'...not just the premier
Christian bioethics institute in Britain,
but one of the finest in the
world, Christian or secular'
Most Rev. Anthony Fisher O.P., Auxiliary Bishop of Sydney
Healthcare Allocation:
An ethical framework for public policy
Anthony Fisher O.P. and Luke Gormally
This volume, prepared on behalf of The Catholic Bishops' Joint
Bioethics Committee, argues that there is a need for an alternative to the most
widely influential understandings of the ethical requirements which healthcare
allocation policy should meet. It offers a detailed critique both of
liberal-welfarist and utilitarian approaches to healthcare allocation. The
authors maintain that an ethically adequate approach to resource allocation in
healthcare must be based on specific ('content-full') understandings of the
human person, of human needs, of human community and the common good, and of the
nature of healthcare. Only if policy is informed by such understandings can it
avoid serious injustice to patients and the abandonment of values essential to
healthcare practice. The volume details the normative requirements allocation
policy should meet, and highlights injustices which are encouraged by current
tendencies in policy, reinforced by decisions in the courts.
Contents
Foreword
Preface
Introduction: "Crisis" in the NHS
Part I Preliminaries
Clarifying some central terms
of the debate
Background to the current crisis
in health care allocation
Some standard responses to scarcity
Ethical issues in the allocation
debate and the content of this Report
Part II Healthcare Allocation:
Unsystematic approaches and the contemporary search for principled solutions
Unsystematic approaches: allocating
resources without planning
The contemporary search for principled
solutions (1) : What basis for principles?
The contemporary search for principled
solutions (2) : Liberal-welfarist approaches
The contemporary search for principled
solutions (3) : Utilitarian-economic approaches
Part III A Framework of moral
understanding for healthcare allocation
Towards a substantive conception
of the human good
Persons and their needs
The nature of human community
and the provision of healthcare
Part IV Criteria and
considerations relevant to allocation decisions
Inadequate allocation criteria
To each according to his/her
need
Other considerations in healthcare
allocation
Part V Catholic Social Teaching
Catholic social teaching and
the allocation of healthcare
Part VI Conclusion
Implications for public policy
Summary and conclusions
Endnotes
Index
Reviews
"Many of the most pressing and complex public healthcare policy issues
today relate to the demands for limited healthcare resources to satisfy
virtually limitless needs. This book, sponsored by the Catholic Bishops
of Great Britain and Ireland and prepared by the Catholic Bishops' Joint
Bioethics Committee, is written to contribute to this important public dialogue.
The purpose of this book is to provide both an ethical critique of prevailing
approaches to healthcare allocation and to identify the basic ethical framework
of moral principles that should govern the just allocation of healthcare
resources. The authors make it clear that this work is not a blueprint for
resource allocation. An ethical framework, although a decisive determinant
of resource allocation policy, is only one factor to be considered. Nor
do the authors believe that a uniquely correct solution or approach to these
issues exists for the United Kingdom or for other similar economies. It
is clear to them, however, that much current thinking about resource allocation
is both intellectually and morally unsatisfactory.
The underlying assumptions and orientations of the book are Christian
and rely in particular on the Christian natural law tradition, especially
in bioethics, and Catholic social teaching. Because the authors hope to
engage in dialogue with a broad audience of policy decisions makers, however,
they have appropriately chosen points of departure, a method of argumentation,
and a language that appeals to reason and experience. This approach should
have a wider appeal, incorporating what the authors refer to as the best
of our "common morality" of principles such as are articulated
in the Bible and the Koran, the Hippocratic Oath, contemporary "virtue
ethics," the common law, international human rights documents, and
the teachings of many thinkers, both secular and religious.
Because the context of this book is resource allocation in the United
Kingdom, particular reference is made to the "crisis" in the National
Health Service (NHS) and to the increasing number of complaints about equity,
comprehensiveness of access, failures of care, and other concerns. Similar
"crises" are also being faced in other developed countries, and
because the approach is essentially at the level of values and principles,
this book can be readily applied in countries other than the United Kingdom,
such as the United States and Canada.
