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on: May 08, 2023, 09:44:07 PM
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Started by RUEBENKRAUT - Last post by Laurin | ||
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https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%202%20Kantian%20Ethics%20And%20The%20Functions%20Of%20Health%20Care.pdf
Kapitel II: KANTISCHE ETHIK UND DIE FUNKTIONEN DES GESUNDHEITSWESENS Kants ethische Theorie Kant bot drei verschiedene Formulierungen des kategorischen Imperativs an, den er als die einzige moralische Norm ansah, die alle Menschen beachten müssen. 31 Alle drei bringen denselben Gedanken zum Ausdruck, wenn auch mit unterschiedlicher Betonung. Die folgende Darstellung wurde von Sullivan übernommen: 32 Formel 1: Formel der Autonomie: "Ich sollte niemals so handeln, dass ich nicht auch wollen könnte, dass meine Maxime ein universelles Gesetz ist." Formel 2: Formel des Respekts vor der Würde der Menschen: "Handle so, dass du den Menschen, ob in deiner eigenen Person oder in der eines anderen, immer als Ziel und niemals nur als Mittel behandeln." Formel 3: Formel der Gesetzgebung für eine sittliche Gemeinschaft: "Alle Maximen, die von unserem Gesetze ausgehen, müssen mit einem möglichen Reiche der Zwecke als einem Reiche der Natur in Einklang stehen." 31 Kant (1788) 32 Sullivan (1994) 25 Für die Zwecke meiner Diskussion ist es nicht wichtig, ob die drei Formulierungen genau miteinander vereinbar sind oder wo die Grenzen ihrer Anwendung liegen. Stattdessen möchte ich die Kerngedanken hervorheben, die ihnen zugrunde liegen, und sie auf die Frage der gerechten Gesundheitsversorgung anwenden. Die erste Formulierung bringt den Gedanken zum Ausdruck, dass wir nicht in einer Weise handeln sollten, die aus Gründen beabsichtigt ist, die, wenn sie als Prinzip ausgedrückt wird, nicht universalisiert werden können. Töten, Gewalt, Zwang und Täuschung sind Beispiele für Handlungen, die sich nicht auf diese Weise universalisieren lassen. 33 Diese Formulierung ist besonders wichtig, um die negativen Rechte zu rechtfertigen, die jeder Mensch genießen sollte, wie etwa die Freiheit von Schaden und Einmischung. 33 O'Neill (1989) 26 Aber die erste Formulierung sichert nicht nur die negativen Rechte der Menschen. Sie ist auch eine zwingende Grundlage für die grundlegenden Rechte, die Menschen in jeder Gesellschaft haben, und eine Ablehnung des Libertarismus, der solche Rechte leugnet. Das Argument ist, dass ein Prinzip der Nicht-Wohltätigkeit nicht eine Maxime werden kann, die als universelles Gesetz gewollt werden kann. Dies ist so, weil es Teil der menschlichen Natur ist, dass wir durch Krankheiten, Unfälle, Verarmung und viele andere Bedrohungen unserer Handlungsfähigkeit als rationale Wesen gefährdet sind. Wir können im Prinzip jederzeit auf die Hilfe anderer angewiesen sein, um überhaupt ein vernünftiges Ziel zu verfolgen, und würden in solchen Fällen die Hilfe anderer wollen. Da wir ein Prinzip der Nicht-Wohltätigkeit nicht konsequent wollen und gleichzeitig diesen Aspekt des menschlichen Daseins verstehen können, kann ein Prinzip der Nicht-Wohltätigkeit nicht zu einem universellen Gesetz werden. Es würde uns in einen Widerspruch verwickeln zwischen dem Wollen eines Prinzips und dem Wollen, das unter den Umständen, unter denen das Prinzip angewendet werden soll, natürlich ist. Daraus folgt, dass das entgegengesetzte Prinzip, das Wohlwollen, als universelles Gesetz betrachtet werden muss. Da Krankheiten und Unfälle typische Bedrohungen für das rationale Handeln des Menschen sind, sollte jede Darstellung dessen, was aus einem Gesetz des Wohlwollens folgt, zumindest die öffentliche Bereitstellung bestimmter Formen der Gesundheitsfürsorge rechtfertigen. Für die Anwendung der kantischen Ethik auf die Gerechtigkeit in der Gesundheitsversorgung ist jedoch die zweite Formulierung ebenso aufschlussreich oder sogar noch aufschlussreicher. Nach Kant ist die Achtung der Menschenwürde eine wichtige Rechtfertigung für die positiven Rechte, die Menschen genießen. Diese ergeben sich aus der Tatsache, dass sie rationale Akteure sind, und nicht aus irgendeiner anderen kontingenten Eigenschaft ihrer selbst, einer bestimmten Gesellschaft oder Tradition. Zu den positiven Rechten gehören unter anderem Eigentumsrechte, Meinungsfreiheit, politische Teilhabe, Wohlfahrtsrechte und das Recht auf gegenseitige Hilfe. Wie ich weiter unten darlegen werde, liefert die zweite Formulierung auch eine unmittelbare Rechtfertigung für die Sicherung des Zugangs zu bestimmten Formen der Gesundheitsversorgung durch öffentliche Bereitstellung. 34 O'Neill (1989); Herman (1993); Rosen (1994) 27 Die dritte Formulierung betrifft Kants Vorstellung von einer idealen Gemeinschaft, in der es nur freie und gleiche Bürger gibt.35 Dies ist die umfassendste Art, Kants Ethik auszudrücken, und hat in den Arbeiten von John Rawls breite Anwendung gefunden. Vereinfacht kann man sagen, dass Rawls' Werk, wie auch das vieler anderer liberaler politischer Philosophen, eine umfassende und explizite Interpretation dessen darstellt, was es bedeuten würde, in einer Gemeinschaft freier und gleicher Bürger zu leben, oder wie Kant es ausdrücken würde, in einem Reich der Ziele. Für meine Zwecke ist diese dritte Formulierung etwas weniger wichtig, da ich mich nicht mit einer idealen Gemeinschaft oder einem vollständigen Satz gerechter Institutionen befassen werde. Die Formulierungen 1 und 2 enthalten beide den Schlüsselgedanken, auf dem ich bei der Formulierung der zentralen Funktionen des Gesundheitswesens aufbauen werde. Was sagen uns diese Formulierungen über eine gerechte Gesundheitsversorgung? Im Folgenden werde ich argumentieren, dass sie Folgendes implizieren: a) Wir haben die Verpflichtung, uns zumindest um einige Aspekte unserer Gesundheit und der Gesundheit anderer zu kümmern, 35 Sullivan (1994) 28 b) Wir sollten zentrale Aspekte der Gesundheit anderer nicht zu einem Mittel machen, um bestimmte individuelle oder gemeinschaftliche Bedürfnisse zu befriedigen. c) Es gibt Grenzen für unsere Verpflichtung, uns um unsere Gesundheit und die Gesundheit anderer zu kümmern, und d) Die verschiedenen Funktionen der Gesundheitsfürsorge werden durch unterschiedliche Arten von Verpflichtungen und Grundsätzen unterstützt. Warum sollten wir uns um unsere Gesundheit und die Gesundheit anderer kümmern? Wie oben dargelegt, besteht die offensichtlichste kantische Rechtfertigung für die Sorge um die Gesundheit anderer darin, dass ein Prinzip der völligen Uneigennützigkeit für Menschen, die rational und durch innere und äußere Ursachen verwundbar sind, nicht universalisiert werden kann.36 Die erste Formulierung oben ist die Grundlage für eine solche Rechtfertigung. Ich glaube jedoch, dass die zweite Formulierung eine umfassendere und direktere Quelle für die Verpflichtung ist, sich um die Gesundheit anderer und von uns selbst zu kümmern, weil die Gesundheitsfürsorge von unmittelbarer Bedeutung für den Respekt vor anderen als rationalen Akteuren ist. 36 O'Neill (1989) 29 Andere als Selbstzweck zu respektieren, impliziert die Sorge um die Erhaltung ihrer Fähigkeit zu der Art von Denken und Handeln, die für ihren Status als Selbstzweck konstitutiv ist. Wir schulden Tieren oder leblosen Objekten nicht den gleichen Respekt, weil sie nicht zu der gleichen Art von rationalem Handeln fähig sind. Das Besondere an der rationalen Handlungsfähigkeit des Menschen ist, dass sie nicht nur die Befriedigung der Grundbedürfnisse des Überlebens oder kurzfristiges zielgerichtetes Handeln einschließt, sondern auch die autonome Wahl umfassenderer Ziele und Lebensentwürfe ermöglicht. Diese umfassenderen Ziele sind oft durch moralische Ideale über die Art und Weise, wie wir leben sollten, motiviert und stellen für die meisten Menschen eine wichtige Quelle der Sinnfindung im Leben dar. Für den Menschen hat rationales Handeln daher immer auch die Dimension des moralischen Handelns. Ich betrachte dieses moralische Handeln als das markanteste und wichtigste Merkmal des menschlichen rationalen Handelns. Im Folgenden werde ich von Menschen als moralischen Akteuren und nicht als rationalen Akteuren sprechen und diesen Teil des rationalen Handelns als Grundlage unserer Würde betonen. All dies wiederum hat weitreichende Auswirkungen auf die Verteilung der Ressourcen im Gesundheitswesen. Der Kerngedanke hinter unserer Verpflichtung, Opfer für die Gesundheitsversorgung anderer zu bringen, ist folgender: Es ist widersprüchlich zu sagen, dass ich eine Person als moralisch Handelnden respektiere und mich nicht um das geistige und körperliche Funktionieren dieser Person kümmere, das zur Aufrechterhaltung ihrer moralischen Handlungsfähigkeit erforderlich ist. 30 Und eine solche Sorge zu haben bedeutet, bereit zu sein, ein Opfer zu bringen, um dieses Funktionieren aufrechtzuerhalten, da die Sorge sonst nicht aufrichtig ist. Hier haben wir es mit einem entscheidenden Unterschied zwischen dem grundlegenden geistigen und körperlichen Funktionieren und dem Glück einer Person zu tun. Ich kann ohne Inkonsequenz sagen, dass ich eine Person als moralisch Handelnde respektiere, ohne mich direkt um ihr Glück zu kümmern, abhängig von den vielen Gründen, warum diese andere Person unglücklich sein könnte. Andere Menschen als moralisch Handelnde zu respektieren, bedeutet jedoch unmittelbar, dass wir uns auch um die Bedingungen kümmern sollten, die sie brauchen, um moralisch Handelnde zu sein und zu bleiben. Das ist so, weil ich nicht plausibel sagen kann, dass ich Sie nur so lange als moralisch Handelnden respektiere, wie Sie einer bleiben. Insbesondere kann meine Sorge um Ihre grundlegenden Fähigkeiten zum moralischen Handeln durchaus Auswirkungen darauf haben, ob Sie weiterhin als moralischer Akteur handeln können oder nicht. In unserer Welt ist dies in der Tat oft der Fall. Kleine Opfer von uns selbst können oft die moralische Handlungsfähigkeit anderer aufrechterhalten. Ich glaube, dass jede inhaltlich plausible Interpretation der zweiten Formulierung des kategorischen Imperativs von uns verlangt, solche Opfer zu bringen. Das Gleiche gilt für unsere eigene grundlegende Gesundheit, da wir als Teil unserer Selbstachtung als moralisch Handelnde nicht gleichgültig sein können gleichgültig sein, was unsere eigene moralische Handlungsfähigkeit aufrechterhält. 31 Der Respekt vor anderen als moralisch Handelnden impliziert jedoch auch, dass wir ein Interesse daran haben sollten, dass ihnen ein Minimum an anderen Mitteln zur Verfügung steht, die sie benötigen, um als moralisch Handelnde zu handeln. Die Verfolgung von Lebensplänen ist nur mit einem Minimum an Mitteln wie Einkommen, Bildung und anderen Möglichkeiten möglich, Mitteln, die Rawls als "primäre Güter" bezeichnet hat. Dies ist wichtig, denn es impliziert, wie ich weiter unten darlegen werde, dass wir moralisch verpflichtet sind, ein bestimmtes Budget für die Gesundheitsversorgung nicht zu überschreiten. Gesundheitsfürsorge und die Ziele des Einzelnen und der Gemeinschaft Der Respekt vor der Würde des moralisch Handelnden bedeutet auch, dass wir andere nicht darauf reduzieren sollten, nur Mittel zur Erfüllung unserer oder der Ziele der Gemeinschaft zu sein. Eine umfassende Auslegung dessen, was es bedeutet, dies nicht zu tun, und die Auswirkungen eines solchen Grundsatzes auf die Begrenzung paternalistischer Handlungen und von Handlungen, die der Vermeidung großen Übels dienen, kann hier nicht versucht werden. Eindeutig unzulässig ist es jedoch beispielsweise, anderen um des persönlichen Glücks willen oder zur Förderung bestimmter Ideale der Gemeinschaft zu schaden. Jede derartige Schädigung müsste durch etwas von höherer moralischer Bedeutung gerechtfertigt werden, denn in diesem Sinne ist das "Recht vor dem Glück, das es bewirken könnte", wie Rawls es formuliert hat. 37 Rawls (1971) 32 Für die Gesundheitsfürsorge bedeutet dieses Argument, dass der Staat beispielsweise das Gesundheitssystem nicht uneingeschränkt zur Maximierung des menschlichen Glücks oder Wohlergehens einsetzen kann, wie es der Utilitarismus moralisch zu fordern scheint. Ein potenzieller Organspender darf zum Beispiel nicht für die Gesundheit mehrerer potenzieller Empfänger geopfert werden, selbst wenn dies den Nutzen maximieren würde. Die grundlegenden Freiheiten des Einzelnen nicht für Gemeinschaftszwecke zu opfern, schließt auch Formen der Eugenik aus, selbst wenn solche Praktiken Teil der gemeinsamen Werte einer bestimmten Gesellschaft wären. Dies sind wichtige Argumente, da sie den Einzelnen bedingungslos davor schützen, durch das Gesundheitssystem zu Unrecht geopfert zu werden - ein Schutz, den weder der Utilitarismus noch der Kommunitarismus bieten können.38 38 Lyons (1994); Holmes (1989) 33 Ich möchte hier jedoch argumentieren, dass die Nicht-Instrumentalisierung anderer als Teil der gegenseitigen Achtung unseres Status als moralische Akteure auch Auswirkungen auf unsere positiven Verpflichtungen in der Gesundheitsversorgung hat. Es bedeutet nicht nur, dass wir anderen keinen Schaden zufügen sollten, um persönliche oder gemeinschaftliche Projekte in der Gesundheitsversorgung voranzubringen, sondern auch, dass wir die moralisch wichtigen positiven Ansprüche des Einzelnen nicht für solche Projekte opfern sollten. Es ist widersprüchlich, zu argumentieren, dass wir einem Individuum niemals auch nur den geringsten Schaden zufügen sollten, egal wie viel Glück es der Gemeinschaft bringen könnte, wenn wir gleichzeitig generell zulassen, dass Individuen sterben, weil wir ihnen die für die Gesundheitsfürsorge erforderlichen Ressourcen nicht zur Verfügung stellen, um sie stattdessen zur Förderung unseres eigenen Glücks einzusetzen. Man kann leicht annehmen, dass das Verbot, anderen zu unserem eigenen Vorteil zu schaden, stärker ist als die Verpflichtung, anderen in Not zu helfen, aber das kann falsch sein. Die vorsätzliche Schädigung anderer kann nicht verallgemeinert werden und ist daher nicht zulässig. Anderen in schwerer Not zu helfen, ist nach der ersten Formulierung nur durch eine Pflicht zur gegenseitigen Hilfe abgedeckt, weil wir nicht konsequent Prinzipien der völligen Nicht-Wohltätigkeit wollen können. Der Grundsatz, anderen nicht mutwillig zu schaden, ist eine vollkommene Verpflichtung, d. h. er gilt für alle Personen, denen ich begegne. Dies gilt nicht für den Grundsatz des Wohlwollens, da ich nicht verpflichtet bin, jedem einzelnen Menschen, dem ich begegne, zu helfen. Das ist so, weil ich das als Mensch mit begrenzten Mitteln nicht tun kann. Die Verpflichtung zum Wohlwollen ist also eine unvollkommene Verpflichtung, da sie nicht immer gilt. Es ist jedoch ein Trugschluss zu glauben, dass ein Prinzip, das nicht immer gilt, schwächer ist als eines, das immer gilt, wenn beide Prinzipien gelten. In solchen Fällen kann die Verpflichtung, zu helfen, stärker sein als die Verpflichtung, nicht zu schaden, je nachdem, welche Folgen die Nichteinhaltung jeder dieser Verpflichtungen hätte. 34 Nach dieser Auffassung von Kants Ethik kann eine Nachlässigkeit mit großen Folgen für ein anderes Individuum ein moralisch größeres Unrecht sein als das Verursachen eines bescheideneren direkten Schadens. Ich werde weiter unten argumentieren, dass diese Interpretation von Kants Ethik eine zwingende Erklärung dafür ist, wie wir unsere Verpflichtungen gegenüber anderen im Hinblick auf die Erfüllung der Grundbedürfnisse der Menschen und der Grundfreiheiten verstehen, wenn wir darüber nachdenken. Ich kann hier nicht erörtern, ob diese Interpretation von Kants Ethik eine ist, die er selbst befürwortet hätte, und ich gehe daher auch nicht davon aus, dass dies der Fall ist. Mein Ziel ist es vielmehr zu zeigen, dass die Konsequenzen einer solchen Interpretation intuitiv ansprechend und wichtig für die Gerechtigkeit im Gesundheitswesen sind und sich aus Kants Darstellung der moralischen Argumentation ergeben würden. Für die Gesundheitsfürsorge ist diese Interpretation von Kants Ethik praktisch sehr wichtig, weil sie impliziert, dass es einige medizinische Bedürfnisse anderer geben kann, die wir um der Projekte der Gemeinschaft oder unserer selbst willen nicht ignorieren können. Dies schließt Projekte ein, die weder hedonistisch noch eigennützig sind, obwohl diese natürlich in den Sinn kommen. Dazu gehören auch Projekte, die einen explizit moralischen Status haben, wie etwa solche, die religiöse oder säkulare perfektionistische Ideale fördern. 35 Die Grenzen unserer Verpflichtungen Sich selbst und andere gleichermaßen als moralisch Handelnde zu respektieren, bedeutet, dass wir nicht verpflichtet sein können, unsere eigene moralische Handlungsfähigkeit zu opfern, um die anderer zu retten, und zwar auch nicht über das Funktionsniveau hinaus, das unser Überleben gefährden würde. Der primäre Grund, das Leben anderer zu verlängern oder zu verbessern, besteht darin, ihnen zu ermöglichen, moralisch handlungsfähig zu bleiben, nicht im Überleben an sich. Das bedeutet, dass wir nicht verpflichtet sein können, uns auf das Niveau des bloßen Überlebens zu reduzieren, nachdem wir die Mittel geopfert haben, die für das Funktionieren als moralische Akteure erforderlich sind. Es gibt also eindeutig eine Grenze für das, was wir als Individuen anderen schulden, um die medizinischen Bedürfnisse zu befriedigen, deren Nichtbeachtung den potenziellen Nutznießer ins Verderben stürzen würde. Andererseits können die Opfer, die wir anderen schulden, ganz erheblich sein, wie die Diskussionen über unsere Verpflichtungen zur gegenseitigen Hilfe gezeigt haben. Der Einzelne kann in der Tat in eine Situation kommen, in der moralische Verpflichtungen zu Recht große Opfer verlangen. Die Grenzen der Opfer, zu denen wir verpflichtet sind, lassen sich am besten mit Amartya Sens Konzept der "grundlegenden Fähigkeiten" beschreiben. 