What Counts as Basic Health Care? Private Values and Public Policy

Abstract

A firm consensus has dominated the American republic's ethos: religious and personal values belong to the realm of the private, separate from matters of public policy. The coming health care debate is about to challenge that separation. Basic health care is on the verge of being recognized as a right for Americans as it has been for most of the modern world. As long as "good health care" was believed to be a matter of fact, there was no conceptual problem for the separation of the public and the private. Medicine was thought to be objective, a matter appropriate for public policy. A national board, with the assistance of objective outcomes research, could determine what was covered. But increasingly the postmodern world recognizes that what is good medicine is nothing more than those services that further the ends of life as defined by the individual. These ends are ultimately religious visions (or the secular equivalent thereof)--matters reserved for the realm of the private. Oregon has already determined which health care deserves state Medicaid funding and the Clinton health care plan promises similarly to establish a single list of services worthy of public support. To the extent that deciding which medical services deserve support derives from decisions about the proper end of life, formulating a single, basic list of services is the moral equivalent of establishing a religion. Consider whether abortion should be included in the government's list. Surely, deciding whether abortion is good or evil is a religious question (or at least a moral one). Whether abortion is included or not, some religious (or philosophical) view of when life has moral standing will become a matter of public policy. Likewise, even though the choices may be more subtle, literally every decision about public funding of health services will be a decision about what fits with a well-lived life. But judgments about what is a well-lived life are traditionally reserved for the private realm. Deciding that a vegetative life is not worth preserving is a value judgment, not a scientific fact. So is deciding it is worth it to fund HIV therapy, infertility services, mammograms, or well-baby clinics. Including--or refusing to include--transplants, immunizations, or genetic engineering depends on whether these procedures fit with our understanding of the human good. Even deciding what it means to be dead challenges our notion of the separation of the public and the private. …