Healthcare Allocation is rightly organized and clearly presented;
its argument is systematic and nuanced. Summaries at the beginning of each
chapter and a concluding summary of the book's line of argument make for
easy reference. Beginning with a preliminary clarification of key terms
and issues in the allocation debate, the book presents a critique of contemporary
approaches to allocation; argues for a justice framework built on an understanding
of the human good, persons and their needs, the common good, distributive
justice, and the nature of human community; and critiques the inadequacies
of the criteria frequently proposed in this debate. It addresses many of
the most hotly debated allocation issues, such as the needs of those at risk:
the frail elderly, the handicapped, the mentally ill, and the poor as
well as the need to respect basic human rights, punitive and prejudiced
health care allocations, and competing social goals. There is a chapter
summarizing Catholic social teaching related to the allocation of healthcare
resources, and brief considerations of other commonly raised issues, such
as how much should be spent on healthcare, healthcare as a right, the public/private
mix, who should be the gatekeepers, and the need for public debate on these
issues.
True to its title and intent, this book serves well as a framework of
principles for treating the many issues and points of view currently under
discussion. It gives an excellent critique of current approaches to resource
allocation such as "ad hocery," the free market, and the liberal-welfarist
and the utilitarian-economic views. These approaches are found to be inadequate
in their understanding of the human good, the needs of the human person,
the community and the common good, and healthcare itself.
The justice perspective emphasized throughout the book is one of its
strengths. A just healthcare service would ensure access for all members
of the community to care sufficient to meet their healthcare needs. Healthcare
services should be allocated according to need, irrespective of factors
such as age, race, sex, religion, social contribution, consciousness, intelligence,
quality of life, provider whim, and ability to pay; however, preference
should be given to those who are disadvantaged. At several points, the book
reflects on the Gospel parable of the Good Samaritan as a useful model for
good practice in healthcare allocation. The chapter on Catholic social and
bioethical teaching and healthcare allocation is an excellent summary of
this teaching and provides a valuable reference for anyone wishing to understand
the specific contribution of Catholic thinking in this area.
Because the book presents an ethical framework of general principles,
it does not develop in detail the many issues it raises. However, it presents
a coherent justice perspective that can be a valuable asset for any healthcare
providers or decision makers who are struggling with these resource allocation
issues."
- Richard M.
Haughian
Health Progress May/June 2002.
"This book makes it clear from the outset what
its purpose is to be. It is to provide an ethical framework for policy making,
but not to set out a blueprint for resource allocation... There is a fascinating
analysis of the ways forward; spend more, be more efficient, distribute
better. The key is the question of justice which is discussed in detail.
The allocation of resources in an ad hocway (the current
practice) is dismissed, as is the use of market mechanisms. It is the "Golden
Rule" which will set the agenda, "Do unto others as you would
have them do to you". Where this model becomes difficult is in its
implementation. In the Chapter on implications for public policy it states
"..it is clear that healthcare spending should be sufficient to ensure
access for all to a level of healthcare adequate to satisfy their general
needs within a reasonable time and without unreasonable disincentives."
Herein lies the nub of the issue. If resources are not adequate to meet
reasonable needs how should they be allocated to satisfy the "golden
rule"? The authors rule out the use of an algorithm for this purpose
and make the point that there is no right answer, only a number of inadequate
answers. Allocation should be by recognising certain moral norms, virtues
and values which guide and structure human choice. The list of such values
and norms is well developed, and this critical section ends with the comment,
"We argued in favour of an egalitarian distribution according to healthcare
need, with a preference for those in greatest healthcare need, those otherwise
disadvantaged, and those upon whom others are dependent".
How then can this book be summarised? First it presents a coherent analysis
of the ethical issues surrounding resource allocation and rationing. Second,
it provides a framework around which decision-making can take place. There
are two remaining issues, recognised by the authors but specifically not
dealt with, which need more attention. The first relates to what constitutes
a "reasonable" level of healthcare allocation and how is this
decision arrived at? The second is what to do if this allocation is not
sufficient, and how then can the "golden rule" be implemented?
These two issues deserve further attention, and this book provides a platform
for further work.
Finally it is always a pleasure to open a book and read a preface by someone
you respected and admired. I was privileged to meet Cardinal Winning on
a number of occasions and to share both his sense of humour and his humanity.
It is fitting that it was he who chaired the Catholic Bishops' Joint Ethics
Committee to begin this work. In his memory it deserves to be developed further."