40 Die Grundfähigkeiten 39 Herman (1993) 40 Sen (1992) 36 sind eine Mischung aus unseren internen funktionalen Eigenschaften als Individuen und den externen Mitteln, über die wir verfügen, um zu funktionieren. Um einige der moralisch wichtigsten medizinischen Bedürfnisse anderer zu befriedigen, scheinen wir gezwungen zu sein, Opfer zu bringen, bis zu dem Punkt, an dem unsere eigenen grundlegenden Fähigkeiten als moralische Akteure bedroht sind. Dies würde eindeutig ein moralisches Unglück für die Personen bedeuten, die solche Opfer bringen müssen, aber es würde sie nicht zu weniger als vollwertigen moralischen Akteuren machen. Ich werde im Folgenden argumentieren, dass wir verpflichtet sind, nach einer Reihe von Grundsätzen zu leben, die solche Opfer in gerechter Weise verteilen. Das bedeutet, dass wir moralisch verpflichtet sind, Institutionen zu schaffen, die einerseits die moralisch zentralen medizinischen Bedürfnisse befriedigen und andererseits vermeiden, dass der Einzelne übermäßig große Opfer bringen muss. Wenn diese Bemühungen erfolgreich sind, würde dies die wichtige Schlussfolgerung implizieren, dass wir moralische Verpflichtungen sowohl gegenüber denjenigen haben, die von den zentralen Funktionen der Gesundheitsversorgung profitieren, als auch gegenüber denjenigen, die in der Lage sind, die für die Bereitstellung dieser Leistungen erforderlichen Opfer zu bringen. Dies würde die institutionelle Gestaltung dieses Teils des Gesundheitswesens einschränken, weil es auf der Grundlage der Gerechtigkeit das Ausmaß begrenzen würde, in dem wir utilitaristische oder perfektionistische Gesichtspunkte verfolgen könnten. Es wird sich zeigen, dass unsere 37 Es wird sich zeigen, dass unsere Verpflichtung, anderen die Gesundheitsversorgung zukommen zu lassen, die sie brauchen, um als moralische Akteure zu funktionieren, unerwartete und weitreichende Auswirkungen auf die sozioökonomische Gerechtigkeit in der Gesellschaft hat. Unterschiedliche Arten der Gesundheitsversorgung unterliegen unterschiedlichen Verpflichtungen Die letzte Schlussfolgerung, die ich aus meiner Interpretation von Kants Ethik ziehen möchte, ist, dass wir nicht die gleiche Art von Verpflichtung haben, moralisch periphere medizinische Bedürfnisse zu unterstützen, wie wir sie für moralisch zentrale Bedürfnisse haben. Als zentral betrachte ich das, was unserem Handeln als moralische Akteure zugrunde liegt, und definiere periphere Bedürfnisse der Gesundheitsversorgung als solche, die die Qualität des Funktionierens betreffen, die deutlich über dem Niveau des Funktionierens liegt, das uns erlaubt, als moralische Akteure zu handeln. Die Unterscheidung ist sozial konstruiert, was sie auch sein muss, um die bedeutenden Unterschiede in den funktionalen Anforderungen für moralisches Handeln in verschiedenen Kulturen und sozioökonomischen Kontexten zu berücksichtigen. Auf diesen Punkt werde ich zurückkommen, wenn ich im Folgenden moralisches Handeln genauer definiere. 38 Ein Beispiel für ein peripheres Bedürfnis ist der Wunsch nach kosmetischer Chirurgie, um in einer Gesellschaft, die Wert auf ein junges Aussehen legt, jünger auszusehen. Wenn man älter aussieht, sind einige Lebensentwürfe in einer solchen Gesellschaft möglicherweise nicht verfügbar. Aber die verbleibenden Lebensentwürfe sind vielleicht breit genug gefächert, um keinen Anspruch auf einen chirurgischen Eingriff zu rechtfertigen. Das heißt, wir können uns im Allgemeinen so verstehen, dass wir andere als moralisch Handelnde respektieren, ohne bereit zu sein, Opfer zu bringen, um anderen eine Schönheitsoperation gegen die Zeichen des Alterns zu ermöglichen. Aus moralischer Sicht haben die peripheren Funktionen der Gesundheitsversorgung eindeutig eine geringere Priorität als die zentralen Funktionen der Gesundheitsversorgung. Dies gilt selbst dann, wenn, wie es häufig der Fall ist, der Wunsch des Einzelnen nach einigen der peripheren Funktionen der Gesundheitsversorgung stärker ist als der Wunsch nach den zentralen Funktionen. Wir schulden anderen die Gesundheitsversorgung nicht, weil sie sie wünschen, sondern weil sie sie brauchen, um als moralische Akteure zu funktionieren. Dies schließt eine unmittelbare Verpflichtung aus, ihnen die Leistungen zu erbringen, die zu den peripheren Funktionen gehören. Wie sollten wir diese peripheren Funktionen bereitstellen? Ihre gerechte Verteilung sollte dadurch gewährleistet werden, dass jeder einen gerechten Anteil an Ressourcen oder an Rawls'schen Primärgütern erhält. Da aber selbst eine gerechte Verteilung von Ressourcen oder Primärgütern nicht alle wichtigen, moralisch willkürlichen Unterschiede in den Lebensaussichten der Menschen berücksichtigen würde, haben diejenigen, denen ein vorzeitiger Tod oder eine Behinderung droht, weitere Ansprüche. Diese haben aus kantischer Sicht ihre Grundlage in dem, was es bedeutet, Menschen zu respektieren, mit denen wir als moralische Akteure interagieren. 39 Moralisches Handeln und Fähigkeiten Ich komme nun auf die oben aufgestellte Behauptung zurück, dass es zwei verschiedene Funktionen der Gesundheitsversorgung gibt, die wir aus moralischen Gründen trennen sollten. Ich habe argumentiert, dass wir, wenn wir mit anderen interagieren, nicht konsequent behaupten können, dass wir sie als moralisch Handelnde respektieren, ohne zumindest eine gewisse Sorge um ihr Überleben oder ihr Risiko, geistig oder körperlich schwer behindert zu werden, zu haben, und dass dies die Definition der zentralen Funktionen der Gesundheitsversorgung leiten sollte. Was genau bedeutet es, ein moralischer Akteur zu sein, und wie kann diese Definition zur Festlegung der zentralen Funktionen der Gesundheitsversorgung verwendet werden? Was es praktisch bedeutet, andere als moralische Akteure zu respektieren, lässt sich weder aus einer Definition des Begriffs moralisches Handeln noch aus einer linguistischen Analyse ableiten. Selbst wenn es möglich wäre, mit solchen Analysemitteln die Richtigkeit des kantischen kategorischen Imperativs festzustellen (was ebenfalls den Rahmen dieser Arbeit sprengen würde), würde eine solche Analyse nicht darüber entscheiden, wie dieser Imperativ in einem konkreten Fall anzuwenden ist. Solche Anwendungen sind immer eine Sache der Interpretation und nicht der Deduktion und hängen zum Teil von Informationen über den Kontext ihrer Anwendung ab.41 40 In diesem Sinne möchte ich einen Vorschlag machen, wie wir den Begriff der Achtung anderer als moralische Akteure im Kontext der folgenden Umstände konzeptualisieren sollten: 1) sehr große Unterschiede im Gesundheitszustand und in der Lebenserwartung, 2) eine Einkommensverteilung, die gerecht wäre, wenn es keine Unterschiede im Gesundheitszustand gäbe, und 3) begrenzte Ressourcen, so dass wir es uns nicht leisten können, alle Unterschiede zwischen Individuen im Gesundheitszustand und in der Lebenserwartung zu beseitigen. Der erste Schritt in dieser Interpretation ist, dass andere als moralische Akteure zu respektieren bedeutet, andere wegen ihrer Fähigkeit zu respektieren, autonome moralische Entscheidungen zu treffen, und nicht, weil sie bestimmte Ideale des Guten fördern könnten. Lebewesen, die nicht in der Lage sind, solche Entscheidungen zu treffen, sollen wir nicht als Selbstzweck behandeln, wie z. B. Tiere. Zu einem respektvollen Umgang mit Tieren gehört z. B., dass wir ihnen nicht ohne angemessene Gründe Schmerzen oder Unbehagen zufügen. Aber es bedeutet nicht, dass wir die Entscheidungen, die sie über ihr Leben treffen, respektieren. Die Art von Entscheidungen, die wir anderen Menschen unbedingt zugestehen müssen, sind also moralische Entscheidungen. Solche Entscheidungen sind etwas spezifisch Menschliches. Wir können uns den Menschen gar nicht vorstellen, ohne ihn gleichzeitig als Individuum zu begreifen, das Entscheidungen mit einer moralischen Komponente treffen kann. 41 O'Neill (1989) 41 Moralisches Handeln ist kein empirisches Konzept, da es eine Perspektive einschließt, der man sich nur durch eine Interpretation dessen nähern kann, was Handlungen für das betreffende Subjekt bedeuten. Es setzt Intentionalität voraus, was bedeutet, dass jemand (zumindest potenziell) eine Wahl als freie Wahl und darüber hinaus als eine Wahl mit normativen Implikationen wahrnimmt. Aus diesem Grund ist es nicht möglich, eine rein biologische oder psychologische Interpretation der moralischen Handlungsfähigkeit zu geben. Moralisches Handeln kann nicht mit einer bestimmten Funktionsweise des Gehirns oder des Körpers gleichgesetzt werden, ohne dass eine Interpretation dessen, was diese Funktionsweise des Gehirns oder des Körpers bedeutet, vorliegt. Daher müssen wir uns auf allgemein gebräuchliche Kriterien berufen, um festzustellen, ob jemand im Alltag moralisch handelt, anstatt zu versuchen, die Bedeutung des moralischen Handelns aus der Biologie oder Psychologie abzuleiten. 42 Unter einem typischen moralischen Handelnden verstehe ich einen Menschen, der selbstbewusst ein Ideal des guten Lebens verfolgt. Obwohl moralisches Handeln viele Entscheidungen mit begrenzter Tragweite und Auswirkung beinhaltet, wie z. B. jemandem in Not zu helfen oder einfach nur ins Kino zu gehen, lassen sich diese begrenzten Entscheidungen am besten als konstitutiv für eine größere Erzählung interpretieren, die ich in Anlehnung an Rawls als "das Ideal des Guten" eines Individuums bezeichnen möchte. Der paradigmatische Fall moralischen Handelns ist das Streben nach solchen Idealen des Guten über eine normale Lebenszeit. Was als Ideal des Guten oder als normale Lebenszeit gilt, ist wiederum eine Frage der Interpretation, die nur in einem bestimmten Kontext möglich ist. Ich behaupte jedoch, dass es zu unserer Vorstellung vom Menschen an sich gehört, ihn als ein Wesen zu begreifen, das Lebenspläne verfolgt, die konstitutiv für seine moralische Handlungsfähigkeit und Rationalität sind. Der Begriff des Wertes, dass Individuen Ideale des Guten wählen und verfolgen, sollte jedoch nicht als ein solches Ideal selbst betrachtet werden. Darüber hinaus sollte die Konstruktion von Gerechtigkeit in der Gesundheitsversorgung, die ich hier versuche, nicht als abhängig von der Akzeptanz eines solchen spezifischen Ideals betrachtet werden. Um die Terminologie von O'Neill zu verwenden, ist die Vorstellung von anderen als moralisch Handelnden keine Idealisierung des Menschen, sondern lediglich eine Abstraktion. Der Liberalismus, der sich aus einer solchen Konstruktion ergibt, ist weder von einem bestimmten Ideal der Lebensführung (wie dem Ideal der "Autonomie") noch von einem politischen Kompromiss zwischen solchen Idealen abhängig. Vielmehr werden dem Einsatz alternativer moralischer Ideale des Guten im politischen Bereich Vernunftbeschränkungen auferlegt. Die spezifische Einschränkung, um die es hier geht, besteht darin, dass Ideale des Guten nicht verwendet werden können, um Institutionen zu rechtfertigen, die bestimmte vermeidbare Bedrohungen der moralischen Handlungsfähigkeit einiger Menschen fortbestehen lassen, da die Rechtfertigung solcher Institutionen mit der gegenseitigen Achtung der moralischen Akteure unvereinbar wäre. 43 Man muss aufpassen, dass man die typischen Merkmale eines moralischen Akteurs und die moralische Handlungsfähigkeit selbst nicht verwechselt. So kann beispielsweise eine Mindestlebenserwartung notwendig sein, um als typischer moralischer Akteur zu gelten, aber ein so langes Leben bedeutet nicht automatisch, dass man ein moralischer Akteur ist. So kann es sein, dass trotz einer normalen Lebenserwartung moralisches Handeln nicht möglich ist, wenn jemand geistig schwer behindert ist. Wenn jemand zwar Ideale des Guten hat, aber aufgrund großer Armut nicht die Mittel hat, sie zu leben, kann er auch nicht als voll funktionsfähiger moralischer Akteur betrachtet werden. Moralisches Handeln beinhaltet also interne und externe Anforderungen, Anforderungen an die Person und ihre Umstände. Meines Erachtens bietet Sen mit seinem Konzept der "Fähigkeiten" eine vielversprechende Möglichkeit, moralisches Handeln zu konzeptualisieren, auch wenn das Konzept recht komplex zu sein scheint. 42 Der Raum der Fähigkeiten wird durch die sogenannten "Funktionalitäten" definiert, die ein Individuum tatsächlich erreichen kann. Zu diesen möglichen Funktionen gehören sowohl diejenigen, die tatsächlich erreicht werden, als auch diejenigen, die angesichts der persönlichen Eigenschaften, der Situation und der Mittel des Individuums erreicht werden könnten. Die Funktionen selbst lassen sich in die beiden großen Kategorien Wohlbefinden und Handlungsfähigkeit einteilen. Es gibt also vier Formen von Funktionen: Wohlbefinden und Handlungsfunktionen als erreichte und Wohlbefinden und Handlungsfunktionen als Freiheiten, die man erreichen kann. Die Fähigkeit, als moralischer Akteur zu handeln, kann dann als eine besonders wichtige Untergruppe von Funktionen betrachtet werden. Diese Untergruppe von Funktionen stellt die Freiheit dar, Ideale des Guten zu wählen und zu verfolgen, und umfasst sowohl Wohlfühlfunktionen als auch Handlungsfunktionen. Wichtige Funktionen des Wohlbefindens können die Freiheit von Schmerz oder Unbehagen, geistige Gesundheit und eine gute Ernährung sein. Zu den Handlungsfunktionen gehört die physische, emotionale und kognitive Fähigkeit, Lebensideale zu wählen und zu verfolgen, wie z. B. eine sinnvolle Arbeit zu verrichten, Freunde zu finden, eine Familie zu gründen und an Kultur und Politik teilzunehmen. 42 Sen (1985), (1992); Nussbaum & Sen (1992) 44 Die Fokussierung auf Funktionen statt auf Einkommen oder Ressourcen ermöglicht es uns, die unterschiedlichen Auswirkungen zu erkennen, die dasselbe Einkommen, dieselben Ressourcen oder Rawls'schen "Primärgüter" auf verschiedene Menschen haben können, auch auf solche mit unterschiedlichen genetischen Anlagen oder früher im Leben erlittenen Nachteilen. So hat beispielsweise ein geistig behinderter Mensch nicht das gleiche Maß an Fähigkeiten wie ein Mensch ohne eine solche Behinderung, selbst wenn beide über das gleiche Maß an Ressourcen und Einkommen verfügen. Unterschiede in der Leistungsfähigkeit können auf viele Gründe zurückzuführen sein, die nicht alle mit der Gesundheit zusammenhängen. So kann eine Person mit besserer Bildung ein höheres Fähigkeitsniveau haben als eine Person mit denselben Ressourcen, aber geringer Bildung. 45 Der Wert vieler Funktionen hängt natürlich von dem Ideal des Gutes ab, das eine Person gewählt hat oder wählen kann. Nur das Fehlen der allgemeinsten Funktionen sollte als moralisch signifikanter Nachteil für das Konzept der moralischen Handlungsfähigkeit gelten. Es handelt sich dabei um die Art von Funktionen, die man haben muss, um zwischen verschiedenen Idealen des Guten zu wählen und sie zu verfolgen, und nicht um die Funktionen, die für bestimmte Ideale des Guten spezifisch sind. Zur Veranschaulichung dieses Punktes betrachte man jemanden mit einem hohen Maß an erreichten Funktionen und Freiheitsfunktionen, die in diesem Fall für ihren Wert von dem Ideal des Guten abhängen, das die Person gewählt hat. Eine solche Person kann unter dem Gesichtspunkt der Gerechtigkeit benachteiligter sein als jemand, der weniger erreicht hat und aus der Perspektive des von ihm gewählten Ideals des guten Lebens weniger erreichen kann, wenn die zweite Person im Gegensatz zur ersten auch wesentliche Errungenschaften haben könnte, wenn sie andere Ideale der Lebensführung annehmen würde. Um ein konkretes Beispiel zu nennen: Was schulden wir im Sinne der Gerechtigkeit einem glücklichen und erfolgreichen, an den Rollstuhl gefesselten Mathematiker im Vergleich zu einem unglücklichen, hinkenden, ungebildeten und erfolglosen Fabrikarbeiter an Unterstützung im Gesundheitswesen? Nehmen wir an, sie verfügen über vergleichbare Gesamtmengen an erreichten Funktionen (obwohl die erreichten Funktionen nicht ohne weiteres vergleichbar zu sein scheinen), da der Mathematiker über sehr wertvolle und hoch entwickelte Spezialfunktionen verfügt, während der Fabrikarbeiter eine breitere Palette grundlegenderer Funktionen zur Verfügung hat. 46 Ich habe argumentiert, dass es im Sinne der Gerechtigkeit in der Gesundheitsversorgung darum gehen sollte, die Fähigkeit jedes Einzelnen zu erhalten oder wiederherzustellen, eine breite Palette von Lebensplänen zu formulieren und umzusetzen. Dies würde bedeuten, dass der Mathematiker im Rollstuhl mehr Anspruch auf Gesundheitsversorgung haben sollte als der hinkende Fabrikarbeiter, da ersterer in seiner moralischen Handlungsfähigkeit stärker eingeschränkt ist. In den Worten von Sen sollten wir davon ausgehen, dass er mehr Anspruch auf Gesundheitsversorgung hat, da er mehr grundlegende Fähigkeiten verloren hat. Wenn diese Analyse des Raums der Fähigkeiten dieses schwierige Konzept nicht interpretiert, scheint es mir möglich zu sein, moralisches Handeln auf folgende Weise zu konzeptualisieren: Dasjenige Maß an Fähigkeiten zu besitzen, das es einem erlaubt, Ideale des Guten zu wählen und zu verfolgen. 47 Der Grad der Befähigung wird durch eine Mischung aus internen und externen Merkmalen einer Person bestimmt. Zu den äußeren Merkmalen gehören die Höhe der Ressourcen und des Einkommens, über die eine Person verfügt, und die Verfügbarkeit grundlegender Freiheiten. Wenn eine gerechte Verteilung dieser äußeren Merkmale in der Gesellschaft erreicht ist, wird niemand daran scheitern, ein moralischer Akteur zu sein, solange er nicht innerlich behindert ist. Solche inneren Behinderungen betreffen die funktionalen Merkmale einer Person, wie ihre geistige und körperliche Gesundheit und ihre Lebenserwartung. Der Gesundheitszustand oder die Lebenserwartung einer Person kann so beschaffen sein, dass die Ideale des Guten, die in der Gesellschaft üblicherweise vertreten werden, selbst bei einer ansonsten angemessenen Verteilung der Einkommensquellen nicht erreicht werden können. Die Benachteiligung eines Menschen kann so groß sein, dass keine zusätzlichen Ressourcen oder kein zusätzliches Einkommen es ihm erlauben würden, solche Entscheidungen zu treffen. In einer Gesellschaft mit einer gerechten Verteilung der Ressourcen und des Einkommens können diejenigen mit solchen internen Beschränkungen ihrer Fähigkeiten die einzige Gruppe sein, die nicht die volle moralische Handlungsfähigkeit erreicht. Dies ist der Fall in einer Gesellschaft, in der die Verteilung von Ressourcen, Einkommen oder Primärgütern den Mitgliedern der am wenigsten begünstigten sozioökonomischen Gruppe, die nicht intern behindert sind, zumindest das Niveau an Ressourcen ermöglicht, das angemessen ist, um einige der Ideale des Guten zu verfolgen, die in einer solchen Gesellschaft typischerweise angestrebt werden. So stellt sich beispielsweise in einer Gesellschaft, in der eine Familie mit Kindern und die Möglichkeit, zwischen verschiedenen Beschäftigungsmöglichkeiten zu wählen, typische Ideale des Guten sind, die Frage, ob die Mitglieder der untersten sozioökonomischen Gruppe tatsächlich eine solche Wahlmöglichkeit haben oder nicht. Wenn dies der Fall ist, scheint ihre moralische Handlungsfähigkeit nicht beeinträchtigt zu sein, da sie über das erforderliche Fähigkeitsniveau verfügen. Müssen sie dagegen jede Form der Beschäftigung akzeptieren und riskieren, bei Arbeitslosigkeit zu verhungern, dann wäre die volle moralische Handlungsfähigkeit für diese Gruppe noch nicht erreicht. 48 In den Vereinigten Staaten, Deutschland und anderen demokratischen Industrieländern sind die meisten äußeren Beschränkungen der moralischen Handlungsfähigkeit selbst für die sozioökonomisch am schlechtesten gestellten Gruppen überwunden worden. Dies gilt sicherlich auch für die anderen westeuropäischen Länder, da sie umfangreiche Wohlfahrtssysteme eingerichtet haben. In diesen Ländern sowie in Kanada, Japan, Neuseeland und Australien haben nur diejenigen, die in ihren grundlegenden Fähigkeiten eingeschränkt sind, keine volle moralische Handlungsfähigkeit. Im nächsten Kapitel werde ich argumentieren, dass die zentralen Formen der Gesundheitsversorgung, um es mit Daniels Worten zu sagen, ein "besonderes soziales Gut" sind, das in seiner moralischen Bedeutung mit den Grundfreiheiten und der Grundwohlfahrt vergleichbar ist. Diese besonderen Güter schulden wir anderen, weil wir sie als moralische Akteure respektieren, und nicht aus Gründen der Verteilungsgerechtigkeit. Anschließend werde ich mich der Frage zuwenden, was der Status der zentralen Pflege für ihr Gesamtbudget bedeutet. |
