Health Policy and Ethics

A Critical Examination of Values from a Global Perspective

Roger Worthington, Robert Rohrbaugh

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315342986
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book demonstrates the utility of healthcare law, policy and professional standards in analysing the ethical issues that arise in the provision of health services. Rejecting moral absolutes, its examination of health law, policy and professional standards and of how societies codify beliefs is pertinent to ethical analysis - and also offers the possibility of practical solutions to healthcare challenges across the globe. Comparing and contrasting ethical and policy issues from countries around the world (with a focus on Asia, Europe and the USA), this book addresses such issues as conflict of interest, the balance between healthcare quality and cost, and the effect of geography and demographics on access to healthcare. Critique and discussion are tempered with suggestions for the evaluation of policy and systems; its pragmatic approach suggests how theory can and should inform practice. Health Policy and Ethics offers refreshing reading for professionals and academics in healthcare, medical ethics and policy. Researchers and students with an interest in healthcare delivery, comparative healthcare policy analysis, and health and human rights will also find much of interest. 'This book offers an unusual and welcome perspective on the rights and wrongs of health policy, with comparisons across space and time, from China to Italy, from Malaysia to India, from pharmaceutical ethics to the overarching topic of rationing.' Theodore Marmor, Professor Emeritus, Yale University School of Management Ethical analysis in this domain is not easy, as things held sacred will at times conflict, and of course within a given society there will be variability in values and priorities between individuals and over time. The anticipated difficulties serve to further emphasize that the ongoing ethical analysis should include input from those with experience and skill at that task. This book successfully demonstrates that point. In addition, Health Policy and Ethics is a welcome bridge between these two fields, and a very worthwhile read for individuals whose primary interest lies in either one. - From the Foreword by Mark R. Mercurio

Part 1

Chapter 1

Introduction

The basic provision of health care services is not something that can be taken for granted, and the extent to which patients are able to access services that they need, when and where they need them varies greatly between and within countries. Health care services, of whatever standard, cannot be provided in an ethical vacuum. While health policy debate is normally dominated by political and economic considerations, there is a moral dimension to the provision of health care, which can profoundly affect the care patients receive as well as the clinical outcomes. It is our belief, therefore, that ethical considerations need to be consciously factored into public policy considerations.

There is a growing recognition that health policy is not value neutral, and as a subject it cannot be regarded as an “ethics free zone.” Leathard and McLaren describe how ethics is increasingly taking a key position in publications on health and social care;¹ Dawson and Verweij note that within bioethics, public health ethics is developing into a sub-discipline of its own,² and Hester describes how ethical deliberation and good public health practice are intrinsically part of good professional practice.³ Murray notes in relation to the health reform program in the USA that:

“There is a broad range of values that we want our health care system to embody and pursue—not just liberty but also justice and fairness, responsibility, medical progress, privacy, and physician integrity, among others.”⁴

This is a tall order, perhaps, but they are important issues that ought to be actively discussed, and in this work we go on to say that being deprived of access to quality and affordable health services can put lives at risk, reduce life-expectancy, and impact on the quality of life of both individuals and populations.

Health care policies determine how health care is provided, and our thesis is that by analyzing health law, health policy and professional standards, something essential about the ethical values espoused by any given society can be revealed. In some countries, financial gain is a preeminent driving force behind the provision of health services, while in others what matters most is simple human survival, and in between these two extremes is a range of social and political models for delivering health care. Ethics is no optional extra within the policy arena, and when the sustainability of human life itself is at stake, the moral dimension to the provision of health care is always present, even if it is not recognized.

In short, our argument is that it is a matter of public interest to make room for serious ethical debate within the context of analyzing and determining health policy. An essential part of this analysis is examining critically the relation between what is legal and what is ethical, and we do not subscribe to the view that they are necessarily one and the same. This area of jurisprudence needs to be considered if ethics and policy are to work closer together. Integrating ethics into health policy discussion may not be achievable unless there is clarity as regards legal frameworks that are applicable in a given setting, and we discuss these issues more fully in the next chapter.

Ethics does not simply deal with abstractions—it can be used as a sharply analytic tool leading to practical suggestions for change. While barriers to change are sometimes physical and intensely practical, they are just as often conceptual and ideological. Effective policies have to be able to coordinate complex arrangements of organizations and services, and the provision of health care typically has to take account of large, diverse populations with different needs and preferences, and of necessity this renders the application of simple formulae near impossible.

Patient safety is an example of a specific issue where an ethical analysis can be useful. Patient safety is an increasingly important issue within systems of health care delivery, and this topic gives rise to policy considerations of their own that require ethical scrutiny. While health policies are not value-neutral, putting ethics and health policy within a single phrase is not something to which people are yet fully accustomed, and we argue that the linkage between these two domains is logical, significant and inescapable. While under Article 25 of the United Nations Declaration of Human Rights health is regarded as a fundamental human right, simply making this assertion does nothing to change the way things are in practice. Rights declarations have their place but effectively they serve as statements of intent; however, the possibility remains that rights-based claims to good quality care are morally defensible and worth close scrutiny.

External economic and political events play a significant part in the policy-making process, and addressing the underlying ethics and putting policies into perspective are important considerations. Improving health care service provision takes a great deal more than merely opening a hospital or spending additional resources. It requires sustained effort as well as an adequate supply of human and material resources in order for lasting improvements to be achieved, including simple access to basic services. Analyzing the ethical implications of health care policies governing efforts to change systems is critical to ensuring that policies are effective. Policies that contradict each other are doomed to fail, and we contend that these pitfalls can only be avoided if there is clarity of thinking and expression about the underpinning values.

