Just Caring Health Care Rationing and Democratic Deliberation

by Fleck, Leonard M.

• ISBN13: 9780195128048
• ISBN10: 0195128044
• Edition: 1st
• Format: Hardcover
• Copyright: 2009-03-30
• Publisher: Oxford University Press

Summary

What does it mean to be a "just" and "caring" society when we have only limited resources to meet unlimited health care needs? Do we believe that all lives are of equal value? Is human life priceless? Should a "just" and "caring" society refuse to put limits on health care spending? In Just Caring, Leonard Fleck reflects on the central moral and political challenges of health reform today. He cites the millions of Americans who go without health insurance, thousands of whom die prematurely, unable to afford the health care needed to save their lives. Fleck considers these deaths as contrary to our deepest social values, and makes a case for the necessity of health care rationing decisions. The core argument of this book is that no one has a moral right to impose rationing decisions on others if they are unwilling to impose those same rationing decisions on themselves in the same medical circumstances. Fleck argues we can make health care rationing fair, in ways that are mutually respectful, if we engage in honest rational democratic deliberation. Such civic engagement is rare in our society, but the alternative is endless destructive social controversy that is neither just nor caring.

Table of Contents

Just Caring: An Introduction	p. 3
The "Just Caring" Problem: Core Argument	p. 5
Rationing Justly: The Moral Challenge	p. 11
Applications of the Deliberative Model	p. 20
The Ethical Challenges of Health Care Rationing	p. 34
The Story of Coby Howard and Its Lessons	p. 35
Why Health Care Rationing Is Inescapable	p. 39
Renal Dialysis and the Medicare End-Stage Renal Disease (ESRD) Amendments	p. 44
The Totally Implantable Artificial Heart (TIAH)	p. 55
Pricing Human Life: Getting Beyond Tragic Choices	p. 71
Is Human Life Priceless?	p. 74
Tragic Choices or Tragic Disingenuousness? Invisible Rationing	p. 81
Invisible Rationing and the Publicity Condition	p. 88
Managed Care and Health Care Rationing	p. 95
Elements of Health Care Justice	p. 100
Is Health Care Morally Special?	p. 103
Non-ideal Justice: A Moral Analysis and Defense	p. 112
Pluralism, Justice, and Rational Democratic Deliberation	p. 124
Rational Democratic Deliberation: Scope and Structure	p. 140
The Scope of Rational Democratic Deliberation	p. 141
Fair Health Care Rationing: Not Markets, Not Physicians, Not Bureaucrats	p. 148
Rational Democratic Deliberation: Taking Seriously the Tragedy of the Commons	p. 151
Rational Democratic Deliberation: Key Structural Features	p. 160
Rational Democratic Deliberation and Fair Health Care Rationing	p. 164
Wide Reflective Equilibrium and Just Health Care Rationing	p. 171
Priority Setting, Wide Reflective Equilibrium, and Rational Democratic Deliberation: Addressing the Stability Problem	p. 177
Facts, Wide Reflective Equilibrium, and Democratic Deliberation	p. 181
Constitutional Principles of Health Care Justice and Rational Democratic Deliberation	p. 184
Evaluating the Deliberative Process	p. 195
Objections and Responses	p. 199
Setting Limits for Effective Costly Therapies	p. 202
Problem Introduction	p. 202
Setting Limits: Options in the ESRD Program	p. 205
Setting Limits: Options for HIV+/AIDS Patients	p. 208
Setting Limits: The Case of Artificial Hearts	p. 219
Setting Limits: Concluding Comments	p. 227
Last-Chance Therapies	p. 229
Introduction: Scope of the Problem	p. 229
Why Last-Chance Therapies? Weak Moral Arguments	p. 231
Last-Chance Therapies and Rational Democratic Deliberation	p. 242
Futility and Last-Chance Therapies	p. 249
Rationing, Catastrophic Illness, and Disabled Patients	p. 254
Introduction: The Scope of the Problem	p. 254
Needs Are Not Enough; Effectiveness Must Matter	p. 256
The Oregon Plan and the Disability Critique	p. 259
Health Care Justice and the Disability Critique	p. 263
Defining the Disabled: Ethical Implications	p. 268
Conclusions	p. 273
Is Age-Based Rationing Ever "Just Enough"?	p. 276
Defining the Problem: Can We Accept Natural Limits to Life?	p. 276
Justice and Age-Based Rationing: Fair Innings	p. 279
The Prudential Life Span Account	p. 285
Age-Based Rationing: Major Objections	p. 290
Age-Based Rationing: Responses to Objections	p. 291
Age-Based Rationing and the Duty to Rescue	p. 294
Conclusions	p. 299
Do Future Possible Children Have a Just Claim to A Sufficiently Healthy Genome?	p. 300
Framing the Issue	p. 303
Preimplantation Genetic Diagnosis (PGD): A Historical Side Note	p. 306
Does Justice Require Public Funding for Limited PGD?	p. 308
Concluding Comments: Justice and Genetic Enhancement	p. 316
Organ Transplantation: When is Enough Enough?	p. 318
Scope of the Issue	p. 318
The Maximization Argument: A Critical Moral Analysis	p. 320
The Pittsburgh Protocol: How Dead Must Donors Be?	p. 324
Organ Procurement and Financial Incentives: A Critical Assessment	p. 327
Presumed Consent/Duty to Donate: Critical Remarks	p. 331
Justice and Multi-Organ Transplants or Retransplants	p. 333
Concluding Comments	p. 341
The Liberalism Problem	p. 342
Justice, Health Care Needs, and Morally Controversial Interventions	p. 342
Liberal Communitarianism: Is It Just Enough? Is It Liberal Enough?	p. 347
Resolving the Liberalism Problem: Public Reason and Public Interests	p. 352
Concluding Reflections	p. 359
The Ethical Challenges of Priority Setting in Public Health	p. 362
Defining the Problem	p. 362
The Scope of Public Health: Challenges and Choices	p. 365
Health Care Justice and Public Health: When Is Enough Enough?	p. 368
Setting Public Health Priorities Justly: The Limits of Moral Theory	p. 375
Financing Health Care Fairly	p. 379
Why National Health Insurance?	p. 379
Why Health Reform?	p. 383
Assessing Competing Proposals for Health Reform	p. 384
Health Savings Accounts: A Critical Assessment	p. 385
Health Care Vouchers: A Critical Assessment	p. 388
Single-Payer Reform: A Constructive Proposal	p. 394
Summary and Reflective Conclusions	p. 399
Notes	p. 403
References	p. 427
Index	p. 447
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