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https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%201%20Premature%20Death%20And%20Disability.pdf Kapitel I: GERECHTIGKEIT UND DIE FUNKTIONEN DER GESUNDHEITSPFLEGE 11 Vorzeitiger Tod und Invalidität in der Gesellschaft Eines der wichtigsten Ziele der Gesundheitspolitik sollte es sein, die Zahl derjenigen zu verringern, die in jungen Jahren entweder sterben oder schwer behindert werden. Es ist bekannt, dass z. B. in den Industrieländern, in denen die durchschnittliche Lebenserwartung heute bei 70 bis 76 Jahren für Männer und 75 bis 82 Jahren für Frauen liegt, etwa 30 % aller Männer und 20 % aller Frauen vor dem Alter von 65 Jahren sterben. 11 Weitere 5 % sind in diesem Alter schwerbehindert. Für die Zwecke dieses Aufsatzes betrachte ich einen Tod als verfrüht, wenn er deutlich vor der durchschnittlichen Lebenserwartung in der Gesellschaft eintritt, beispielsweise im Alter von 65 Jahren oder jünger in den USA. Ich werde diesen Schwellenwert weiter unten begründen, wenn ich dargelegt habe, worin meiner Meinung nach unsere Verpflichtung besteht, Leben zu retten. Unter Schwerbehinderung sind Fälle zu verstehen, in denen die geistigen oder körperlichen Funktionen erheblich beeinträchtigt sind, wie z. B. bei Psychosen, Blindheit, Querschnittslähmung oder ständigen Schmerzen und Beschwerden. 11 U.S. Kongress, OTA (1993) 12 Vorzeitiger Tod und Behinderung werden gewöhnlich als besonders tragisch empfunden, weil sie laufende Projekte und Beziehungen zunichte machen. Jede Moraltheorie, die dem Wohlwollen irgendeine Bedeutung beimisst, würde uns daher raten, zu versuchen, die Belastung durch solche vorzeitigen Todesfälle und Behinderungen zu verringern. Die Meinungsverschiedenheiten beginnen bei der Frage, ob wir als Gesellschaft verpflichtet sind, zu versuchen, solche vorzeitigen Todesfälle und Behinderungen zu verringern, wie diese Verpflichtung beschaffen ist und wo ihre Grenzen liegen. Um diese Fragen zu erörtern, werde ich zunächst die häufigsten Ursachen für solche Tragödien und die Frage, ob sie verhindert werden können, untersuchen. Dann werde ich mich mit der Frage befassen, was nötig wäre, um diese Ursachen zu verhindern. Haben wir es insbesondere mit einer ernsthaften Ressourcenknappheit zu tun, wenn es darum geht, derartige Zustände zu lindern? In den Industrieländern sind Herzkrankheiten, Krebs und Unfälle die Hauptursachen für den frühen Tod und die Behinderung von Männern. Zusammen sind sie für mehr als 60 % aller Todesfälle vor dem Alter von 65 Jahren verantwortlich. Bei Frauen ist die Situation ähnlich: Herzkrankheiten und Krebs sind ebenfalls die Hauptursachen für frühzeitigen Tod und Behinderung. 12 Es ist erwiesen, dass ein großer Prozentsatz der vorzeitigen Todesfälle und Behinderungen durch mehr und bessere medizinische Versorgung sowie durch präventive Maßnahmen vermieden werden könnte. Die größte Wirkung hätte die medizinische Grundversorgung und die Untersuchung und Behandlung von Personen mit Risikofaktoren, die bekanntermaßen für schwere Krankheiten prädisponieren. Beispiele hierfür sind Blutdruck- und Cholesterinscreening sowie Screening auf Darm-, Brust- und andere Krebsarten. 12 (ebd.) 13 Unter den Maßnahmen, die der Einzelne ergreifen kann, um die Wahrscheinlichkeit eines vorzeitigen Todes und einer Erkrankung zu verringern, stehen Raucherentwöhnung, Ernährungsumstellung und regelmäßige Bewegung an erster Stelle. Unter diesen Maßnahmen kommt der Raucherentwöhnung eindeutig die größte Bedeutung zu, da Rauchen sowohl zur Belastung durch Herzkrankheiten als auch durch Krebs beiträgt. 13 Man schätzt, dass Rauchen für 30 % aller Krebstodesfälle und für 25 % aller Todesfälle durch Herzkrankheiten verantwortlich ist. 14 Die Ernährung ist nachweislich ein entscheidender Faktor für die Wahrscheinlichkeit, an Herzkrankheiten und Krebs zu erkranken, und rangiert nach dem Rauchen an zweiter Stelle; sie ist für eine unbekannte Zahl aller Fälle von Herzkrankheiten und schätzungsweise 35 % aller Krebsfälle verantwortlich. 15 13 MacKenzie (1994) 14 Doll & Peto (1981) 15 Hennekens (1994) 14 Wie viel sollte die Gesellschaft in Anbetracht der Tatsache, dass eine große Zahl vorzeitiger Todesfälle und Behinderungen vermieden werden könnte, ausgeben, um die Zahl der Risikopersonen zu verringern? Ist es unter dem Gesichtspunkt der sozialen Gerechtigkeit etwas Besonderes, wenn ein Mensch relativ jung stirbt oder schwer behindert wird? Haben wir als Gesellschaft angesichts der Ressourcenknappheit, die zur Grundvoraussetzung jedes Gesundheitssystems gehört, eine besondere Verpflichtung, zu versuchen, vorzeitigen Tod und Behinderung zu vermeiden? Diese Fragen sind Teil einer allgemeineren Fragestellung, nämlich der Frage, welche Aufgaben das Gesundheitssystem haben sollte. 16 Diese Fragen sind nicht neu. Ich würde jedoch behaupten, dass sie in letzter Zeit aus den folgenden vier Gründen noch dringlicher geworden sind. Erstens haben wir in diesem Jahrhundert einen dramatischen Anstieg der durchschnittlichen Lebenserwartung sowohl in den Industrieländern als auch in den nichtindustrialisierten Ländern erlebt. Dadurch hat sich die Bandbreite der Lebenserwartung und der Aussichten auf ein behinderungsfreies Leben innerhalb der Gesellschaft vergrößert. Zweitens sind die Möglichkeiten, denjenigen zu helfen, die von vorzeitigem Tod und Behinderung bedroht sind, stark gestiegen, insbesondere durch Fortschritte in der medizinischen Versorgung, Epidemiologie und Gesundheitspolitik. Drittens sind die potenziellen Kosten für Prävention und Behandlung durch die Verfügbarkeit neuer und besserer Technologien gestiegen. Und schließlich sind wir erst seit kurzem in der Lage, im Voraus diejenigen zu identifizieren, die das höchste Risiko haben, Krankheiten zu entwickeln, die zu vorzeitigem Tod und Behinderung führen. Dies erhöht nicht nur unsere Möglichkeiten, den Risikopersonen zu helfen, sondern verwandelt auch ihren Status von einem statistischen Risikoträger in ein identifizierbares Individuum. Dies macht aus moralischer Sicht einen Unterschied, denn wenn wir eine Person als Risikoträger hätten identifizieren können oder müssen, ohne etwas gegen dieses Risiko zu unternehmen, würden wir möglicherweise unrechtmäßig gegen diese bestimmte Person handeln. 16 Daniels (1985) 15 Wie stark sind die Ressourcen für die Vermeidung oder das Hinausschieben von vorzeitigem Tod und Behinderung eingeschränkt? Es wird oft behauptet, dass Prävention und frühzeitige Behandlung, die einen vorzeitigen Tod verhindern, Geld sparen, das sonst für die Behandlung fortgeschrittener Krankheitsstadien ausgegeben würde. Wenn dies allgemein zuträfe, könnten sich die Ausgaben für die Verhinderung von vorzeitigem Tod und Behinderung bezahlt machen. Obwohl es in einigen Fällen zu Kosteneinsparungen kommt, ist dies nicht die Regel, und es gibt einige Fälle, deren Behandlung extrem teuer ist. 17 Zu diesen Fällen gehören beispielsweise solche, die nur dann erfolgreich behandelt werden können, wenn sie durch Screening-Programme entdeckt werden, die relativ ineffizient sind, weil nur wenige Tests wirklich positiv sind und viele Tests falsch positiv ausfallen. Dies gilt für das Brustkrebs-Screening und das Cholesterin-Screening in einigen relativ jungen Altersgruppen. 18 Andere extrem kostspielige Fälle der Prävention vorzeitiger Todesfälle betreffen Maßnahmen zur Verhütung von Verletzungen durch Sicherheitsvorschriften, die in Bezug auf die Dollar pro eingespartem Lebensjahr teurer zu sein scheinen als die medizinische Versorgung. Die Kosten für Sicherheitsvorschriften können bis zu 100 Milliarden Dollar pro gerettetem Lebensjahr betragen. 19 Wir könnten also 10 % der derzeit geschätzten jährlichen Ausgaben für die Gesundheitsversorgung in den USA für die Rettung eines statistischen Lebensjahres ausgeben. 17 Weinstein (1990) 18 Tengs (1994) 16 Es ist also klar, dass die Industrieländer mit ziemlicher Sicherheit einen viel größeren Anteil ihres BSP für die Prävention von vorzeitigem Tod und Behinderung aufwenden könnten als sie es jetzt tun, und dennoch einen gewissen zusätzlichen Nutzen daraus ziehen könnten. Dies gilt umso mehr, als wir, wie ich weiter unten argumentieren werde, vorzeitigen Tod und vorzeitige Behinderung zumindest teilweise als abhängig von der durchschnittlichen Lebenserwartung in einer Gesellschaft betrachten sollten. Dies würde bedeuten, dass die Definition des vorzeitigen Todes dynamisch ist, und dass einige Todesfälle immer als vorzeitig angesehen werden müssen. Gerechtigkeit und die Funktionen des Gesundheitswesens 19 (ebd.) (1993) 20 Buchanan (1983) 17 Es mangelt nicht an Vorschlägen darüber, was Gerechtigkeit in Bezug auf die Struktur der Gesundheitssysteme erfordert. 20 Die meisten Vorschläge konzentrieren sich zu Recht auf Fragen der Verteilungsgerechtigkeit, denn die Art der Gesundheitsversorgung, die die Menschen in Anspruch nehmen, ist sehr unterschiedlich (insbesondere, aber nicht nur in den USA), und die Kosten für die Gesundheitsversorgung steigen in allen Industrieländern.21 Eine Möglichkeit, die Gerechtigkeit im Gesundheitswesen zu untersuchen, ist die Frage, ob es ein Recht auf Gesundheitsversorgung gibt. Dies ist eine wichtige Frage, denn in den westlichen Demokratien haben Ansprüche auf Gesundheitsversorgung durchaus politische Bedeutung. Wir sollten uns jedoch darüber im Klaren sein, dass die Art unserer Verpflichtungen, für die Gesundheitsversorgung anderer zu sorgen, letztlich bestimmt, welche Art von Gesundheitsleistungen jemand als Recht beanspruchen kann und wo die Grenzen dieser Ansprüche liegen. Dennoch ist es sinnvoll, zu untersuchen, was ein Recht auf Gesundheitsversorgung nach Ansicht der Verfechter der am weitesten verbreiteten Gerechtigkeitstheorien bedeuten könnte. Die Theorie, die am engsten mit der Gesundheitsökonomie, wie sie in den USA praktiziert wird, und auch mit dem Einsatz moderner Techniken der Politikanalyse verbunden ist, ist der Utilitarismus.22 Im Utilitarismus gibt es keine deontologisch zu rechtfertigenden Pflichten oder Rechte. Es ist eine wichtige theoretische Frage, ob der Utilitarismus überhaupt mit der Einführung von Rechten vereinbar ist, aber soweit dies der Fall ist, kann man sagen, dass er nur solche Rechte befürwortet, die langfristig zur Maximierung des Nutzens führen.23 Die moralische Verpflichtung des Einzelnen, solche Rechte zu unterstützen, würde aus einer allgemeineren Verpflichtung folgen, die sich zum Beispiel aus dem universellen Wohlwollen oder aus für beide Seiten vorteilhaften Konventionen ergibt. Ein Recht auf Gesundheitsversorgung würde sich aus der empirischen Annahme ergeben, dass die Ausweitung eines solchen Rechts zur Maximierung des Nutzens beitragen würde. Die abgedeckten Leistungen sowie das für ein solches Recht auf Gesundheitsversorgung festgelegte Budget würden ebenfalls durch die Regel der Nutzenmaximierung geregelt. 21 U.S. Kongress, OTA (1993) 22 Brock (1993) Lyons (1994) 18 Alternativ würden kommunitaristische Gerechtigkeitstheorien, stark vereinfachend, allen Mitgliedern der Gemeinschaft ein Recht auf Gesundheitsversorgung zugestehen, wenn dies das gemeinsame Verständnis davon zum Ausdruck bringt, was Gerechtigkeit in der Gesundheitsversorgung für die betreffende Gemeinschaft bedeutet. 24 Dies würde zu ganz unterschiedlichen Ansprüchen auf Gesundheitsversorgung in verschiedenen Gesellschaften führen, da verschiedene Gesellschaften nach ganz unterschiedlichen gemeinsamen Werten leben. Es würde kein Recht auf irgendeine Art von Gesundheitsversorgung implizieren, wenn dies die Werte einer bestimmten Gemeinschaft am besten zum Ausdruck bringt. Schließlich ist auch für liberale Gerechtigkeitstheorien ein Recht auf Gesundheitsversorgung nicht automatisch Bestandteil einer gerechten Gesellschaft. Liberale Theorien räumen dem Einzelnen in der Tat bestimmte Rechte ein, die weder durch utilitaristische noch durch kommunitaristische Überlegungen außer Kraft gesetzt werden können. Die Frage ist, ob die Gesundheitsversorgung zu den Rechten gehören sollte, die jedem gewährt werden. 24 Walzer (1983) 19 Libertäre Liberale lehnen dies mit der Begründung ab, dass dies entweder zentralere Rechte der Steuerzahler oder der Angehörigen der Gesundheitsberufe verletzen würde. 25 Sie könnten eine erzwungene Besteuerung zum Zweck der Gewährung von Rechten im Gesundheitswesen als eine Form von Zwangsarbeit betrachten. Ebenso wird es als erheblicher Eingriff in die persönliche Freiheit der Ärzte angesehen, zu behandeln, wen sie wollen, wenn sie gezwungen werden, allen Mitgliedern der Gesellschaft Gesundheitsdienstleistungen anzubieten. Bei den liberalen Theorien, die ein Recht auf Gesundheitsversorgung befürworten, kann man zwischen zwei Gruppen unterscheiden. Auf der einen Seite gibt es diejenigen, die behaupten, dass die Gesundheitsversorgung ein Recht ist, das sich aus unserer allgemeineren Verpflichtung ergibt, jedem Bürger einen gerechten Anteil an Ressourcen oder dem, was Rawls als "Primärgüter" bezeichnet hat, zur Verfügung zu stellen. Der Begriff bezieht sich auf universelle Ressourcen und Privilegien, die von denjenigen gewünscht werden, die wissen, was typischerweise für die Verfolgung einer Vielzahl von Lebensplänen erforderlich ist. 26 Auf der anderen Seite stehen diejenigen, die behaupten, dass die Verpflichtung zur Bereitstellung von Gesundheitsfürsorge anders geartet ist als die Verpflichtung zur Bereitstellung von Ressourcen oder Primärgütern und vor den Rechten stehen sollte, die sich aus dieser Verpflichtung ergeben. Das beste Beispiel für diese Art der Abgrenzung der Gesundheitsversorgung von anderen sozialen Gütern wurde von Norman Daniels entwickelt. Er argumentiert, dass ein Recht auf Gesundheitsversorgung aus unserer Verpflichtung folgt, allen Menschen gleiche Chancen zu bieten, bevor wir mit der Verteilung von Primärgütern oder Ressourcen beginnen.27 25 Nozick (1974) 26 Dworkin (1993) 20 Alle diese Ansätze wurden aus verschiedenen Blickwinkeln kritisiert, und ich werde diese Kritik hier nicht wiederholen.28 Stattdessen möchte ich eine bestimmte Art von Kritik vorbringen, die auf alle oben untersuchten Theorien zuzutreffen scheint, und meinen eigenen Vorschlag unterbreiten, wie wir bei der Klärung unserer Intuitionen über Gerechtigkeit in der Gesundheitsversorgung vorankommen könnten, indem wir dieses Problem vermeiden. Diese Art der Kritik liefert uns auch einige wichtige Konzepte dafür, wie wir über das Problem der Verhinderung von vorzeitigem Tod und Behinderung im Besonderen denken sollten, und kann erklären, warum die umfassenden Theorien der Gerechtigkeit in der Gesundheitsversorgung, die für diese Kritik offen sind, uns keine befriedigende Antwort auf dieses Problem geben können. 27 Daniels (1985) 28 Buchanan (1983); Emanuel (1991) 21 Allen oben genannten Theorien gemeinsam ist die Annahme, dass unsere Verpflichtung zur Bereitstellung einer bestimmten Form der Gesundheitsversorgung nur aus einer allgemeineren Verpflichtung zur Bereitstellung anderer, ganz anderer Formen der Gesundheitsversorgung folgen kann. Utilitaristen sind der Ansicht, dass die Verpflichtung zur Bereitstellung einer bestimmten Form der Gesundheitsfürsorge nur aus einer ganz allgemeinen Verpflichtung zur Maximierung des Nutzens folgen kann. Kommunitaristen sind der Ansicht, dass die Verpflichtung zur Bereitstellung jeglicher Form der Gesundheitsversorgung aus einer allgemeinen Verpflichtung resultiert, die Werte einer bestimmten Gemeinschaft zu teilen und zum Ausdruck zu bringen. Unter den Liberalen gibt es diejenigen, die der Meinung sind, dass die Verpflichtung zur Gesundheitsfürsorge Teil der Verpflichtung ist, eine gerechte Verteilung der Ressourcen zu gewährleisten, und diejenigen, die argumentieren, dass sie sich aus unserer Verpflichtung ergibt, allen Menschen gleiche Chancen zu bieten. Ich möchte diese zentrale Annahme in Frage stellen, nämlich dass alle Formen der Gesundheitsfürsorge durch eine Art von Verpflichtung abgedeckt sind, und werde dies von einem weitgehend kantianischen Standpunkt aus tun. Stattdessen behaupte ich, dass es eine spezifische Art von Verpflichtung gibt, die sich von unseren Verpflichtungen in Bezug auf andere, nicht-kantische Funktionen der Gesundheitsversorgung unterscheidet. 22 Keine der allgemeinen Verpflichtungen, die sich aus den anderen Theorien ableiten lassen, wird den Gründen gerecht, warum wir meiner Meinung nach eine besondere Verpflichtung haben, vorzeitigen Tod und Behinderung zu verhindern. Die Verhinderung eines vorzeitigen Todes und der Schutz vor schwerer Behinderung sind meiner Ansicht nach Verpflichtungen, die wir als Teil der Achtung anderer als moralische Akteure haben. Die Vermeidung von vorzeitigem Tod und Behinderung sind also die zentralen Funktionen der Gesundheitsversorgung, da sie aus einer Verpflichtung erwachsen, die wichtiger ist als Nutzenerwägungen, die Äußerung gemeinsamer Werte, Chancengleichheit oder die gerechte Verteilung von Ressourcen. Aus Gründen der Gerechtigkeit sollten wir daher die Gesundheitsversorgung nicht als ein einziges soziales Gut betrachten und unsere Verpflichtung, allen Menschen die für die zentralen Funktionen der Gesundheitsversorgung erforderlichen Leistungen zur Verfügung zu stellen, als vorrangig vor der Bereitstellung aller anderen Leistungen ansehen. Für andere Funktionen der Gesundheitsversorgung gibt es andere allgemeine Verpflichtungen, die einen plausibleren Grund für die Bereitstellung der entsprechenden Gesundheitsdienste liefern. Es wird oft behauptet, dass der kantischen Ethik die Mittel fehlen, die für die praktische Ethik oder für politische Fragen des "wirklichen Lebens" benötigt werden, und sie wurde als leerer Formalismus ohne vertretbare praktische Implikationen kritisiert.2 Obwohl ich denke, dass diese Kritik von kantischen Moralphilosophen erfolgreich widerlegt wurde, ist es etwas überraschend, dass es in der aktuellen angloamerikanischen Debatte über Gerechtigkeit im Gesundheitswesen bisher keine umfassende kantische Theorie der gerechten Gesundheitsversorgung gibt. Obwohl mein Versuch auch keine solche Theorie ist, wird er von der Überzeugung geleitet, dass Kants Moralphilosophie viel zu dieser Debatte beizutragen hat. Ich glaube, dass eine breit angelegte kantische Argumentation uns helfen kann, die besondere moralische Bedeutung der Verpflichtung, Leben vor Tod und schwerer Behinderung zu bewahren, zu verstehen und gleichzeitig die Kosten dieser zentralen Funktion des Gesundheitswesens auf prinzipielle Weise zu begrenzen. 29 Mill (1994) 23 Durch die Betrachtung der Gerechtigkeit im Gesundheitswesen vom kantischen Standpunkt aus hoffe ich auch, die Debatte darüber anzuregen, wie der Kantianismus zum Verständnis spezifischer Fragen der sozialen Gerechtigkeit herangezogen werden kann. Es ist argumentiert worden, dass die kantische Ethik die sicherste Grundlage für den Liberalismus darstellt. 30 Die Frage ist, ob sie auch in der Lage ist, vernünftige Lösungen für spezifische Fragen der Gerechtigkeit zu finden, wie z. B. Gerechtigkeit im Gesundheitswesen. Ich glaube, dass sie das kann. 30 Rosen (1994) 24 |
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Die Dissertation ist in Englisch geschrieben, klingt teilweise aber sehr hölzern, als ob sie mit einer Maschine aus dem Deutschen übersetzt worden wäre.
