Book Review — Healthcare Allocation: An Ethical Framework for Public Policy

May-June 2002

REVIEWED BY RICHARD M. HAUGHIAN, DTH

Anthony Fisher, OP, and Luke Gormally, eds.

The Linacre Centre for Healthcare Ethics, London, 2001. 238 pp., $22

Many of the most pressing and complex public health care policy issues today relate to the demands for limited health care resources to satisfy virtually limitless needs. This book, sponsored by the Catholic Bishops of Great Britain and Ireland and prepared by the Catholic Bishops' Joint Bioethics Committee, is written to contribute to this important public dialogue.

The purpose of this book is to provide both an ethical critique of prevailing approaches to health care allocation and to identify the basic ethical framework of moral principles that should govern the just allocation of health care resources. The authors make it clear that this work is not a blueprint for resource allocation. An ethical framework, although a decisive determinant of resource allocation policy, is only one factor to be considered. Nor do the authors believe that a uniquely correct solution or approach to these issues exists for the United Kingdom or for other similar economies. It is clear to them, however, that much current thinking about resource allocation is both intellectually and morally unsatisfactory.

The underlying assumptions and orientations of the book are Christian and rely in particular on the Christian natural law tradition, especially in bioethics, and Catholic social teaching. Because the authors hope to engage in dialogue with a broad audience of policy decisions makers, however, they have appropriately chosen points of departure, a method of argumentation, and a language that appeals to reason and experience. This approach should have a wider appeal, incorporating what the authors refer to as the best of our "common morality" of principles such as are articulated in the Bible and the Koran, the Hippocratic Oath, contemporary "virtue ethics," the common law, international human rights documents, and the teachings of many thinkers, both secular and religious.

Because the context of this book is resource allocation in the United Kingdom, particular reference is made to the "crisis" in the National Health Service (NHS) and to the increasing number of complaints about equity, comprehensiveness of access, failures of care, and other concerns. Similar "crises" are also being faced in other developed countries, and because the approach is essentially at the level of values and principles, this book can be readily applied in countries other than the United Kingdom, such as the United States and Canada.

Healthcare Allocation is tightly organized and clearly presented; its argument is systematic and nuanced. Summaries at the beginning of each chapter and a concluding summary of the book's line of argument make for easy reference. Beginning with a preliminary clarification of key terms and issues in the allocation debate, the book presents a critique of contemporary approaches to allocation; argues for a justice framework built on an understanding of the human good, persons and their needs, the common good, distributive justice, and the nature of human community; and critiques the inadequacies of the criteria frequently proposed in this debate. It addresses many of the most hotly debated allocation issues, such as the needs of those at risk — the frail elderly, the handicapped, the mentally ill, and the poor — as well as the need to respect basic human rights, punitive and prejudiced health care allocations, and competing social goals. There is a chapter summarizing Catholic social teaching related to the allocation of health care resources, and brief considerations of other commonly raised issues, such as how much should be spent on health care, health care as a right, the public/private mix, who should be the gatekeepers, and the need for public debate on these issues.

True to its title and intent, this book serves well as a framework of principles for treating the many issues and points of view currently under discussion. It gives an excellent critique of current approaches to resource allocation, such as, "ad hocery," the free market, and the liberal-welfarist and the utilitarian-economic views. These approaches are found to be inadequate in their understanding of the human good, the needs of the human person, the community and the common good, and health care itself.

The justice perspective emphasized throughout the book is one of its strengths. A just health care service would ensure access for all members of the community to care sufficient to meet their health care needs. Health care services should be allocated according to need, irrespective of factors such as age, race, sex, religion, social contribution, consciousness, intelligence, quality of life, provider whim, and ability to pay; however, preference should be given to those who are disadvantaged. At several points, the book reflects on the Gospel parable of the Good Samaritan as a useful model for good practice in health care allocation. The chapter on Catholic social and bioethical teaching and health care allocation is an excellent summary of this teaching and provides a valuable reference for anyone wishing to understand the specific contribution of Catholic thinking in this area.

Because the book presents an ethical framework of general principles, it does not develop in detail the many issues it raises. However, it presents a coherent justice perspective that can be a valuable asset for any health care providers or decision makers who are struggling with these resource allocation issues.

Richard M. Haughian, DTH
President
Catholic Health Association of Canada

 

Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.