Leonard M. Fleck

Just health care rationing: a democratic decisionmaking approach.

Michael S. was born in 1984 to unmarried teenage parents who were without health insurance. He was born with necrotic small bowel syndrome. Surgery at-birth determined that he would not be able to process food in the normal way. Hence, he would have to remain in an intensive care unit, fed via total parenteral nutrition (TPN). After six months the hospital administrator approached the attending physician and pointed out that Michael was responsible for

Ethics and consent to treat issues in acute stroke therapy

250,000 in uncompensated care costs. Michael could live another six to eighteen months, which would mean potential uncompensated care costs of one million dollars. The administrator reminded the physician that this was the only hospital in town that provided charity care to the poor, and that if Michael remained in the hospital then the emergency room would have to be closed to all the poor, except those with true life-threatening medical problems. The state was willing to care for Michael and place him in a nursing home, but it would not provide TPN, which would mean Michael would die of infection and/or starvation within two weeks. 1

Rationing: Don't Give Up

Consent to treat with thrombolytic therapy for acute ischemic stroke presents an ethical dilemma for hospitals, physicians, patients, and their families. This article presents four aspects of this controversial topic and provides recommendations for conditions that allow for ethical consent to treat.

Ethics, professionalism, and humanities at Michigan State University College of Human Medicine

Its not only necessary, but possible, if the public can be educated.

Healthcare Justice and Rational Democratic Deliberation

This article describes the variety of approaches used at Michigan State University’s College of Human Medicine for teaching ethics, professionalism, and humanities to undergraduate medical students: courses in ethics and health policy; mentoring programs; selectives in history, literature, and spirituality; structured patient care experiences; and discussions with students in their clinical years on the ethical and professional challenges confronting them in their clinical experiences. Some of these approaches, such as the structured patient-care experience, may be unique to Michigan State. The authors place special emphasis on discussing the challenges that confront this curriculum, including struggles to keep up with the pace of change in the health care system, preserving and highlighting the linkages between the “ethics” and the “professionalism” strands of the curriculum, making optimal use of Web technologies, successfully communicating to students the ultimately practical importance of the medical humanities other than ethics, and solving the problems of geography created by a widely dispersed community campus system.

Whoopie pies, supersized fries. "Just" snacking? "Just" des(s)erts?

How can we meet competing healthcare needs fairly under reasonable resource constraints? That is the third question Daniels addresses in his essay, and I will use it to frame my comments. I endorse the broad framework for understanding healthcare justice that Daniels has presented. That is, his fair equality of opportunity account (1985) should be thought of as an essential part of any adequate account of healthcare justice. However, as he readily concedes, that account is too broad to do the very ane-grained work that needs to be accomplished when we must make concrete rationing and prioritization decisions. That work can be best accomplished through a rational democratic deliberative process. But Daniels himself (1993, 1996) has called our attention to what he labels “the democracy problem.” In brief, it is this: If a rationing decision that emerges from a democratic deliberative process is open to moral criticism as being unfair, then there must be independent (extrademocratic) moral principles that justify that judgment. If so, the democratic process itself is otiose. On the other hand, if the deliberative process itself is ascribed ultimate moral authority, then we risk majoritarian moral arbitrariness. I myself believe that the “democracy problem” is manageable, both pragmatically and theoretically. The key to managing it is a much richer (more substantive) articulation of what rational democratic deliberation is all about in the context of healthcare rationing. This, I also believe, can be accomplished within the spirit of Rawls’s Political Liberalism (1993), which is Daniels’s goal as well. Two concepts are especially central in this project. One is what I have referred to metaphorically as “constitutional principles of healthcare justice.” The other is the notion of “nonideal justice.” I have sketched out both notions in earlier essays (1994, 1999) in both theoretical and practical terms, and I am now anishing a book-length project that carries that analysis much further. The basic relationship is that these constitutional principles of healthcare justice deane the political space that is the domain of nonideal healthcare justice. Within that space there will be an indeanitely large number of possible trade-offs, possible alterations in healthcare priorities, and possible rationing alternatives that will all be “just enough,” or, to put it in more Rawlsian language, that will express reasonable enough fair terms of cooperation. The choices that are actualized will depend upon the deliberative process itself. So long as the fairness of that process is assiduously maintained, the results will be both fair and politically legitimate. Some philosophers may be disturbed by what they regard as morally arbitrary results from the deliberative process being accorded moral legitimacy. Their general criticism is that for any speciac rationing problem there really is a “most just” or “most morally justiaed” outcome that alone should be granted moral legitimacy and that we would get to if we persisted long enough with sophisticated moral argument and analysis. However, if we take seriously (with Rawls) the fact of reasonable value pluralism and the “burdens of judgment” (1993, Lectures II and VI), then we realize that this criticism is rooted in a philosopher’s utopian action. That sort of quest for precision is apt in mathematics and engineering, but it will be counterproductive in the domains of morality and public policy. This inapt quest for precision is what gets the democracy problem going. But if, with respect to any particular rationing or priority-setting problem, there are several options that are all “just enough” (fair choices in the deliberative process), then the force of the democracy problem is signiacantly reduced. What we do need to avoid is giving political legitimacy to results of the deliberative process that are seriously unjust. Our constitutional principles of healthcare justice are intended to prevent exactly that. Those principles establish deliberative boundaries that may not be violated. It might appear that these principles could precipitate the reemergence of the democracy problem. However, for that to occur, these principles would have to have a legitimating source outside public reason and the deliberative process. They do not. Just as the Founding Fathers of the United States served as political focal points for the distillation of the U.S. Constitution and its principles from the democratic political/philosophical discussions of the day, so philosophers today should play a similar role with respect to the articulation of principles of healthcare justice. From my perspective this is what Daniels has done in his fair equality of opportunity account. That is, he has provided us with one very important constitutional principle of healthcare justice. There are, of course, multiple such constitutional principles. They can come into conoict with one another in the context of speciac rationing problems. But the task of specifying, adjudicating, and applying these principles is something that can be accomplished through democratic deliberative processes. Daniels’s anal-

Just caring: In defense of limited age-based healthcare rationing

The annual cost of healthcare in the United States reached

Just health care (I): Is beneficence enough?

2.5 trillion in 2009 (about 17.6% of GDP) with projections to 2019 of about

“Just Caring”: Can We Afford the Ethical and Economic Costs of Circumventing Cancer Drug Resistance?

4.5 trillion (about 20% of likely GDP).

It’s NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment

The debate around age-based healthcare rationing was precipitated by two books in the late 1980s, one by Daniel Callahan and the other by Norman Daniels. These books ignited a firestorm of criticism, best captured in the claim that any form of age-based healthcare rationing was fundamentally ageist, discriminatory in a morally objectionable sense. That is, the elderly had equal moral worth and an equal right to life as the nonelderly. If an elderly and nonelderly person each had essentially the same medical problem requiring the same medical treatment, then they had an equal right to receive that treatment no matter what the cost of that treatment. Alternatively, if cost was an issue because the benefits of the treatment were too marginal, then both the elderly and nonelderly patients requiring that treatment ought to be denied it. If there were something absolutely scarce about the treatment, then some fair process would have to be used to make an allocation decision (and that fair process could not use some age cutoff among the allocation criteria).