Hier ist sozusagen die Rückübersetzung ins Deutsche, gemacht mit DEEPL.COM. Weil DEEPL einige Macken hat, mußte ich Stücke tweilweise umstellen (Seitenzahlen und anderes verschieben), damit sie richtig übersetzt werden. Einen wesentlichen Block habe ich in Fettschrift hervorgehoben. Der könnte ihm das Genick brechen... https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Introduction.pdf Seite 1 GERECHTIGKEIT UND DIE FUNKTIONEN DES GESUNDHEITSWESENS Karl W. Lauterbach Eine Dissertation, die der Fakultät der Harvard School of Public Health in teilweiser Erfüllung der Anforderungen für den Grad eines Doktors der Wissenschaften im Bereich Gesundheitspolitik und -management vorgelegt wurde Boston, Massachusetts Mai 1995 Seite 2 Diese Arbeit wurde unter der Aufsicht von Professor Marc Roberts geschrieben, der mich vor einigen Jahren ermutigt hat, mich mit diesem Thema zu befassen, und der mir bis zu ihrer Fertigstellung als Lehrer und Freund zur Seite gestanden hat. Ich hatte das Privileg, mit ihm unzählige Diskussionen über Ethik und Gesundheitspolitik zu führen, bei denen ich jedes Mal etwas Neues lernen konnte. Seine Unterstützung war äußerst großzügig, und ich bin ihm zu großem Dank verpflichtet. In ähnlicher Weise bin ich den anderen Mitgliedern meines Forschungsausschusses, den Professoren Arthur Applbaum, Michael Reich und Amartya Sen, zu Dank verpflichtet, die mir wichtige Kommentare und Kritiken gaben, die die Entwicklung meiner Gedanken tiefgreifend beeinflussten. An dieser Stelle möchte ich die unschätzbaren Anregungen meiner anderen Lehrer in Philosophie, Professor Norman Daniels, Derek Parfit, Hilary Putnam, John Rawls, Tim Scanlon und Dennis Thompson, würdigen, ohne deren Arbeit diese Arbeit nicht entstanden wäre. Mein Dank gilt auch meinen Freunden und Kollegen in der Abteilung für Medizinische Ethik an der Harvard Medical School, wo ich die Gelegenheit hatte, meine Ideen zu diskutieren und viele wertvolle Anregungen erhielt. Schließlich möchte ich meine wichtigsten Unterstützer nennen, meine Lebensgefährtin Angela sowie Carl-Stanley und Rosa-Lena, unsere Kinder. Sie haben mich glücklich gemacht und ermutigt. Auch Angela schulde ich großen Dank dafür, dass sie ihre Ansichten zu diesem Thema mit mir geteilt und das Manuskript getippt hat. Cambridge, Mai 1995 iii INHALTSVERZEICHNIS EINFÜHRUNG 1 Kapitel I: GERECHTIGKEIT UND DIE FUNKTIONEN DER GESUNDHEITSPFLEGE 11 Vorzeitiger Tod und Invalidität 11 Gerechtigkeit und die Funktionen des Gesundheitswesens 16 Kapitel II: KANTISCHE ETHIK UND DIE FUNKTIONEN DES GESUNDHEITSWESENS 24 Kants ethische Theorie 24 Warum sollten wir uns um unsere Gesundheit und die Gesundheit anderer kümmern? 28 Gesundheitsfürsorge und die Ziele des Einzelnen und der Gemeinschaft 31 iv Seite Die Grenzen unserer Verpflichtungen 35 Unterschiedliche Arten der Gesundheitsfürsorge werden von unterschiedlichen Verpflichtungen abgedeckt 37 Moralisches Handeln und Können 39 Kapitel III: GESUNDHEITSVERSORGUNG ALS BESONDERES SOZIALES GUT BEI ENDLICHEN RESSOURCEN 49 Die zentrale Gesundheitsversorgung ist ein besonderes soziales Gut 49 Der Einwand des bodenlosen Abgrunds 53 v Seite Kapitel IV: GESUNDHEITSPOLITIK UND DIE FUNKTIONEN DER GESUNDHEITSVERSORGUNG 76 Gesundheitspolitik in Deutschland 76 Gesundheitspolitik in den U.S.A. 86 Kosteneffizienz und Gerechtigkeit in der Gesundheitsversorgung 92 Rettung der moralischen Handlungsfähigkeit von Behinderten 99 SCHLUSSFOLGERUNG 104 REFERENZEN 111 EINLEITUNG Die Bestimmung des moralischen Wertes der Rettung von Leben durch Hinausschieben des Todes und Aufrechterhaltung der grundlegenden Qualitäten des Lebens erfordert, zwei gegensätzliche Intuitionen miteinander zu vereinbaren. Die erste ist, dass die Rettung von Leben moralisch so wichtig ist, insbesondere wenn junge und identifizierbare Individuen gefährdet sind, dass der Wert einer solchen Maßnahme nicht einmal in Geld ausgedrückt werden kann. Stattdessen scheinen wir eine uneingeschränkte Verpflichtung zu haben, Leben zu retten, wenn wir dies ohne Risiko für unser eigenes Leben tun können und nur finanzielle Kosten damit verbunden sind. Die widersprüchliche Intuition ist, dass wir das Leben nicht um seiner selbst willen schätzen. Stattdessen erhält das Leben einen Großteil seines moralischen Wertes durch Erfahrungen, die es für das Individuum, dessen Leben es ist, und für andere, die diese Erfahrungen teilen, wertvoll machen. Diese Erfahrungen wiederum hängen unter anderem von den Ressourcen ab, die wir als Individuen zur Verfügung haben. Daher erscheint es angemessen, die Höhe der Ausgaben für das Lebenssparen im Zusammenhang mit allen anderen Ausgabenentscheidungen, die wir zu treffen haben, zu bestimmen. Die erste Intuition veranlasst uns dazu, unsere Verpflichtung, Leben zu retten, von den Verpflichtungen zu trennen, die wir haben, um eine gerechte Verteilung der Ressourcen zu gewährleisten. Die zweite Intuition würde den Schutz vor dem Verlust von Leben und lebensbedrohlichen Krankheiten zu einem Teil dessen machen, was jeder kaufen kann oder nicht, sobald wir eine gerechte Verteilung der Ressourcen gewährleistet haben. Was wir als gerechten Anteil an den Ressourcen betrachten, hängt natürlich von der allgemeineren Auffassung von sozialer Gerechtigkeit ab, die wir akzeptieren. Es stellt sich also die Frage, ob unsere Verpflichtung zur Bereitstellung von Gesundheitsfürsorge vorrangig oder nachrangig gegenüber anderen sozialen Verpflichtungen ist. Beide Positionen sind in der Literatur über Gerechtigkeit gut vertreten. Ein Beispiel dafür, die gesamte Gesundheitsversorgung zu einem isolierten sozialen Gut von besonderer moralischer Bedeutung zu machen, liefert das Buch Just Health Care von Norman Daniels.¹ Daniels begründet ein Recht auf Gesundheitsversorgung für jeden Bürger in einem so wohlhabenden Land wie den USA mit dessen zentraler Bedeutung für die "Chancengleichheit". Er kommt zu dem Schluss, dass die Gesundheitsversorgung entsprechend den medizinischen Bedürfnissen der Menschen verteilt werden sollte und nicht über den freien Markt aus dem gerechten Anteil des Einkommens des Einzelnen. Die alternative Position wird von Allan Gibbard2 und Ronald Dworkin3 vertreten. Beide argumentieren, wenn auch von unterschiedlichen Vorstellungen von sozialer Gerechtigkeit ausgehend, dass Gerechtigkeit in der Gesundheitsversorgung erfordert, dass alle Formen der Gesundheitsversorgung einem fairen Anspruch auf Ressourcen unterliegen und die Präferenzen des Einzelnen für die Gesundheitsversorgung einschließlich der Krankenversicherung widerspiegeln sollten. 1 Daniels (1985) 2 Gibbard (1983) 3 Dworkin (1993) 3 Der erste Ansatz scheint richtigerweise die Überlebenschancen einer Person von der Einkommensverteilung abzukoppeln, er scheint aber auch zu weit zu gehen, denn er würde die gesamte Gesundheitsversorgung von Entscheidungen darüber abkoppeln, welche Versicherung wir freiwillig abschließen würden, wenn wir einen fairen Anteil am Einkommen hätten. Es ist nicht plausibel zu argumentieren, dass jede Form der Gesundheitsversorgung, einschließlich einer Gesundheitsversorgung, die die Lebensqualität nur geringfügig verbessert, wichtiger ist als alle anderen sozialen Güter, die die Lebensqualität derselben Person effektiver verbessern könnten.4 Andererseits muss der erste Ansatz auch durch prinzipielle Möglichkeiten ergänzt werden, der Verpflichtung der Gesellschaft, Ressourcen für die Gesundheitsversorgung auszugeben, Grenzen zu setzen. Andernfalls müssten wir möglicherweise alles ausgeben, was wir haben, nur um Leben zu retten. Der zweite Vorschlag gibt solche Grenzen vor. Aber er unterscheidet grundsätzlich nicht zwischen den verschiedenen Formen der Gesundheitsversorgung. Außerdem kann er der Intuition nicht gerecht werden, dass die Verfügbarkeit bestimmter Formen der Gesundheitsversorgung nicht davon abhängen sollte, wofür wir uns entscheiden würden, wenn wir einen angemessenen Anteil am Einkommen hätten. 4 Buchanan (1983) 4 Ich werde argumentieren, dass von einem unparteiischen Standpunkt aus die Verhinderung eines vorzeitigen Todes und die Erhaltung eines Mindestmaßes an geistiger und körperlicher Funktionsfähigkeit die moralisch zentralen Funktionen der Gesundheitsversorgung sein sollten. Sie sollten nicht Gegenstand einer gerechten Einkommensverteilung sein, sondern durch Ansprüche geschützt werden, die durch unparteiisch annehmbare Prinzipien festgelegt sind, einschließlich Prinzipien, die die Grenzen dieser Ansprüche regeln. Ich werde vorschlagen, dass wir uns bei der Verteilung der Ressourcen, die unsere Überlebenschancen und unsere Fähigkeit zur Teilnahme am moralischen Leben bestimmen, auf eine bestimmte Reihe von unparteiisch gerechtfertigten Gerechtigkeitsprinzipien stützen sollten. Insbesondere werde ich argumentieren, dass solche Ansprüche nicht als Mittel zur Maximierung des allgemeinen Wohlergehens in der Gesellschaft oder als Ausdruck der von ihr akzeptierten Gemeinschaftswerte betrachtet werden sollten, wie es utilitaristische und kommunitaristische Ansätze zu diesem Thema nahelegen. Ich stütze mich dabei auf ein breit gefächertes kantianisches Verständnis der moralischen Argumentation, das ich in Kapitel II entwickeln und in den übrigen Kapiteln anwenden werde. Die erfolgreichste aller neueren kantischen Theorien der Gerechtigkeit ist natürlich John Rawls' Versuch, die kantische moralische Argumentation auf die umfassendsten Fragen der Gesellschaft anzuwenden, nämlich auf die Gerechtigkeit in den grundlegenden Institutionen.5 Obwohl Rawls die von Kant vorgeschlagene Verbindung zwischen Rationalität und Autonomie nicht unterstützt, ist die von Rawls in A Theory of Justice angewandte Methode der moralischen Argumentation grundsätzlich kantisch. Ich werde einige Schlüsselideen aus Rawls' Werk übernehmen, darunter die Idee der Bedeutung von Lebensplänen für die Definition moralischen Handelns. 5 Rawls (1971) 5 Schließlich werde ich mich auf Amartya Sens jüngste Arbeiten zur Ameisengleichheit stützen, weil sie für das Verständnis der komparativen Vorteile verschiedener Menschen von Bedeutung sind.6 Ich werde argumentieren, dass die Ermöglichung eines Mindestmaßes an körperlicher und geistiger Funktionsfähigkeit sowie das Überleben für eine angemessene Lebensspanne die moralisch wichtigsten Aufgaben der Gesundheitsversorgung sind und in der Rangfolge der Prioritäten von der Verteilung anderer Gesundheitsdienste oder anderer sozialer Güter getrennt werden sollten. Dazu werde ich Sen's Konzept eines "capability set" verwenden, um die zentralen Funktionen der Gesundheitsversorgung zu definieren. Auf diese Weise kann ich den Schlüsselbegriff, der aus kantischer Sicht die zentralen Funktionen des Gesundheitswesens isoliert, nämlich den Begriff der moralischen Handlungsfähigkeit, mit Inhalt füllen. Darüber hinaus wird die von mir vorgeschlagene Methode zur Festlegung des Gesamtbudgets für die moralisch zentralen Funktionen des Gesundheitswesens eine Analyse der Auswirkungen verschiedener Entscheidungen auf die Verteilung der Fähigkeiten beinhalten. Dies steht im Gegensatz zu dem, was normalerweise für solche Zwecke vorgeschlagen wird, nämlich Wohlfahrtsabwägungen. Die gesundheitspolitische Bedeutung dieses Aufsatzes lässt sich an mindestens vier Aspekten ablesen. Der erste betrifft die Debatte über die Frage, ob es ein Recht auf Gesundheitsversorgung gibt. 6 Sen (1985), (1990), (1992); Nussbaum & Sen (1992) 7 Buchanan (1983) 6 Obwohl ich dieses Thema nicht umfassend aufgreife, da ich nicht auf die Frage eingehe, ob die moralisch wichtigsten Funktionen der Gesundheitsversorgung zu Ansprüchen führen sollten, die durch individuelle Rechte geschützt sind, ist meine Analyse durchaus mit einer solchen Forderung vereinbar. Ich werde mich nicht auf die Rechte konzentrieren, sondern auf die Pflichten, die wir uns selbst und anderen gegenüber haben. Die Frage, ob solche Verpflichtungen durch Rechte durchgesetzt werden sollten oder nicht, ist eine andere Frage, die ich nicht behandeln werde. Die Antwort auf diese Frage hängt von Themen ab, die über die Gerechtigkeit in der Gesundheitsversorgung hinausgehen und den institutionellen Rahmen der Gerechtigkeit in der Gesellschaft im Allgemeinen betreffen. Es ist auch wichtig zu wissen, dass ich damit nicht sagen will, dass es neben den zentralen Funktionen keine Rechte auf Gesundheitsversorgung geben sollte. Ich behaupte nur, dass, wenn es solche Rechte gibt, die entsprechenden Pflichten auf der Grundlage anderer Prinzipien begründet werden müssen als die, die unsere Beziehung zu den zentralen Funktionen der Gesundheitsversorgung definieren und rechtfertigen. 8 Gibbard (1983); Buchanan (1983) 7 Die zweite gesundheitspolitische Debatte, mit der sich dieser Aufsatz befasst, ist der Versuch, ein "Grundminimum" an Gesundheit festzulegen, auf das jeder Anspruch haben sollte, unabhängig davon, ob ein solcher Anspruch eine Frage von Rechten sein sollte oder nicht.8 Es ist oft argumentiert worden, dass die Idee eines "Grundminimums" im Grunde bedeutungslos ist, weil es keinen ethisch vertretbaren Weg gibt, dieses Grundminimum zu definieren. Obwohl ich hier nicht die Aufgabe übernehme, ein Grundminimum zu konstruieren, versuche ich zumindest, eine ethisch vertretbare inhaltliche Definition für die zentralen Funktionen der Gesundheitsversorgung zu finden, die zu dem gehören sollten, was wir als Grundminimum definieren. Eine Möglichkeit, sich ein Grundminimum vorzustellen, besteht darin, die Ansprüche auf die zentralen Funktionen der Gesundheitsversorgung mit dem zu kombinieren, was nach unserer unparteiischen Auffassung angesichts einiger Verpflichtungen, die wir in verwandten Bereichen der Gerechtigkeit haben, wie z. B. einer fairen Einkommensverteilung, für jeden bereitgestellt werden sollte. Drittens gibt uns dieser Aufsatz Anlass, darüber nachzudenken, ob es Einschränkungen für den ethisch vertretbaren Einsatz der Politikanalyse zur Bewertung der moralischen Bedeutung von Gesundheitsleistungen gibt. Ich werde explizit argumentieren, dass wir, wenn wir die Politikanalyse zur Bewertung einiger Gesundheitsleistungen verwenden, den moralischen Wert von Leben nicht nach dem Grad ihrer erwarteten geringeren Lebensqualität oder ihrer Behinderung abwerten sollten, solange diese Leben immer noch eine moralische Ablehnung des Handelns zulassen. Ich werde den moralischen Wert einiger lebensrettender Leistungen mit Gesundheitsleistungen vergleichen, die aus anderen Gründen wichtig sind. 9 Brock (1992) 8 Ich werde jedoch behaupten, dass das Kosten-Nutzen-Verhältnis eine wichtige Rolle bei der Entscheidung spielt, welche lebensrettenden Dienste wir im Rahmen unserer Verpflichtungen gegenüber anderen in Bezug auf die ethisch zentralsten Funktionen der Gesundheitsversorgung finanzieren sollten. Die letzte gesundheitspolitische Frage, für die dieses Projekt relevant zu sein scheint, ist die Zulässigkeit der Altersrationierung. 10 Auch hier werde ich dieses Problem nicht direkt ansprechen. Meine Kriterien für die Definition und Rechtfertigung der moralisch zentralsten Funktionen des Gesundheitswesens werden jedoch das Alter und die Lebenserwartung als moralisch bedeutsame Proxies verwenden. Die Gründe, warum Alter und Lebenserwartung von Bedeutung sind, sind moralische Gründe, die weitgehend unabhängig von der Idee des Guten sind, die wir akzeptieren. Ich werde die Behauptung aufstellen, dass sie als moralisch wichtig für die Rationierung bestimmter Gesundheitsressourcen angesehen werden sollten, und zwar weitgehend unabhängig von den wirtschaftlichen Auswirkungen oder der sozialen Akzeptanz eines solchen Vorgehens im Hinblick auf die vorherrschenden Vorstellungen vom Guten in einer Gesellschaft. Ich präsentiere meine Analyse in vier Kapiteln. Im ersten Kapitel werde ich einige der empirischen Fakten darlegen, die für die ethische Behandlung relevant sind. Es ist wichtig für uns zu erkennen, dass unser Potenzial zur Rettung von Leben vor vorzeitigem Tod und Krankheit aufgrund verbesserter Technologie ständig zunimmt und dass wir praktisch unbegrenzte Ressourcen für diesen Zweck ausgeben könnten, während wir weiterhin einige kleine Vorteile erzielen. Diese Zunahme verschärft nur ein kritisches ethisches Problem, nämlich die Frage, wie die moralische Bedeutung der Vermeidung eines vorzeitigen Todes und der Verhinderung einiger besonders schwächender vorzeitiger Krankheiten mit anderen Funktionen des Gesundheitssystems verglichen werden kann. 10 Daniels (1988) 9 In Kapitel II werde ich meine methodologischen Mittel entwickeln. Der Hauptgedanke ist, dass die kantische Ethik uns die richtige Erklärung dafür liefert, warum wir uns um die Überlebenschancen anderer Menschen kümmern sollten, nämlich dass es sich um eine Verpflichtung handelt, die Teil der Achtung anderer als moralische Akteure ist. Um eine ethisch sinnvolle Währung zu entwerfen, in der sowohl der Nutzen als auch die Kosten der Erfüllung dieser Verpflichtung ausgedrückt werden können, werde ich Amartya Sens Konzept der "Fähigkeiten" verwenden. Ich werde argumentieren, dass die zentralen Funktionen des Gesundheitswesens aus ethischer Sicht diejenigen Fähigkeiten betreffen, die es uns ermöglichen, als moralische Akteure zu handeln. In Kapitel III werden die wichtigsten Verteilungsforderungen für die ethisch zentralen Funktionen der Gesundheitsversorgung vorgestellt, wie sie sich aus den Kapiteln I und II ergeben. Ich plädiere für Prinzipien, die es ermöglichen, ein ethisch vertretbares Budget festzulegen, um einen vorzeitigen Tod und den Verlust der moralischen Handlungsfähigkeit zu verhindern, und erkläre, was dies für die Gesundheitspolitik und die Verteilung des Einkommens in einer gerechten Gesellschaft bedeuten würde. Dies ist ein Versuch, uns zu einer Versöhnung der beiden Intuitionen zu bewegen, die ich oben dargelegt habe, nämlich dass einige Funktionen des Gesundheitswesens moralisch besonders sind, dass es ihnen aber dennoch nicht gestattet werden sollte, alle unsere Ressourcen zu verbrauchen. 10 In Kapitel IV werde ich meine Analyse auf die Gesundheitssysteme in Deutschland und den Vereinigten Staaten anwenden. Ich werde zeigen, dass die zentralen Funktionen des Gesundheitswesens in beiden Ländern nicht angemessen erfüllt werden, vor allem aufgrund von Mikroallokationsproblemen. Darüber hinaus scheinen die Gesamtbudgets für die Gesundheitsversorgung in beiden Ländern von falschen Überlegungen bestimmt zu sein. Abschließend werde ich auf den möglichen Nutzen und Missbrauch von Kosten-Wirksamkeits-Analysen für die Zuweisung von Gesundheitsleistungen im Rahmen eines gerechten Gesundheitsbudgets eingehen. |
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https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%204%20Health%20Policy%20And%20The%20Functions%20Of%20Health%20Care.pdf 76 CHAPTER IV HEALTH POLICY AND THE FUNCTIONS OF HEALTH CARE Health Policy in Germany The analysis of justice in health care I presented, in principle, supports the political call for securing access to the central forms of health care for everybody. Access must be such that everyone has the means to get the health care he is entitled to through the central functions. Formal access which cannot be taken advantage of because one cannot afford to pay does not count for much when we are sincerely interested to sustain the moral agency of others and ourselves. Impartial Kantian justice leaves open the question of how health care is to be provided and how the health care of those who cannot pay for themselves should be financed. The only restraints which need to be observed are that the provision of health care is effective and that its payment does not put high enough a burden on the socio-economically worst-off that they will as a result have less than adequate incomes. These two constraints decide neither between the most 76 important currently competing models of health care provision nor payment systems. In the provision of health care models of what is called "managed care" and "fee-for-service" medicine are the two most important approaches. In managed care, the primary provider of health care is an institution, not a physician. Within this institution, usually a so called "health maintenance organization" (HMO), employed physicians distribute services among patients according to the rules and criteria of the institution. Managed care is becoming the dominant model of provision in the U.S.. In contrast, in Germany micro-allocations are made fairly autonomously by individual physicians who are generally working on a fee-for- service basis, and only in hospitals micro-allocations are made according to institutional rules. However, both models of provision are, in principle, capable of distributing services in a way that the central functions of health care are not sacrificed for the peripheral functions, as long as providers recognize the moral importance of this division. In Germany, physicians in ambulatory care currently work with a more or less fixed budget per office which can be distributed by the physicians among patients and a variety of services in almost any possible way. Thus, there is little or no principles of micro-allocation which are binding for a physician. I would argue that principles of micro-allocation, however, are extremely important for a just health care 78 distribution. Without such principles, even an impartially just total budget can be too high and too low at the same time. It can be too high for the peripheral functions of health care and too low for the central functions. This unjust distribution appears to be the case in Germany in the sector of ambulatory care. Germany, together with Japan, has the highest number of physician-office visits, averaging 11 visits per person per year (in comparison the U.S. has only 6 visits). Most of these visits concern minor ailments such as mild headaches, infections, or the renewal oft standing prescriptions. In contrast, potentially life-saving and disability-preventing health services appear to be much underused. To give just one example, Germany (unlike the U.S or the United Kingdom) does not have a national program for heart disease prevention which could be implemented through the high number of yearly office visits. Mainly for that reason, Germany has not seen a comparable reduction in mortality from myocardial infarction (only one fourth of what was achieved in the U.S. during the last 20 years). The situation is similar for cancer, where the U.S. has recently achieved a decline in breast cancer (incidence and mortality) through implementing large screening programs whereas in Germany the incidence of breast cancer is still rising. 