Short literature notices

Abstract

What does it mean to be a ‘‘just’’ and ‘‘caring’’ society when we have only limited resources to meet virtually unlimited health care needs? In Just Caring. Health Care Rationing and Democratic Deliberation Leonard Fleck identifies health care rationing as the moral problem of contemporary health care. At present, millions of Americans go without health insurance, thousands of whom die prematurely, unable to afford the health care needed to save their lives. If these facts run contrary to our sense of justice, as the author believes they do, health care rationing decisions are necessary and a fundamental reform of the American health care system is warranted. Although Just Caring seems to be written for an American public primarily, the book is extremely interesting for Europeans as well. Firstly, Fleck provides us with a very detailed account of the present state of the American health care system. Secondly, the problems Americans and their health care have to deal with are not unique to the United States. Although the American system seems to result in inequities Western Europeans particularly are largely unfamiliar with, at a more fundamental level both sides of the Atlantic share an interest in tackling the same problems: ageing populations, advancing medical technology and rising costs. In the end every health care system faces the challenge of meeting virtually unlimited health care with limited resources. First of all, the author argues convincingly the inescapability of health care rationing. The so-called ‘‘efficiency first’’ approach, defended by policy analysts who hold that health care rationing is unnecessary once all the waste is removed from the system, is misleading in that the proposals they put forward are very often disguised rationing decisions themselves. Fleck makes quite clear that greater efficiency, more astute health care management, or finding the right incentives to shape the behavior of patients or physicians is not going to obviate the need for rationing decisions with life and death consequences for different individuals or different groups of individuals. If an individual is in need of health care but is denied access to health care, such an individual is affected by a rationing decision if that health care is available to others. Such decisions are not necessarily morally wrong by themselves, but the problem is that they tend to be implicit. Nowadays, rationing decisions are almost never visible and explicit as rationing decisions. The reasoning is very seldom public and outsiders are denied the opportunity to correct possible errors. It is not open to critical assessment. Furthermore, implicit rationing tends to disadvantage the weak and vulnerable in society, as is made painfully clear by the numerous examples given by the author. Of course, as phenomenon implicit rationing is not unique to the American health care system. Rationing is primarily a moral problem that ought to be resolved in accordance with the requirements of morals and justice. Economic, managerial and organizational considerations come second. Since rationing is generally implicit, Fleck argues, there is no assured rational relationship between medical need or likelihood of medical benefit and the care that is actually provided. Secondly, and equally important, there is no assured connection between the values that drive implicit rationing decisions and the values of R. Andorno (&) Institute of Biomedical Ethics, University of Zurich, Zollikerstrasse 115, 8008 Zurich, Switzerland e-mail: andorno@ethik.uzh.ch