Pragmatism and ethics need not work in opposition. Much will depend on how policies are formulated and how they relate to other policies, and often it is unclear who is making policy decisions according to what criteria. Policy confusion can ultimately lead to patients being harmed, for example, through lack of proper planning, and lack of access to necessary and appropriate treatments. Policy decision-making must reflect realities, but having no regard to the moral basis of health care provision makes it unlikely that anything resembling fair and equitable social arrangements will ever be achieved.

Health care policies to a greater or lesser extent reflect the collective values of society. Even in complex, socially diverse societies it is reasonable to suppose that some ethical values will be held in common, such as respect for patient autonomy, even though this concept may have different meanings for different people. The contention is that values change over time, they are not always made explicit, and they can vary significantly according to cultural and geographical context. Therefore, room must be made in a healthy society for reasonable accommodation towards a divergence of viewpoints, analysing the nature and scope of those values that are applicable to the provision of health services.

While there is ongoing debate about ethics and the global dimensions of public health,⁵ little effort is generally expended in terms of analyzing the moral values behind health care. Significant differences exist between one country and another when it comes to being able to access quality, affordable health care in a timely manner. This is why we think that insights can be gained from looking at different countries in terms of how they deal with these issues. In this book we choose an international perspective to demonstrate that ethical analysis of health care policy in international settings offers a useful tool for exploring the values that underpin the provision of health care, and we go on and attempt to consider practical implications in terms of patient care.

Many obstacles to the effective provision of health care services exist, and these will have different characteristics in different national and international settings. Accessing health care in rural China, for instance, is a different proposition from accessing care in rural India or in the jungle areas of Malaysia, and it is certainly quite different from accessing health care in urban settings that have good, centralized systems for the provision of services.

Outline

This book comprises three parts. Part 1 sets out the theoretical, analytic framework for policy decision-making, providing an overview of health policy analysis and a rationale for the book as a whole. It examines relationships between law, health care and ethics, and different frameworks that can be used in policy analysis. These chapters are based mainly on frameworks and events relating to the UK. Firstly, when theoretical discussion takes place in the abstract it is difficult to make the leap from theory to practice and it is the intention of the authors that this book will have practical value. Secondly, in order to see if and how alternative frameworks might apply to important issues such as rationing or macro policy decision-making, there needs to be a fact basis upon which to build the arguments.

The British National Health Service (NHS) has many peculiar characteristics, and without first-hand experience, either as a provider or as a consumer of services, many features of the system might appear strange, even irrational. That may be, and it is argued in Chapter 4 that like ethics, logic is not a dominant feature in policy debate. The government in immediate post-war World War II Britain undertook a bold experiment in universal coverage, one that has survived (more or less intact) for over 60 years. Dramatic change has taken place with the health service; nonetheless, for good or bad the NHS has a uniqueness that in and of itself makes it interesting in terms of moral policy analysis. Papers in the second part of the book are for the most part not UK-based. It would be impossible to be truly global within the confines of a single volume; however, in Part 2, short chapters address different countries with a variety of different health care systems that collectively serve to illustrate: a) the nature of some of the problems encountered in providing health care services, b) something about the social values pertaining to those countries, and (c) the usefulness of an ethical component to the policy analysis.

Chan and Marienfeld on Chinese Ethics and Health Care

Readers may be familiar with some of the ethical principles commonly employed in the West when analyzing clinical cases. But these are not the only types of ethical reasoning, and this chapter outlines some of the Chinese philosophies that have helped shape health policy decision-making in China. These ethical principles are of ancient Confucian origin, but they are not disconnected from modern medical practice, even if they need adapting in order to be of use in facing modern challenges. This chapter explores links between ancient and modern philosophies and health care practice and considers how Chinese health care has managed to stay relatively close to its philosophical roots.

Pressures arising on account of rapid social, political and economic change have meant the need to adapt, and there is evidence to suggest that the ancient principles are especially challenged in trying to meet the health care needs of growing and increasingly urbanized populations. These challenges are exemplified well by the case example of a young man and his family attempting to access care in connection with the onset of a psychotic disorder.

Worthington on Ethics and Professionalism in Modern India

This chapter similarly looks to the past in order to understand some of the issues facing health care professionals, this time in present-day India. India also has rich philosophical traditions, and yet this complex nation is slowly becoming disconnected from its own philosophical roots. This has a direct bearing on the way that medicine is practiced, and while Western models of health care delivery are being adopted in India, unlike in the West ethics and professionalism are rarely taught in medical schools, and the legal and ethical frameworks of medical practice are not well defined. If they are defined, then the mechanisms to uphold them are weak, and standards of professionalism are being seriously challenged from commercial pressures and more widely from evolving social change. In the past these values were not necessarily made explicit because it was not considered necessary to do so; they were considered an intrinsic part of everyday traditional culture. That situation, however, no longer applies.

In most countries, there are significant differences in health care provision for urban and rural populations, and India is no exception. Large sections of the rural population have only limited access to medical care, and sometimes the only way that people living in remote regions can access services is by travelling long distances and waiting to be seen in the poorly funded state-run hospitals. This chapter includes an account of some of these difficulties, especially the implications that arise in the context of rural health care in the Himalayas. A case example involving a mother who is experiencing a difficult birth offers a poignant example.

Ahmad on Health Policy Developments in Malaysia

Health care in Malaysia has some particular characteristics that make it an interesting example to study in terms of health policy trends. It operates within a fairly stable political environment, which means that unlike most other countries, long-term policy planning is a “norm.” Current trends, however, mean that a private sector is becoming increasingly dominant, and in order to avoid restricting access to health care, insurance-based solutions are now being sought.

This needs to be viewed against a poli...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Foreword
• About the authors
• Contributors
• Part 1
• Part 2
• Part 3
• Index