79 Within the existing budget in ambulatory care, a shift towards the central functions of health care appears to be both possible and necessary in Germany, and the prevention of cardiovascular diseases and cancer would appear to be the two most important goals. This should possibly include a shift towards spending less on the slightly life-prolonging less effective treatments of chronic diseases in old age towards preventing and treating these and acute diseases among those who develop them fairly early in life. On a different micro-allocation issue Germany is doing quite well in comparison to almost any other health care system including Canada and England. The system, in general, does not offer better or more extensive central health care to better-off socio-economic groups, which is in agreement with my analysis. To save the moral agency of others is of equal importance regardless of whether a person is rich or poor. The main reason why the care is distributed equally is a fairly homogenous fee-schedule for physicians which allows the better-off to pay only slightly more of what the worst- off pay, that is not permitting the better-off to pay more than the regulated fee privately. This fee-schedule is binding for almost all German physicians. Those who are not prepared to comply with it can only treat the 1 percent of Germans who are not insured. Thus, there is only very little 80 financial incentive to treat the better-off differently, and there is, in fact, some reason to believe that they sometimes experience inferior services. Those sickness funds that insure the general population ("statutory sickness funds" covering more than 85%/ of the population) require more rigorous training from licensed physicians for some services, such as ultrasound examinations, than private insurance companies do.55 It generally cannot be said that the system disadvantages the poor through lower quality of care or less than equal access. The way the system is financed also does not appear to be grossly unfair and may meet the requirements of my ethical analysis. The system is unlike the British system not tax financed but financed through insurance contributions that made in equal parts by those who are employed and their employers, covering all family members of the employed person. The insurance rate is fixed (on average, about 12% of the total wage), and therefore contributions rise with income. At an income level of what amounts to upper- and middle-class incomes the contributions do not rise anymore, however. This is meant to keep the better-off socio-economic groups in society within the statutory sickness funds and not let the private insurance sector grow significantly beyond 55 Michael Arnold, University of Tübingen, (personal communication) 81 10% of the population. The socio-economically better-off are perceived as politically essential for maintaining or improving the quality of care in the whole system, and a more progressive mode of financing the system is supposed to harm those who have no alternative of leaving it. To the extent that this assumption is true, this move appears to be justified on the grounds that it is better than any alternative for those prone to early death and disability and, at the same time, does not place too heavy a burden on the poor. The total budget of the health care system in Germany is currently about 9.1%, and the government has enforced strict cost-containment rules through a series of reforms which do not allow the systen to go beyond this level. In contrast to the U.S., Germany has succeeded in controlling its health care costs through the last 18 years when the first cost- containment bill was passed. The question is, however, if this budget is adequate for a country with this level of resources available. In one sense, the budget is clearly inadequate. It has not prevented that about 30% of the population dies before the age of 65. In Germany, only a minority of blue-collar workers stay healthy enough to work until the officially recognized retirement age of 65 years. The average retirement 82 age is by now about 57 years for workers, with most of them retiring involuntarily because of disabling chronic diseases. It is therefore the case that a majority of workers cannot enjoy what is recognized as a normal work-life because of premature death or severe disablility. This is in contrast to what the higher ranks of white-collar employees and professionals can expect, many of them even being able and permitted to work beyond the official retirement age of 65. It is clearly inappropriate that the government has so far sponsored little research into the determinants of these differences. It is only known that mortality and morbidity for some diseases are higher among blue-collar workers and among lower socio-economic groups in general, for example, but to what extent this explains the observed differences in life-expectancy is not known. It is also unknown to what degree the health care system could address these differen- ces, and how much resources such an attempt would take. It appears doubtful that these differences can be significantly ameliorated through shifting from the peripheral functions of health care to the central functions alone, however. Since working to the officially recognized retirement age is a very central ideal of the good in Germany, a country which distributes to many social benefits of (material and immaterial, such as public recognition) through the working 83 process, it would be unjust to leave those differences to good health policy alone without regarding them as matters of respecting others as moral agents. If it was indeed the case that a higher budget for health care would allow more people to work until the official retirement age, the government's strict enforcement of the current cost-containment policies may be ethically indefensible. I am here not suggesting that the officially recognized retirement age should be taken as that age which is suffi- cient to allow everyone (or even most people) to fulfill their life-plans. I suspect that most life-plans in Germany currently go somewhat beyond that age. But in order to be conservative about my assumptions of what age is adequate, I have presented the case for the very widely held ideal of the good of a complete work-life in Germany. It appears that the budget for health care cannot guarantee that even this age is reached by as many people as possible. Furthermore, I also do not want to imply that health care is the only or the best means to achieve that goal. I am convinced that it could have a great impact, in particular through preventive medicine. But I also recognize the importance of working conditions and socio-cultural factors such as attitudes towards health. Not all of these factors are equally worthy af attention for purposes of justice. To 84 the extent that people choose freely to assume more risky life-styles (such as dangerous sports or eating habits), it appears that those behaviors which are an important component of the ideal of the good which a person has accepted may be beyond the most immediate concerns of justice. They rarely are no matter of justice at all, however, because to the extent that I risk my own life I also fail to be able to support those who depend on me. I have tried to argue above that this includes more than those with whom I am in direct and voluntary relationships. It should also include those who without the institutions I am able to support cannot continue to survive as moral agents. It is the case in Germany now that the socio-economi- cally worst-off groups have an income that allows them to pursue a wide range of life-plans, since the welfare system provides fairly generous benefits, including free health care which is equal to what everyone else gets. The most serious exception to this quite general claim are those who are unemployed in the long run. Although they enjoy adequate material benefits which allow for complete moral agency, they are not at a high level of capability that can only be relized through employment. I consider this to be a very important problem of social justice in Germany. It is, therefore, an important empirical issue whether 85 the health care budget can be raised without causing higher levels of unemployment, and whether the capability reducing consequences of unemployment can effectively be ameliorated through government efforts to reduce long-term unemployment. In general, however, I believe that Germany could increase its current health care budget without putting burdens on the worst-off which would reduce their capabilities below an adequate level. Even if the health care budget could not be increased without raising unemployment, there appears to be an obligation to do so if it was shown to be effective. The reason is that those who are unmemployed but have an adequate income still have a wide range of ideals of the good available that can be considered adequate. They can engage in highly recognized voluntary projects, participate in politics and culture, raise a family, or develop private projects. All of this is possible because of the generally generous welfare system which provides free education (including university education), health care, housing, and the public financing of political or community activities. To the extent that an increase in the health care expenditures would put these benefits also at risk, it might in fact reduce the worst-off to less than an adequate level of 86 capabilities. It is beyond the scope of this analysis to predict at what percentage of the gross national product (GNP) spent on health care this point would be reached, although the strict limitation of expenditures currently enforced by the government together with a total lack of interest in targetting the expenditures at the central functions of health care seem to be the two biggest ethical problems for the allocation of resources in the German health care system. Health Policy in the United States In the United States, only the elderly and the socio- economically worst-off enjoy a right to health care which covers many of the central functions. The Medicare and Medicaid programs do not cover the whole population, and most of those who are in the age-range that is central for fulfilling life-plans are either privately insured or not insured at all. In case they require care which they cannot pay for either through insurance or directly, they have no entitlement against the state for coverage. Although any American is normally in a position to get some care in case of emergencies, even life-saving or disability-preventing elective services can be denied to those who are not able to pay. 87 The dependency of the extent and quality of all types of care on the ability to pay is clearly unjust since it includes the central functions of health care. It implies that society is not prepared to make the sacrifices necessary to save the moral agency of those who cannot provide for their own health care or have in the past chosen not to do so. Although we would not have an obligation to provide those with resources that have chosen to squander (or not to insure against bad luck) their assets, at least beyond a minimally adequate level of welfare, we cannot leave unattended those who chose not to take out health insurance although they could have done so from their income. Instead, we should not allow anyone to be uninsured, since it is part of the human condition that we can come into situations where we are not appropriately insured and would will to be treated nevertheless. It appears that we should not allow anyone to not be insured against premature death and severe disability at least, although everyone should be free to not make use of the services covered through their insurance in case of illness. As in the U.S. they do, the better-off should in principle have an opportunity to buy a more extensive coverage for the central functions. This is a right they enjoy as part of their basic liberties. On the other hand, the state can regulate the market for additional insurance if 88 this benfits the central health care of those who are at the highest risk of premature death or illness, regardless of whether they are rich or poor. In Germany, it has been made difficult (but not impossible) for the better-off to buy better care in order to rise the standard coverage to the highest possible level of quality. In the U.S., the negative impact of making it easy for the better-off to leave the insurance system that covers most people on the quality of care of those who cannot opt out of the public system is not sufficiently recognized in the health policy debate, and needs to be taken into consideration when solutions for covering everyone with insurance for the central functions of health care are sought. Similar to Germany, micro-allocations in the U.S. are often not deliberately targetted at the central functions of health care. However, this appears to be happening to a greater extent than in Germany. Most HMO's do not cover the treatments of those minor ailments that consume a large part of Germany's ambulatory care resources, such as headaches or minor infections. Also, managed care has put some focus on the outcomes of treatments in order to improve the quality of care. Such studies rarely enter German ambulatory care practices, and are also less frequently part of hospital micro-allocations than in the U.S. 89 Obviously, these comparisons are not meant to substitute for detailed empirical studies. Instead, I make them to show in what way a general theoretical approach to justice in health care ccould have substantive implications that allow for the normative comparison of health care systems. It allows us, for example, to determine what kind of research is necessary to further just health care allocations. Studies that analyze the outcomes of treatments on survival and the ability to function emerge as particularly important. The U.S. is world-wide the leading undertaker of such studies, which include studies regarding the outcomes of preventive interventions. A focus on the total health care budget and on ways of financing this budget has dominated the discussion in justice in health care in Germany, leaving aside important issues of micro-allocation. This has helped to cause a relative lack of studies that would allow one to implement a more just micro-allocation in Germany. In the U.S., in contrast, such research has been done, although not because it has been thought to be important for purposes of social justice. Because the practice of physicians in the U.S. is far more regulated than in Germany (with no managed care, few guidelines for treatment from speciality-associations, and very little malpractice litigation) and because of the relative abundance of outcomes studies of different 90 treatments in the U.S., a shift towards a more just micro- allocation pattern appears to be more feasible currently than in Germany. This is a very important opportunity, because the total budget spent on health care in the U.S. is quite large and estimated at about 14% of the GNP. A shift of resources within this fairly large budget towards the central functions of health care would presumably have considerable impact. The assessment of the adequacy of the total budget for health care in the U.S. is quite difficult. It has been estimated that about 20% of children are currently put at risk by hunger and poverty. Also, the quality of public education and the housing conditions of the poor are often not adequate. To the extent that these generalizations are true, the socio-economically worst-off do not obviously enjoy the level of resources which is adequate even for complete moral agency. On the other hand, long-term unemployment appears to be somewhat less of a problem. It is important for economists to study whether these conditions can be improved while at the same time making available and improving the central functions of health care for everyone. Since the GNP of the U.S. is still slightly higher than that of Germany or Sweden, countries in which these twin goals have been achieved to a much higher degree, I suspect that through structural and redistribu-tional interventions by the government such changes are in principle feasible, although I 91 cannot make this case myself. In the U.S., there is even more pluralism of ideals of the good than in Germany, and the tentative claims I made about the central importance of a full work-life for most Germans cannot be made here. This may undermine any attempt to construct a minimum age which can be accepted by most for being able to pursue typical life-plans. Still, I believe that such a construction is possible. This is so because despite the pluralism of ideals of the good, there is actually very few which extend into old age. Many Americans begin new life-plans after retirement, such as moving to a different part of the country or beginning new professions or educations. Although these initiatives are very encouraging since they change the often painful experiences of getting older in society, they do not give rise to health care entitlements of equal moral importance than of those who have had little or no chance for pursuing their first set. Since there is a wide variety of life-plans that can be fulfilled without having to live into old age, and only very few that extend into old age, the case for not setting the age limit for the central functions appears not to be weakened by the pluralism typical of U.S. society. A clear articulation of what the most important entitle- ments are for purposes of justice seems to be a crucial 92 element for furthering the debate about health care reform in the U.S. Many opponents of universal health care coverage of the population liken health care to other goods of consump- tion. For some health services, I think this comparison is adequate. Concerning the health care with minimal or no functional implications, it is difficult to give criteria that would distinguish health care from often quality-of-life improving commodities. The impartial reasons for universal coverage can be better articulated by not speaking about health care per se but about what I called the central functions. This is a better strategy than calling for a "basic minimum" of health care, which gives little or no focus for what should be covered. To campaign for the kind of health care which allows as many Americans as possible to fulfill their life-plans gives a clear and compelling reason why central health care is so important. A basic minimum can address many health differences between people, not all of them equally matters of justice. Cost-Effectiveness and Justice in Health Care Cost-effectiveness studies are another example of research important for just micro-allocations. Like in outcome studies, the U.S. is far ahead in this field in comparison to Germany. Although in one sense the costs of health care services to restore or maintain moral agency are 93 a morally arbitrary factor, there are impartial considera- tions that can urge us to consider them as being morally relevant for just micro-allocations. The intuition of moral arbitrariness can be expressed through the question of why someone's priority rank on a list for health care entitlements should depend on the costs of the service one needs, rather than the nature of the health problem it addresses alone.56 One may argue that equally significant losses in capabilities should count as equally important morally, even if they involve for their treatment or their prevention quite unequal costs.57 I think that this intuition is true. There appears to be an even more concern about cost-effectiveness analysis when the costs of health services vary for quite arbitrary or even morally suspect reasons, such as the high profits in parts of the health care industry or lack of government interest in the development of a cheaper treatment for a disease, e.g., since the majority of the population is not likely to develop it. My argument for nevertheless allowing the costs to play a morally significant role moves in two steps. The first step is to demand that cost differences that are due to unfairness in other social institutions should not count. Such 56 Rawles (1989) 57 Brock (1993) 94 unfairness is for example given if the differences in cost are due to deliberate neglect of research into specific diseases for morally unacceptable reasons, such as discrimi- nation by scientific institutions or the government as research sponsor. Examples for this include racial or gender discrimination through not funding research into certain diseases. It has e.g. been argued that the cost-effectiveness of coronary bypass-surgery of women is often lower than that for men because the technology was developed through research done mostly for and with men in a climate in which diseases of men were supposed to be more important to cure. If women were now excluded from this health service because of lower cost-effectiveness, they would be unfairly harmed. Although it can be very difficult in practice to and to determine cost differences as unfair, the idea should not immediately be dropped since it can be a useful concept, for example when it is invoked for directing our research funds. It stresses the importance of using research funds in a way that all groups in society are fairly represented, since those who are underrepresented may be disadvantaged twice: first since there is less choice of treatment for them, and secondly, the existing treatments may be of low cost- effectiveness and, thus, not be covered by insurance. Furthermore, from this perspective we can see the contribution to social justice which research can make that 95 aims at particularly cost-effective treatments rather than at treatments which are maximally effective but are extremely costly. The second step in the argument towards the inclusion of cost-effectiveness as a moral factor in ranking the priority of health services for the central functions of health care is a consideration of impartial agreement among those at risk of premature death or loss of moral agency. If the total budget for that purpose is set at an ethically adequate level and the existing cost-effectiveness differences are not due to morally objectionable causes, it seems prima facie fair within the group of the potential beneficiaries to attempt to maximize the total number of life-years that could be saved. This is so because everyone in that group of people stands to lose the same, namely the basic capabilities of moral agency, and there are no morally inadmissible trade-offs with other social goods involved. On reflection, we seem to intuitively agree that cost- effectiveness ranking in such a situation can be a morally important determinant for which health services we should publicly finance. The reason is that within the group of those at risk of losing their basic capabilities, to maximize the aggregate benefit can be seen as a demand of fairness itself. If we were to squander resources available for that 96 group, let us say through determining whom to save through a lottery, we had acted unfairly to those who would have been saved the loss of moral agency if we had use a maximizing strategy. This is so because if the members of that group had been asked before knowing where they would be placed with their disease in a cost-effectiveness ranking, they would have objected to the principle of a lottery which would reduce theirs and others' chances of rescue. At the same time, no one could have rejected an ex ante maximizing strategy, since for everyone the same kind of loss was at stake. In this specific context, impartial ex ante reasoning appears to be morally acceptable since it does not violate the categorical imperative. Any ex ante chosen distributional principle by those who face the premature loss of moral agency will later be regretted by those who are put to a disadvantage by it. But contrary to a situation where a fair budget has not been allocated, no further sacrifices by anyone can be expected, and maximizing the yield of the budget does not reduce anyone's just entitlements. There are , however, some complexities here which I can only mention rather than discuss in detail. One is the question if the prima facie intuition that we should maximize the number of life years with moral agency is ultimately 97 defensible. How should we, for example, think of cases where we either add little life-expectancy for many versus a lot of life expectancy for a few? What role does it play at what age moral agency is lost prematurely? The objections against cost-effectiveness analysis that are usually brought forward when it is used for prioritizing health care services either concern the complete lack of any explicit distributional consideration, e.g. when the technique is justified for purely utilitarian reasons, or they concern the non-permissable comparison of social goods of different moral importance, as happened when the first version of the Oregon Health Plan was introduced. In that version, some expensive life-saving procedures ranked lower than inexpensive pain-reducing preocedures. Thus, tooth- capping was given priority over appendectomies. It cannot be justified, however, as Dworkin persuasively argued, to allow a young individual to die from appendicitis which can be cured without remaining disability through surgery by putting the money into a large number of capped teeth. 