Principles for national health care reform.

The Ethics Working Group of the Clinton White House Health Care Task Force was assembled at the beginning of March 1993. One product of that group was a list of "Principles and Values" that the White House Domestic Policy Council published under the heading "Ethical Foundations of Health Care Reform."(1) Space prevents listing them all, but they included a call for the following: universal access to equal, comprehensive benefits that meet our needs over the life span; a fair financing system that imposes burdens according to ability to pay and distributes burdens fairly across generations; the wise allocation of resources within health care and between health care and other goods; the delivery of effective services and the avoidance of ineffective ones through the provision of high quality care; a simply organized, efficiently managed system in which individual choice, personal responsibility, and professional integrity are all respected; and fair procedures for making decisions and resolving disputes. Especially in light of the recent controversy about "principlism" in bioethics, I would like to explain the intended use of these principles in this "public ethics" setting, for they are the product of a reasonable division of moral labor. A first point about these principles is that they were not derived from or developed in light of some particular body of systematic ethical theory.(2) Within the group, only an informal attempt was made to connect them to broader notions of justice, equality, and community. The search for principles and values was the result of a charge to the Ethics Working Group to draft a "preamble" to the legislation (which did not yet exist), drawing on broad traditional values in American culture. Within our group we were able to arrive at agreement on these midlevel principles and values, specifying desirable features of health care reform, even though we lacked agreement on what sort of ethical theory might provide deeper, more systematic support for these values and principles. By seeking agreement on principles and values without agreement on underlying theory, we paid a price. No one reform proposal can fully comply with all the principles and values, since all feasible proposals will involve different trade-offs among them. A body of systematic theory could have provided more guidance about which kinds of trades are more acceptable by providing grounds for claims about priority among the principles. But that deeper layer of theory was unavailable once the decision was made that disputes about theory would be divisive in a group as diverse as the Ethics Working Group, to say nothing about society at large. In effect, then, we are forced to think about trade-offs and partial compliance with the principles in a more intutionistic way, guided by what information we have about the context. Though we were aware that the principles and values were not rigorously formulated and that we lacked consensus about priorities among them, we still hoped they would provide a useful framework for focusing discussion on morally sensitive and controversial choice points in the design of a health care system. We hoped they would provide a way of showing that the politically motivated compromises underlying the Clinton proposal--such as retaining private insurance or an employer mandate--would come at some moral cost. We even hoped, perhaps naively, that avowal of these principles might slow the process of compromising away compliance with them. Many of us, perhaps everyone on the Ethics Working Group, would have preferred working on a Canadian-style singlepayer system. We agreed to work on the Clinton proposal because we thought we could isolate key moral commitments that the president's more complex system could still honor. In a longer version of these remarks, I shall comment on how these principles provide a matrix for thinking about issues of fairness that are at stake in the choice among competing reform proposals. …