Introduction：Health care is not cheap. Far from it. In 2007, health care spending in the United States consumed $2.24 trillion or 16.2% of the gross domestic product (GDP).1 In the same year, the average American spent $889 in “out of pocket” health care expenses.2 While the cost of America’s consumption is high relative to the rest of the world, the excessive and growing cost of health care is a global problem. In 2006, total health care spending amounted to 15.3% of the GDP of the United States, 10.0% of the Canadian GDP, 11.0% of the French GDP, and 8.1% of the Japanese GDP.3 Those numbers have been steadily climbing. In 1980, the respective percentages of GDP were 8.7%, 7.0%, 7.0%, and 6.5%.4 Recent estimates suggest that total health care spending in the United States will reach a staggering 20.3% of GDP, or $4.35 trillion, by 2018.5 The same estimates suggest that 2018 per capita expenses will reach $13,100 and out of pocket consumer expenses will reach $1286 (a 45% increase from 2007 out of pocket levels).Many commentators have declared that if limits are not placed on access to health care (limiting access being the preferred or most direct means of limiting consumption), health care expenditures can easily reach 100% of GDP in industrialized nations, even without accounting for wasteful expenditures.Just as medical resources are costly, so are they scarce. 本文来自辣.文,论-文·网原文请找腾讯752018766
Einer Elhauge described four conceptual paradigms that are intended to provide the universe of possible theoretical approaches to ration health care resources as a means of controlling costs: the Market, professional, political, and moral paradigms. He defines the “moral paradigm” negatively: “What unites the various positions [that together constitute the moral paradigm] is not their uniformity but their insistence that allocation decisions should be derived from moral analysis, rather than dictated by market forces, professional judgment, or political accountability.” As his language implies, he adopted this negative definition as a means of synthesizing many various positions that on the surface have nothing in common other than the negation of the other three paradigms. In truth, the various positions of the moral paradigm have a great deal in common. They all adopt moral reasoning as a tool for rationing health care and generally assume that the adoption of moral reasoning is not merely good policy, but that it is an imperative. Elhauge’s conception is thus far too narrow. By reconceptualizing the moral paradigm as an imperative, rather than as a unique philosophical approach to rationing, this paper articulates a new application of the moral paradigm that might help resolve the problem of rationing medical care.
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This paper argues that the moral paradigm is both useful to the creation of good public policy and necessary to the extent we desire a solution that is politically salable. Essentially, it argues that the moral paradigm demands greater process for those who are denied access to medical care and that we design our institutions responsible for rationing to incorporate this call for greater process. The moral paradigm thus need not provide a substantive approach to rationing, such as by negating “non-moral” approaches. It serves merely to complement Part I of this paper will introduce three principal methods of rationing and by illustrating the problems with each of them. Part II will further develop the moral paradigm, articulate my reconceptualized pluralist version of the moral paradigm , and articulate a moral argument for inserting a process-based element into rationing. Part III will propose the creation of an administrative adjudicatory board that grows directly out of the process argument. The objective is to use the moral paradigm as an overlay on any rationing scheme. Part IV will consider the structure and function of the administrative adjudicatory body proposed in this paper–suggesting some of the powers that ought to be granted to adjudicators and the structural limits that ought to be placed upon the adjudicatory process–in order to ensure efficacy and reduce the risks of abuse of power.
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