58 The reason for this also follows from the presented analysis: to allow an individual to die extinguishes not only his future experien-ces of pain-free life but also the human being as a moral agent, a loss that could clearly be rejected by the indivi-dual in question if all that could be gained through 58 Dworkin (1993) 98 his sacrifice was to save others from temporary pain and a loss of teeth. 59 As with outcome studies, cost-effectiveness analysis therefore emerges as a very important instrument of a just micro-allocation. It has many ethical pitfalls, however, when it is used. From what I said above, it is clear that it cannot substitute for principles of justice in micro- allocations, it can only help to implement them. Services with equal cost-effectiveness measured in "quality-adjusted- life-years", for example are not equally important from a moral point of view if they address different age-groups, or concern the same age-groups but remove reductions in the qualitiy of life in different ways. In general, those services, other things being equal, that address younger age- groups and more functional aspects of the quality of life should be given some priority. To go beyond these general remarks, however, would require a discussion of specific cases since more specific general criteria do not appear to be available. I will, however, comment on the use of quality of life in cost-effectiveness analysis and when it is used in the disabled for a just micro-allocation of the central health care services. 59 Rawles (1989) 99 Serving Moral Agency in the Disabled The arguments I have made above about the moral importance of avoiding the premature loss of moral agency can be said to hold by and large independently of the levels of well-being a person has achieved or is likely to achieve in the future. The central functions of health care should address those who, in principle, can pursue life-plans regardless of their subjectice quality of life. This implies that they do not cover those who have no chance to achieve the level of functioning needed to do that, such as the permanently and totally incompetent or miserable. I want to emphasize, however, that this does not imply that the lives of those human beings should not be saved, since there are other important moral reaons to save them. 60 I will now more explicitly argue why we should not determine what lives should be saved from death or loss of moral agency according to how far they go beyond a minimum of functioning needed for moral agency or how desirable these lives are. I have argued above that in the group of services which avoid premature death and the loss of moral agency we should allocate health care in a way that are most cost-effective. It 60 Brock (1993) 100 initially appears intuitively right to consider quality-of- life and disabilities in these cost-effectiveness calcula- tions. One way to start the argument for including the quality-of-life in deciding whose life or moral agency should be saved is to say that there are states that are "worse than death" that would clearly not warrant being maintained. As this shows, quality-of-life is a matter of degree, and it appears not to be plausible to not consider differences in quality-of-life at any level which ist somewhat better than "worse than death" for the allocation of resources. 61 This reasoning is false, however, since it only makes sense to say of someone else's life that it is in a state "worse than death" if it not only is miserable for the indiviudal himself, say through great discomfort of pain, but that additionally the person has lost the minimum level of mental and physical functioning needed for moral agency. This is so because there is a sense in which a life of residual moral agency cannot be worse than death interpersonally. We cannot have an interpersonal standard for trading-off moral agency for well-being experience and, therefore, also cannot make the claim that someone else's life is "worse than death" if it still allows for moral agency. Well-being depends on the ideal of the good a person has chosen, whereas moral agency does not. Furthermore, well-being includes more than 61 Glover (1977) 101 experiences. For a person for whom a life in extreme pain still contributes to the fulfillment of his meaning in life, life may be going well although his experiences are miserable. To not save the life of such a person because we do not share the judgement or cannot even imagine that his life still goes well can be unjust as long as we can still recognize him as a moral agent. This may even support health care entitlements if we can say that the experiences this life still allows are worse than no experiences at all even from the standpoint of the individual concerned. Not all ideals of the good even have a concern for experienced well-being. Extreme stoicism in principle could be indifferent about this dimension. Ruling that those who do still care for their own survival, but face an extremely low level of experiences should have lower priority would, in effect, discriminate against their ideals of the good. Because of its special value, moral agency should be protected quite independently of considerations of ideals of the good, including ideals that imply that health is only of moral importance to the extent that it avoids bad and promotes good experiences. Kantian ethics, therefore, supports the idea that the kind of health care which sustains human agency should be distributed in an entirely egalitarian way. The protection of 102 The basic capabilities of everybody should morally count equally for the state. Kantian ethics arrives at this egalitarian claim through recognizing that the most distinguishing human characteristic, moral agency, is the most valuable asset of everyone and is distributed equally among people, regardless of whether a person is happy or unhappy, rich or poor, privileged or disadvantaged, disabled or not. If moral agency does not come by degrees, and is a sufficient reason for entitlements through the central functions of health care, these entitlements shoud not be diminished because of existing disabilities of impairments that still allow for moral agency. As Bernard Williams observed, identifying the morally most important characteristic is one of the reasons why Kantian ethics has found wide resonance in common sense morality 62. If this characteristic was available only for a few, it would be hard top justify why we should respect everybody as a free and equal citizen, which is the aspiration of modern democracies. Those who de facto lack moral agency are also worthy of respect because they are also human beings, although they temporarily or always lack the means of realizing the capacities that are needed to be a free and equal citizen. Amartya Sen has made the argument that equal respect for everybody as a moral agent is a 62 Williams (1985) 103 feature of all of the currently competing moral theories. He attributes this to the force of the Kantian idea that the expression of equal moral concern for others is what morality is about 63. In health care this implies that the kind of care which is directed at saving moral agency should also not depend on features external to moral agency itself. To the extent that we allow this to happen, e.g. through favoring those who are more productive or enjoy a higher quality of life, we do not treat people as equals in a morally central aspect. For cost-effectiveness analysis, this implies that for the central functions of health we should focus on "life-years-gained-allowing-for-moral-agency", irrespective of their quality. This adresses life-years that are gained because we avert death or severe disability. I cannot further the question here of what should count as severe disability, but it is clear that the focus should be on gross functional impairments rather than on disabilites that insignificantly reduce someone's choices of the good. 63 Sen (1992) https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Conclusion.pdf 104 CONCLUSION I have argued in this thesis that the principles which are impartially justifiable in the distribution of health care services seem to disallow the trade-off of an individual's moral agency through loss of a minimum set of capabilities for aggregate gains of capabilities beyond the minimum, the welfare of all members of society, or that of certain subgroups in society, including the socio- economically worst-off. I derived what is impartially justifiable or not from an interpretation of Kant's ethics for justice in health care. These moral obligations derived hold in particular for premature death and and disability prevention which are the most frequent cause of early loss of moral agency. A just society should establish impartially acceptable principles of how the obligations for these central functions of health care are met. These principles should be set independent from trade-offs with more peripheral functions of health care or other welfare goals. I suggested that we should determine a budget which cannot reasonably be rejected by those threatened by premature death or disability. This total budget should be spent on insurance for both preventive and curative health care services which effectively avoid loss of moral agency. I argued that the 105 services for that purpose should be ranked according to their cost-effectiveness, but that cost differences that are due to morally objectionable causes such as discriminatory research efforts of the government in the past should be discounted. What a reasonable budget is depends partly on empirical facts such as the economic means of a society, the costs of health care services, and the proportion of people threatened by premature death and loss of moral agency. It seems ethi- cally required that in a society with a higher average level of income we should be under an obligation to sacrifice a greater part of our income to prevent premature death and loss of moral agency than in a society with, on average, a lower level of income. In particular, the budget for the central functions of health care should be set at the highest level that is feasible in order to still allow the socio- economically worst-off group to pursue the characteristic life-plans of a society. I further argued that in cost-effectiveness analysis the benefits should not include a discounting measure for the lower quality of life when my proposal is applied for determining whose life or basic capabilities we should save. For measuring other benefits, such as the benefits of non life-saving programs or life-saving programs at ages well beyond the adequate life-expectancy, such discounting 106 measures may indeed be justifiable.64 It may be possible to argue that an impartially justifiable set of principles would suggest or even mandate the inclusion of information about quality-of-life on that level of health care. I rejected the proposal to discount the moral value of saving a life of lower quality from premature death or loss of moral agency because the reason why such lives should be saved is independent of their quality and should in its strength, therefore, also not vary with it. We should save such lives because of our commitment to human dignity itself which is sustained by our moral agency, at every level of it. We have to distinguish between the moral and the prudential value of saving lives. I have argued that the moral value of saving lives from premature death and the loss of moral agency cannot convincingly be derived from what lives we would prudently want to save. The moral value of saving lives from premature death and loss of moral agency appears to be to some degree independent of the prudential value of saving such lives. We value our lives for reasons that go beyond the fact that we are moral agents, which may not give some of us much of a reason to value life at all. But the lives of others we should help to protect from premature death or loss of moral agency we should value for that reason. 64 Brock (1992), (1993) 107 If, instead of following my proposal, we ranked health care services for premature death and loss of moral agency prevention according to their willingness-to-pay value in society we might have a means to contribute to the maximi- zation of human well-being in society. But such ranking should be rejected, since it is not impartially justifiable to use the health care which protects against premature death and the loss of moral agency for the purpose of societal aggregate well-being maximization. The respect of others as free and equal citizens puts constraints on what we can define as the morally central functions of health care in that respect. This is the most important consequence of a commitment to a broadly Kantian account of moral reasoning for justice in health care. To assume that as a community we could define the goals. of health care without such constraints is plausible from a communitarian or a utilitarian view of ethics and meta- ethics. Such a communitarian view was, for example, presented by Ezekiel Emanuel, who adopts a Hegelian critique of the kind of Kantian moral reasoning used in this essay. 65 His alternative proposal would allow relatively small communities to use their own values to define the role of health care for all possible functions of health care, including premature death and loss of moral agency prevention. I have tried to 65 Emanuel (1991) 108 respond to a criticism of Kantian moral reasoning made by Emanuel and other communitarians. 66 They claim that there cannot but be impartially accepted principles for the distribution of health resources in the absence of shared ideals of the good. For the sake of furthering this discussion, I have tried to provide such a set of principles for what I believe are the ethically central functions of health care; still, there is an important point to the communitarian critique since I am less confident about the availability of such principles for less central functions of health care. This gives us reason not to speak about justice. For the less central functions Dworkin's approach is, I think, the most promising, in which he considers health insurance as an important resource which everyone should be entitled to according to a fair distribution of income. If his approach is adopted for more peripheral health care functions, there can be trade-offs between health care and other social goods such as education or income, and these trade-offs can be determined partly by the ideals of the good that the majority of society accepts. 67 To the extent that there are not many substantive and 66 Williams (1985), Walzer (1983) 67 Dworkin (1993), (1981) 109 universal principles of prudential reasoning, Dworkin's proposal may converge with communitarian proposals to distribute health care under the conditions of a fair income. distribution. The disagreement between Dworkin and communitarians would then be about what constitutes a fair distribution of income. This kind of convergence also may be expected because what is prudential for someone to do depends on the ideal of the good she accepts. Nevertheless, neither for reasons of prudence nor for the expression of community values shhould the state be permitted to sacrifice the most basic capabilities of moral agents, a point which neither communitarians like Emanuel nor equality-of-resource focussed liberals like Dworkin appear to be able to fully accommodate. It can even less be accommodated by utilitarian theories of just health care because in such theories moral agency is just one value among others and can be traded-off against other values in whatever way is dictated by aggregate total utility reasoning. Communitarian and utilitarian theories of justice have for health care distribution similar problems as they face for the distribution of the basic liberties. 68 The health care which protects our moral agency against premature extinction should not be permitted to become part of either a 68 Lyons (1994) 110 communitarian or utilitarian distributional mechanism for (at least partly) the same reasons for which we should not allow the basic liberties to be included there. The problem is not that they might, depending on circumstances, not get their proper affirmation in such a mechanism, but that they are in such a mechanism in the first place. 69 The affirmation of the basic liberties, as well as the protection of moral agency, should be unconditional, beyond the influence from our accepted ideals of the good, and beyond collective self- interest. 69 Williams (1973) 111 REFERENCES AARON, H., and SCHWARTZ W. (1984). The Painful Prescription. Washington, DC: Brookings Institute. 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https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%203%20Central%20Health%20Care%20As%20A%20Special%20Social%20Good%20In%20The%20Face%20Of%20Finite%20Resources.pdf CHAPTER III CENTRAL HEALTH CARE AS A SPECIAL SOCIAL GOOD IN THE FACE OF FINITE RESOURCES From a Kantian point of view one can argue that together with the basic liberties and the level of resources of the least well-off socio-economic groups, those functions of health care which protect or restore moral agency are the most important social good. As such they should be insulated against trade-offs with other social goods such as the econo- mic goals of a society. In different ways, the basic liber- ties, basic welfare, and the central forms of health care all protect those capabilities that are constitutive of our moral agency. Therefore, they should the primary focus for constructing just institutions in society. Otherwise we have to live with institutions that do not embody universalizable principles and mutual respect as moral agents. The basic liberties, basic welfare, and the central functions of health care do have a long tradition of being insulated against other considerations such as improving average welfare. This intuitively compelling insulation is 49 50 very difficult to accommodate within utilitarian or communitarian theories of justice.43 In such theories, rights are either reduced to their instrumental value, for maximizing the welfare of society, or seen as fulfilling a particular society's ideal of the good. In contrast, we often intuitively think that these rights have an important non- instrumental and non-contextual value. My suggestion here is that such insulation is rooted in the immediate and direct threat that the violation of such rights implies for individual's moral agency. The functions of the basic liberties and welfare entitlements, as well as those functions of health care that protect our morally most significant capabilities, are in that respect similar. Suppose we do grant that these social goods are morally special because they protect our status as moral agents. This does not imply that the social goods that are less central, are not morally important. For example, consider resources beyond the minimum level such as a maximally unconstrained freedom of speech, or an entitlement to the most extensive potentially beneficial education. The absence of any of these social goods does not reduce someone to being less than a full moral agent. Still they do contribute to capabilities in a way that extends the range of ideals of the good one could 43 Daniels (1985) 44 Scheffler (1988); Lyons (1994) 51 enjoy. Thus, capabilities. cannot be regarded as a non- continuous step-function. Moral agency, in contrast, is to be understood as a step function, in a sense. At a certain level of capabilities, a person becomes able to pursue the ideals of the good that are typical of its society. This threshold level is somewhat different from society to society because, for example, it takes different life-expectancies in diffe- rent societies to pursue the ideals of the good typical for it. Any threshold we define as the goal at which protecting moral agency should be targeted will, therefore, be somewhat arbitrary, and achievements above that goal are also always morally important. To say that some forms of health care are not part of the central functions of health care means that not all forms of health care are a special social good. Likewise, not all income is a special social good, but minimum income is. And the basic liberties are special, whereas maximally extensive liberties cannot plausibly be regarded as more important than minimum health care or income. This ranking of social goods does have important implications for justice in health care. First, it is normally not acceptable to spend so much on the non-central health care that the resources of the worst-off socio- 52 economic groups fall below the level which is necessary for them to pursue typical ideals of the good in society. Thus, basic welfare support is more important than some forms of health care. This is a key argument for avoiding having health care become an entitlement which takes up all of our resources. To spend money on the peripheral functions of health care, at the expense of neglecting the welfare of the poor, is like improving the socio-economic status of the better-off at the expense of the central health care of those who are in need of it. We should, therefore, neither see health care as an unrestricted social good we can use in order to maximize utility in society, nor as an unrestricted means toward the fulfillment of the ideals of the good that the majority in society pursues. The central functions of health care should rather be seen as a necessary component of any just society that can afford to provide them, no matter what specific ideals of the good are pursued by the majority. However, recognizing that the central functions of health care are a special social good does not imply that an individual has an unlimited entitlement to health care in order to preserve their moral agency. This would imply that such a person is prepared to reduce others to merely being the means to achieve their ends. It could imply, for example, 53 that someone would sacrifice the external means of the basic capabilities of others in order to save their own internal means. Such an intention is not compatible with respecting others as moral agents. It is, therefore, crucial to provide an interpretation of what it could mean to require others to make substantial sacrifices for saving one's own moral agency without thereby reducing them to being the means toward our ends. On a societal level, it must be possible to limit, in a principled way, the costs we have to shoulder in order to be able to say we have discharged the obligation of respecting all citizens as moral agents through making the central functions of health care available to all citizens. This is a difficult task since, as I have argued in the first chapter, the moral agency of some cannot be saved regardless of how much we as a society would decide to spend on health care. The Bottomless Pit Objection The most serious objection against insulating the morally central functions of health care from being traded