commodification of Medical and Health Care:   The Moral Consequences of a Paradigm Shift from a Professional to a Market Ethic,�  Journal of Medicine and Philosophy  , Edited by Kevin Wm. Wildes and M. Cathleen Kaveny, 1999, Vol. 24, No. 3, pp. 243-266. 

 

 

             

             

             

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