against other social goods is indeed that this might require us to spend almost unlimited resources on health care. This 54 would make our lives long and safe but impoverished.45 How can we prevent health care from becoming, to use Daniels' term, a "bottomless pit", 46 while at the same time recognizing that any just society must make some sacrifices to protect the moral agency of its citizens? How can the ideal of justice with respect to the central functions of health care meet this constraint of feasibility? Before I address the bottomless pit objection for health care directly, I want to note that a similar objection can be raised against the widely supported insulation of the basic liberties from such trade-offs. The state is commonly assumed to be under an obligation to protect the basic liberties of people. This is acknowledged even by libertarians who want to reduce the role of the state to that of a "nightwatchman".47 But how much should the state spend for meeting this obligation? It is clear, for example, that with more law enforcement or national defense spending we could protect the basic liberties of some individuals better than we do now. It is possible that in the future spending on internal and external security could become more expensive than health care at least in some societies. Because of increased threats 45 Buchanan (1983); Dworkin (1993) 46 Daniels (1981) 47 Nozick (1974) 55 from wars, terrorism or civil unrest, potentially useful expenditures could increase limitlessly. Thus, the bottomless pit objection does not seem to me to be a problem specific to health care. For our time, however, the bottomless pit objection is clearly more relevant to the central functions of health care than to the basic liberties or welfare. There already is an almost unlimited potential for spending money on health care to avoid the premature loss of moral agency through health care. But going from this fact to a bottomless pit claim depends on the following specific unspoken assumption: If we have a moral obligation, we are under this obligation until we have done everything we can to fulfill it. I think that this assumption can be challenged on grounds of impartiality. My suggestion is that we have the potential to agree on interpretation on what it means to respect others as moral agents that also specifies the limits on our obligations. Moreover, these limits do not have to lead back to the trade- offs between saving lives and more peripheral social goods which, I argued, are objectionable. Limits on an individual's obligations to provide others with health care are here analyzed under the assumption that the individual is living a reasonable life in a just society. This implies, for example, that the limited life-expectancy 56 or health of those whom we should support are not the result of some external factors that we could object to, such as the exploitation by others, or the willful self-inflicted des- truction of health. In such a situation, our duty to invest into their health as part of respecting them as moral agents can be diminished. An individual who is living in a just society, meeting the undiminished maximum claims by those who stand to lose their moral agency, can also not be expected to sacrifice her own moral agency to save that of another person. This is so because there cannot be an impartial justification for the claim that she should regard her own moral agency as less important than that of another person. the person, who without the first person making such a sacrifice, has to die cannot make an impartial Kantian argument that she should be given whatever is required for her to remain a moral agent, since she also has to respect the potential giver as a moral agent. On reflection, this Kantian interpretation of impartiality seems highly plausible. Contrast it with a utilitarian interpretation of impartiality. For a utilitarian, such a sacrifice may be morally required in certain circumstances. For example, suppose the potential recipient is a great contributor to society's utility, whereas the potential sacrificer contributes very little. Yet most people find such a conclusion repugnant. 57 The Kantian explanation for this intuitive judgement is that our interest in the survival of others is neither to insure survival per se nor to achieve utility maximization, but to allow everyone the pursuit of ideals of the good. To sacrifice one person's capabilities to pursue such ideals in order to save those capabilities in another person is to fail to respect the former as a moral agent and to reduce them to the means of providing something for someone else. This limitation is subject itself to reasonable qualifications. The second person could perhaps require the first to make sacrifices that temporarily reduced them below that level of income or resources needed to pursue various ideals of the good. Similarly, I believe we plausibly can infringe on a person's basic liberty in some slight way to save another person's life, contrary to what Kant appears to have argued about such cases. But the basic argument clearly rules out long or permanent severe deprivations. For example, if someone, through making a large sacrifice would be perma- nently so impoverished that he could not hope to ever establish a family, to raise and educate his children, or to pursue any other commonly accepted ideal of the good, he does not appear to be under an obligation to make such a sacrifice even in cases where it would save another person's life. This may at first appear as an unjustifiable 58 restriction on the maximum sacrifice a person may be required to make to save another person's life. But since the reason we have to sustain the life of others is to sustain their moral agency,leno individual can justify a demand for a sacrifice that would put significant and permanent external limits on someone else's moral agency in order to have the internal limitations on their own moral agency removed. This, again, would imply that the moral agency of the sacrificer is not adequately respected. On the other hand, a sacrifice up to the point where moral agency becomes impaired does appear justified. In any just society, one has an entitlement to the amount of income equal to the threshold level which is adequate, given that such an entitlement can be provided for everyone, but not automatically to more than that if sacri- fices are needed to meet categorical obligations we have towards others. An additional factor that needs to be considered here is the effectiveness of potential sacrifices. I have so far implicitly assumed that one person could, through their sacrifice, restore another person who is in need back to full moral agency. The sacrifice could, however, be extremely ineffective, restoring the other person only to a fraction of typical moral agency by allowing only a couple of weeks of additional survival, for example. 59 than simi From an impartial perspective, the effectiveness of a sacrifice does seem to have moral significance. It would not be defensible to require at least a very large sacrifice for very little gain. For example, we could not reduce the level of resources of a socio-economic group by 50 percent of its original level-- all the way to the minimum threshold for several decades-- in order to allow a single person to function as a moral agent for an additional day. The point is that moral agency gets its importance from its relationship to the pursuit of ideals of the good. It is not a clearly defined mode of human functioning which is either achieved or not, although there is some threshold level involved since it requires adequate functioning for an adequate life-expect- ancy, which again depends on the life-plans typical for a society. An additional day in a typical life does not allow for a larger set of life-plans. Thus, the posited huge sacrifice does not really add any significant capabilities to the recipient's life. What a morally significant gain in capabilities is depends on the specific features of a society and cannot be specified in advance for all just societies. For example, in a society in which most ideals of the good are limited to young people, where aging is dreaded and the old see little meaning in life, sacrifices by older people, as well as gains by older people, may be impartially less morally significant 60 than similar gains or losses in younger people. Not all the societies that focus on the young would, of course, impartially have to be considered just. If aging is considered to be meaningless or dreaded, this may have produced pattern of discrimination and neglect of older people. From a Kantian perspective, it would be important to know whether the old people actually did have an opportunity to develop ideals of the good that included a meaningful old age. If this were not the case, the resulting distribution of ideals of the good among various ages would not be a morally privileged starting point for deliberating what kind of sacrifices and gains in survival or resources are impartially justifiable. To give another example, suppose the majority in a society, for religious reasons, favoured survival into old age and an ascetic life-style. An oppressed minority, however, preferred ideals of the good that favored higher investments in education and consumption. In such circumstances, discounting sacrifices of those who are younger, and highly valuing even small gains in survival for the old, may not be impartially justifiable. For this would mean that the relatively powerless minority could not realize its own ideals of the good through culture and politics. 61 From this discussion we can synthesize the following parameters that should influence how much an individual can be expected to sacrifice in order to save the moral agency of others in any just society: 1. The distribution of ideals of the good pursued in a sacrisociety and how this came about. 2. The life-expectancy which is generally accepted as necessary for pursuing these ideals. 3. The minimum level of resources needed to pursue some of these ideals in the absence of internal limits on basic to a capabilities. 4. The current and future level of resources of potential sacrificers. 5. The effectiveness of the sacrifice, including how many other persons have to make a sacrifice of the same magnitude in order to help one other person. The maximum justifiable sacrifice in any just society is then defined as that sacrifice which would reduce the level of resources of the sacrificer from its current level to the 62 minimum acceptable level. This does, on the level of society, give a first principled answer to the bottomless pit- objection. The point is that even if we could potentially spend an unlimited amount to save the moral agency of a single person, in any just society a person does not have an unlimited claim. The claim comes to a halt when the sacrifices made by society reduces the level of resources of at least one other person below the minimum level needed to maintain moral agency. This analysis thus also implies that, in a just society, those who are threatened by premature death cannot require the sacrifice of the moral agency of even a single individual to save their own. To proceed otherwise would lead us into a trade-off among moral agency of various persons, where one person is sacrificed to save others. To take moral agency seriously and not to make others the means to our ends means that such trade-offs are not permissible. Thus, regardless of the number of those whose moral agency is threatened by death or severe disability, we do have a limit for how much any one individual can appropriately be required to sacrifice to provide even the central functions of health care to others. I will now turn to the economic context in which the maximum sacrifices that an individual can be impartially 63 expected to endure and derive the implications of the obligations of individuals to contribute to the central health care of others for the total budget. A just society is characterized, among other things, by a fair distribution of resources, a political process and public culture that allow all groups in society to express and advance their ideals of the good, and a public awareness of the legitimacy of existing institutions. A fair distribution of income implies that the worst-off socio-economic groups have available at least that level of resources which is needed to choose and pursue a reasonable range of the ideals of the good in that society, including full political participation. Note that I do not here assume that the distribution of income also has to fulfill Rawls' difference principle, i.e. that the distribution of income should be such that it raises (in Pareto-improvement steps) the income level of the socio- economically worst-off to the highest possible level. If there were no differences in internal limitations on the basic capabilities, further redistributions of income would, in a just society, not be justified. But since there are such differences, we are under an obligation to sacrifice part of our fair share of income. For those who are close to or at the minimum level of income needed to have an adequate range of life-plans, no further sacrifices can be demanded. But even for those who are better off there are limits on the 64 potentially justifiable sacrifices such that they might not even be under an obligation to reduce themselves to the minimum level. To the extent that the higher share of income of those who have it, can be considered just, it must an impartial justification. The most important such justifi- cation is that such inequalities in income in any existing just society benefit the socio-economically worst-off group.48 This is so because of the efficiency gains for the economy which are made possible through the incentive effects of the possibility of a higher than average income. If the better-off would consistently have to reduce themselves to the minimum adequate income level to help the worst-off, this would impair the absolute capabilities and ultimately the status as moral agents of the worst-off, in a way that overshadowed any gain to them that this sacrifice produced. This implies that the better-off cannot be under an obligation to always reduce themselves to the minimum income level, since such a principle would imply a lack of concern. for the status as moral agents of the worst-off. Still, they are clearly under an obligation to make substantial sacri- fices if by doing so those who depend on these sacrifices can become full moral agents. It appears that they are under an Rawls (1971) 65 obligation to make that sacrifice which would reduce their income to the level where doing any more would have a negative impact on efficiency that in turn would reduce the worst-off below the level of adequate income. The claim made here is not that the better-off are under an obligation to not sacrifice slightly more than the amount just described. Indeed, it might be virtuous for them to do just that, since their sacrifice might not have a negative impact on the status of the worst-off when it is made voluntarily. The claim is rather that a greater sacrifice cannot be demanded of them, since this, if generalized as a principle, by definition would reduce the worst-off to being less than moral agents. If the better-off would voluntarily sacrifce a lot more than what they are obliged to sacrifice, they might actually put the worst-off at risk. This could be so because of macro- economic reasons, such as the need for consumption of goods. not related to health care in order to make those investments that allow the economy to grow or, at least, to remain productive. I also do not think that the institutionalization of justice in health care should rely on individuals going through these considerations, and then making the appropriate 66 sacrifice. All I argue is that this justification of the determination of who should sacrifice how much for saving others is compelling. If this is the case, institutions may be designed that enforce such sacrifices and can be considered as legitimate. My analysis in a sense extends Rawls' difference principle in a world in which there are large differences in health status. It implies that there are claims for funding health care that limit everyone's income. As a result, when there are large health care needs, the income of the socio- economically worst-off should not be much more than adequate and that of the better-off should not be higher than what is needed for incentive reasons to maintain the worst-off at the adequate level. This is the only way we can take seriously our obligation to help those who are threatened by premature death and disability and, at the same time, not sacrifice anyone inappropriately. The need to take into account the negative impact on the worst-off of less unequal distribution of income answers the bottomless pit objection. My analysis does require that the income differences between the better-off and the worst-off should be minimized and that the socio-economically worst-off group should not do much better than what is needed for them to have an adequate range of life-plans available. This is so that there are as 67 many resources as possible available to help the really worst-off, namely those with short life-spans and severe disabilities. It is of interest to observe that even if one rejects Rawls' difference principle in the absence of such differences in health status, taking these differences seriously from a Kantian point of view moves one toward accepting a distribution of income which is quite Rawlsian. However, now the focus is on maximizing the prospects of those with inadequate health rather than the prospects of the socio-economically worst-off. The socio-economically worst- off, however, provide an anchor for total spending on health care, since they cannot be deprived of income below what they require to remain full moral agents. I will now consider a possible objection to my analysis, namely that my proposal cannot be impartially justified because it would not be accepted from behind a veil of ignorance. I explained that I did not use a veil of ignorance to develop my proposal because such a veil would either be too thick; not allowing us enough information on the distribution and consequences of disease and the costs of their care, or too thin; not justifying the choices that may result from its use as impartially just. To support this latter claim I want to consider a theory 68 of just health care offered by Ronald Dworkin.49 In it, he tries to solve the bottomless pit objection through using a thin veil of ignorance, and as a result his solution differs substantially from mine. This in turn helps us see why a thin veil really does no useful philosophical work. Dworkin rejects the kind of special status for any form of health care that I proposed for the central functions of health care. He argues that the total budget for, and the distribution of health care resources, are fair if everyone gets at least the amount of health insurance that would be chosen by a representative individual having a fair income share, complete knowledge about the current state of medical care (including the cost-effectiveness of the available procedures and the incidence and prevalence of all diseases), but lacking any knowledge of their own genetic dispositions. The representative chooser is then asked how much of their resources and for what kind of health care services she would spend, using the values and ideals of the good that currently hold. This approach, which was called the "prudential allocation approach" by Brock, attempts to construct impartial fairness from prudential considerations. It leads us to impartiality through blinding the representative 49 Dworkin (1993) 69 choosers about their identity. 50 It differs from traditional Kantian ethics among other things in that it takes prudence as the starting point to construct social justice, although it does not regard prudence as a substitute for justice. The same method of reasoning was useed before by Daniels in order to ascertain a just distribution of health care resources between different age groups. 61 Behind Dworkin's veil, the choosers have to make a choice that is prudential given the comprehensive ideals of the good they accept. Thus, Dworkin does not specify the concerns he expects people to have when they decide on the amount and type of insurance to purchase. In fact, such a proposal would yield quite different insurance packages for different people, in different societies, even with the same amounts of resources being available. This is so because what it is prudent to do would, at least partly, depend on what ideals of the good are accepted. Moreover, as I argued above, not all of the resulting budgets and distributions would be fair, as demonstrated in the example of the age-discrimi- nating society. I am in general skeptical about the success of approaches that try to construct impartiality from prudence 50 Brock (1986) 51 Daniels (1985), (1988) 70 or rational self-interest. First, to model moral motivations through non-moral motivation is theoretically unnecessary since moral motivation is universally available to all of those who can be moved at all by moral concerns. There is no compelling philosophical argument available that could by necessity morally motivate an amoralist 52 and reference to explicitly moral rather than self-interested reasons may better motivate most individuals to act morally. 53 Secondly, such an argumentative strategy seems to be misleading, as was pointed out by Scanlon and Barry. 54 A prudential choice, made not knowing one's identity, may not carry moral weight as a heuristic metaphor for constructing social justice. We may afterall plausibly ask ourselves why we should be morally bound by what we would have chosen *for* *us* if we had less information about ourselves than we actually do now. But these methological points are not my only concerns. Suppose a determinate prudential solution is possible, and that every citizen has an insurance package which it would have been prudent for them to buy from an average income, having no knowledge about their own risks. Even then we would have a group of people who are still threatened by premature death and disabilitly. Some of them 52 Scanlon (1982); Nagel (1991); Williams (1985) 53 Nagel (1991) 54 Scanlon (1982); Barry 1989) 71 will need services against which they have not taken out insurance, for example because they have very rare or unknown diseases. Or they may need services that are relatively expensive and insurance would not have appeared prudent. In such a situation, everyone has a fair share of income and some health insurance. But there is still the group of those who, through further sacrifices of others, could be spared their loss of moral agency. We are again faced with the possibility that we could further reduce the number of those who lose their status as moral agents yet we are not prepared to make further sacrifices that would not put anyone else's moral agency at risk. If we take out obligation to respect others as moral agents seriously, I would argue, we need to make these sacrifices up to that point where the worst-off are reduced to the minimally acceptable income level. As a matter of fact, the sacrifices we might be demanded to make include giving up some of the insurance we would have taken out from behind the weil of ignorance. We might have prudently taken out generous life-prolonging care for older age, but we now recognize that the opportunity costs of having such protection is to allow others to die who have not had any chance to fulfill their life-plans. To say that they 72 would not have taken out insurance before against the conditions that now shorten their life now, does not diminish the obligation we have when we encounter them as fellow moral agents whom we could save. From a Kantian point of view, this result should not be surprising. It is inconsistent to will that everyone should have the kind of insurance that would prudently have been chosen having an average income when, at the same time, we know that this insurance will not always rescue us from the loss of any functioning as a moral agent. For such a situation we would will the help of others. The prudential allocation principle, thus, does not appear to pass the test provided by the interpretation of the categorical imperative I offered, in which rational agency is a matter of having the minimum capabilities to pursue typical ideals of the good in a society. Dworkin's solution to the bottomless pit objection is essentially an attempt to make health insurance part of a fair distribution of income, without in any way taking account of the special status of the central functions of health care. The insulation of health care from the distribution of income is also an important principle of Daniels' theory of just health care which has influenced my proposal in many ways. Daniels regards health care as an entitlement every 73 individual should have regardless of their share in income in order to ascertain equality of opportunity. Opportunity is broadly construed by Daniels and like capabilities focuses on the life-plans people can choose and execute. However, Danieals does not commit himself explicitly to Rawls' reasons for establishing why equality of opportunity is morally important. He only claims that his account of justice in health care are should be appealing to any general theory of justice that acknowledges a principle of equiality of opportunity. The central difference between this way of distributing health care and my own proposal is that I tried to offer an argument why everyone should have an adequate amount of capabilities rather than an equal amount of opportunities to pursue life-plans from a Kantian point of view. Kant's ethics does not support the idea that everyone should have an equal opportunity of pursuing life-plans since we can respect others as moral agents without making large sacrifices to broaden their choices beyond an adequate range. There is also no need to refer to the notion of "species typical functioning" Daniels uses in order to determine our obligations to provide others with health care. If others do have an adequate range of ideals of the good available, why should we be under an obligation to provide them with health care that additionally restores them to species typical 74 functioning? To take just one example, imagine that a society has managed to make a broad range of life-plans available to those who are physically moderately disabled, and thereby not able to function as is typical for our species. Suppose further that their disability could never be fully rectified, but could be slightly improved at enormous costs. Why should we be under an obligation to make these investments, in particular if these resources could be needed to secure the income level of the worst-off socio-econonomic group in society at a level that allows them to have a full range of life- plans available? A further difference between Daniels' theoriy and my suggestion is how we address the bottomless pit objection. Daniels seems to be suggesting that the bottomless pit objection can be avoided if we allow the political process to determine a total budget for health care, taking seriously that it needs to be sustainable in the long run. i try to go further and argue at what level the budgted sould be sustainable and what our primary concern should be for limiting it to that level. In the next chapter, I will try to be more specific about how we should limit the total budget and how we should 75 distribute it by spelling out some of the consequences of my approach for evaluation justice in the health care systems in the U.S. and in Germany. |
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Page 1 JUSTICE AND THE FUNCTIONS OF HEALTH CARE Karl W. Lauterbach A Thesis Submitted to the Faculty of The Harvard School of Public Health in Partial Fulfillment of the Requirements for the Degree of Doctor of Science in the Field of Health Policy and Management Boston, Massachusetts May 1995 Page 2 i This thesis was written under the supervision of Professor Marc Roberts who, some years ago encouraged me to take on this subject, and has tutored me as a teacher and friend to its completion. I had the privilege of countless discussions with him about ethics and health policy, each of which teaching me something new. His support was extremely generous, and has greatly indebted me to him. I am similarly indebted to the other members of my research committee, to Professors Arthur Applbaum, Michael Reich, and Amartya Sen, who provided important comments and criticisms which profoundly influenced the development of my thoughts.I would also like to thank Professor Arthur Applbaum for teaching me about professional ethics in his capacity as Director of the Graduate students' Fellowship Program in Ethics and the Professions, which supported me during the academic year 1992-1993. At this time I would like to acknowledge the invaluable inspiration of my other teachers in philosophy, Professor Norman Daniels, Derek Parfit, Hilary Putnam, John Rawls, Tim Scanlon, an Dennis Thompson, without whose work this thesis would not have been written. I also wish to thank my friends and colleagues in the Division of Mediical Ethics at he Harvard Medical school, where I had the opportunity to discuss my ideas and received many valuable suggestions. Finally I would like to name my most important sources of support, my companion Angela, and Carl-Stanley and Rosa-Lena, Page 3 ii our children. They gave me happiness and encouragement. I also owe Angela many thanks for sharing her views on this subject with me, and for typing the manuscript. Cambridge, May 1995 iii TABLE OF CONTENTS INTRODUCTION 1 Chapter I: JUSTICE AND THE FUNCTIONS OF HEALTH CARE 11 Premature Death and Disability 11 Justice and the Functions of Health Care 16 Chapter II: KANTIAN ETHICS AND THE FUNCTIONS OF HEALTH CARE 24 Kant's Ethical Theory 24 Why Should We Be Concerned with Our Health and the Health of others? 28 Health Care and the Ends of the Individual and the Community 31 iv Page The limits to our Obligations 35 Different Kinds of Health Care Are Covered by Diferent Obligations 37 Moral Agency and Capability 39 Chapter III: HEALTH CARE AS A SPECIAL SOCIAL GOOD IN THE FACE OF FINITE RESOURCES 49 Central Health Care Is a Special Social Good 49 The Bottomless Pit Objection 53 v Page Chapter IV: HEALTH POLICY AND THE FUNCTIONS OF HEALTH CARE 76 Health Policy in Germany 76 Health Policy in the U.S. 86 Cost-Effectiveness and Justice in Health Care 92 Saving Moral Agency in the Disabled 99 CONCLUSION 104 REFERENCES 111 INTRODUCTION Determining the moral value of saving lives through postponing death and sustaining life's basic qualities involves reconciling two opposing intuitions. The first is that saving lives is morally so important, in particular when young and identifiable individuals are at risk, that the value of doing so cannot even be expressed in monetary terms. Instead, we seem to have an unlimited obligation to save lives if we can do so at no risk to our own life and only monetary costs are involved. The conflicting intuition is that we do not value life for its own sake. Instead, life gets much of its moral value through experiences, which make it valuable to the individual whose life it is and to others who share these experiences. Those experiences, in turn, depend on, among other things, the resources we as individuals have available. Thus, it seems appropriate to determine how much to spend for life saving in the context of making all the other expenditure decisions that we face. The first intuition pulls us in the direction of insulating our obligation to save lives from the obligations we have for assuring a fair distribution of resources. The second intuition would make protection against the loss of life and life threatening illness part of what everyone may or may not want to buy once we have guaranteed a fair 2 distribution of resources. What we consider to be a fair share of resources of course depends on the more general conception of social justice that we accept. Thus, the question is if our obligation for health care provision is prior to, or secondary to, other social obligations. Both of these positions are well represented in the literature on justice. An example of making all health care an insulated social good of special moral importance is provided by Norman Daniels' book Just Health Care.¹ Daniels justifies a right to health care for every citizen in a country as affluent as the U.S. because of its central importance for "equality of opportunity". He concludes that health care should be distributed according to people's medical needs and not not through the free market from an individual's fair share of income. The alternative position is defended by Allan Gibbard 2 and Ronald Dworkin.3 They both argue, although from different conceptions of social justice, that justice in health care requires that all forms of health care should be subject to fair entitlements of resources and reflect an individual's preferences for health care including health insurance. 1 Daniels (1985) 2 Gibbard (1983) 3 Dworkin (1993) 3 The first approach seems, correctly, to insulate someone's survival prospects from the distribution of income, however, it also seems to go too far, because it would insulate all health care from decisions about what insurance we would voluntarily purchase if we had a fair share of income. It is not plausible to argue that every form of health care, including for example health care that merely slightly enhances the quality-of-life, is more important than all other social goods which might enhance the quality-of- life of the same person more effectively.4 On the other hand, the first approach also needs to be supplemented with principled way to set limits to society's obligation to spend resources on health care. Otherwise we might have to spend all we have just for saving lives. The second proposal does give such limits. But it does not, in principle, distinguish among different forms of health care. Moreover, it cannot accommodate the intuition that the availability of some forms of health care should not depend on what we would choose once we had a fair share of income. I will argue that, from an impartial point of view, the prevention of premature loss of life and the preservation of a minimum level of mental and physical functioning should be the morally central functions of health care. They should not be subject to a fair distribution of income but be protected 4 Buchanan (1983) 4 by entitlements which are set by principles that are impartially acceptable, including principles governing the limits of these entitlements. I will propose that we should use a particular set of impartially justified principles of justice to guide the distribution of those resources that determine our survival prospects and our ability to take part in the moral life. In particular, I will argue that such entitlements should not be viewed as a means to maximize the general welfare in society or as the expression of its accepted community values, as is suggested by utilitarian and communitarian approaches to this issue. My effort is guided by a broadly Kantian understanding of moral reasoning which I will develop in Chapter II and apply in the remaining chapters. The most successful of all recent Kantian theories of justice is, of course, John Rawls' attempt to apply Kantian moral reasoning to the broadest issues of society, justice in justice of basic institutions.5 Although Rawls does not endorse the link between rationality and autonomy that Kant proposed, the method of moral reasoning employed by Rawls in A Theory of Justice is basically Kantian. I will draw several key ideas from Rawls' work, including the idea of the importance of life plans for defining moral agency. 5 Rawls (1971) 5 Finally, I will draw on Amartya Sen's recent work on ant equality because of its importance for understanding the comparative advantages of different people.6 I will argue that to allow for minimum some physical and mental functioning, as well as for the survival for an appropriate life-span, are morally the most important tasks of health care and should be separated in priority rankings from the distribution of other health care services or other social goods. To do this, I will use Sen's concept of a "capability set" to help define the central functions of health care. This will allow me to give content to the key notion which, from a Kantian point of view, insulates the central functions of health care, namely the notion of moral agency. Furthermore, the method I suggest for deciding what the total budget for the morally central functions of health care should be will involve an analysis of the effects of various choices on the distribution of capabilities. This is contrast to what is normally suggested for such purposes, namely welfare trade-offs. The health policy significance of this essay can be seen in at least four aspects. The first concerns the debate about the question if there is a right to health care. Although I do not take up this issue comprehensively, since I 6 Sen (1985), (1990), (1992); Nussbaum & Sen (1992) 7 Buchanan (1983) 6 will not address the question if the morally most important functions of health care should lead to entitlements protected by individual rights, my analysis is quite compatible with such a claim. Instead of focussing on rights, I will focus on the obligations we do have to ourselves and to others. It is a separate question which I will not consider if such obligations should be enforced through rights or not. The answer to that question depends on issues that go beyond justice in health care and concern the institutional framework of justice in society more generally. It is also important to recognize that I do not wish to imply that there should not be any rights to health care apart from the central functions. I only argue that if there are such rights, their corresponding obligations need to be argued for using a different set of principles than those that define and justify our relationship to the central functions of health care. The second debate in health policy on which this essay touches is the attempt to specify a "basic minimum" of health to which everyone should be entitled, regardless of whether such an entitlement should be a matter of rights or not.8 It has often been argued that the idea of a "basic minimum" is essentially meaningless because there cannot be 8 Gibbard (1983); Buchanan (1983) 7 an ethically defensible way to define that basic minimum. Although I am not taking on the task of constructing a basic minimum here, I at least attempt an ethically defensible substantive definition for the central functions of health care that should be included in whatever we define the basic minimum to be. One way to conceive of a basic minimum is to combine the entitlements of the central functions of health care with what we impartially believe should be provided to everyone given some of the obligations we have in related domains of justice, such as a fair income distribution. Third, this essay does does give us reason to consider whether there are constraints on the ethically defensible uses of policy analysis for ranking the moral importance of health care services. I will explicitly argue that when we use policy analysis to evaluate some health care services, we should not discount the moral value of lives according to or their level of their expected lower quality-of-life disability, as long as these lives still allow for moral also plead for the ethical rejection of agency. I will comparing the moral value of some life-saving services with health care services which are important for other reasons. However, I will claim that cost-effectiveness has an important role in determining which life-saving services we should fund as part of our obligations to others with respect 9 Brock (1992) 8 to the ethically most central functions of health care. The final health policy issue for which this project seems relevant is the permissibility of age-rationing. 10 Again, I will not address this problem directly. However, my criteria for defining and justifying the morally most central functions of health care will use age and life-expectancy as morally significant proxies. The reasons why age and life- expectancy do matter are moral reasons, which are largely independent of the idea of the good we accept. I will make the claim that they should be regarded as morally important for the rationing of of some health care resources largely independent of the economic ramifications or the social acceptability of doing so in terms of the predominating ideas of the good in a society. I present my analysis in four chapters. In the first chapter, I will provide some of the empirical facts relevant issues of the ethical treatment involved. It is important for us to recognize that our potential for saving lives from premature death and illness is constantly growing due to improved technology and that we could spend virtually unlimited resources for that purpose while continuing to gain some small benefits. This increase only aggravates a critical ethical problem, namely how to compare the moral importance 10 Daniels (1988) 9 of avoiding premature death and preventing some especially debilitating premature illnesses with other functions of the health care system. In Chapter II, I will develop my methodological resources. The main idea is that Kantian ethics gives us the right account of why we should be concerned with the survival prospects of other human beings, namely that it is an obligation which is part of respecting others as moral agents. In order to be able to conceive of an ethically meaningful currency in which both the benefits and the costs of discharging this obligation can be expressed I will make use of Amartya Sen's concept of "capabilities". I will argue that the central functions of health care, from an ethical point of view, concern those capabilities that allow us to function as moral agents. In Chapter III, the main distributional claims for the ethically central functions of health care are introduced, as they follow from Chapters I and II. I make the case for principles that allow for setting an ethically defensible budget for the purpose of preventing premature death and loss of moral agency, and explain what this would imply for health policy and the distribution of income in a just society. This is an attempt to move us towards a reconciliation of the two intuitions I presented above, namely that some functions of 10 health care are morally special but that they should still not be permitted to consume all of our resources. In Chapter IV, I will apply my analysis to the health care systems in Germany and the United States. I will show that the central functions of health care are not adequately served in either country, mostly because of micro-allocation problems. Furthermore, the total budgets on health care in both countries appear to be determined by the wrong kind of considerations. Finally, I will comment on the potential use and misuse of cost-effectiveness analysis for allocating health services within a fair health care budget. https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%201%20Premature%20Death%20And%20Disability.pdf Chapter I: JUSTICE AND THE FUNCTIONS OF HEALTH CARE 11 Premature Death and Disability as a society One of the most important goals in health policy should be to reduce the number of those who either die or become severely disabled early in life. It is well known that in industrialized countries e.g., in which the average life expectancy now ranges between 70 to 76 years for men and 75 to 82 years for women, about 30% of all men and 20% of all die before the age of 65. 11 An additional 5% are severely disabled at that age. For the purpose of this essay I regard a death as premature if it occurs significantly before average life-expectancy in society, say at age 65 or younger in the U.S.. I will justify this threshold below when I have introduced what I believe is the nature of our obligation to save lives. Severe disability is meant to cover cases of significant impairment of mental or physical functioning, such as psychosis, blindness, paraplegia,or constant pain and discomfort. Premature death and disability are usually perceived as especially tragic because they frustrate ongoing projects and relationships. Any moral theory that gives any weight at all to benevolence would thus advise us to try to reduce the 11 U.S. Congress, OTA (1993) 12 burden of such premature death and disability. The disagree- ments start when the question is raised if we as a society are under an obligation to try to reduce such premature death and disability, what the nature of that obligation is, and what its limits are. To explore these issues, I will first consider the most common causes of such tragedies and whether they can be averted. Then I will address the question of what it would take to avert these causes. In particular, do we face a serious scarcity of resources when it comes to ameliorating such conditions? The diseases that account for most of the early death and disability in men in industrialized countries are heart disease, cancer, and accidents. Together these account for more than 60% of all deaths before age 65. For women the situation is similar, with heart disease and cancer also being the leading causes of early death and disability. 12 It is well established that a large percentage of early death and disability could be averted through more and better medical care as well as through preventive interventions. The greatest impact would come from primary care and the screening and treatment of individuals with risk factors that are known to predispose for serious illnesses. Examples for this are blood pressure and cholesterol screening, as well as 12 (ibid) 13 screening for colorectal, breast, and other cancers. Among the measures an individual can take to reduce the likelihood of premature death and illness, smoking cessation, diet modification, and regular exercise rank first. Among these smoking cessation is clearly of the biggest importance because smoking contributes both to the burden from heart disease and from cancer. 13 It is estimated that smoking is responsible for 30% of all deaths from cancer and for 25% of all heart disease deaths. 14 Diet is an established determinant for the likelihood to develop heart disease and cancer also and ranks second after smoking, accounting for an unknown number of all cases of heart disease and an estimated 35% of all cases of cancer. 15 Given that a large number of cases of premature death and disability could be averted, how much should society spend to reduce the number of those who are at risk? Is there anything special from the point of view of social justice when an individual dies or becomes severely disabled relatively young? Given the scarcity of resources, which is part of the background condition of any health care system, as a society do we have a special obligation to try to avoid 13 MacKenzie (1994) 14 Doll & Peto (1981) 15 Hennekens (1994) 14 premature death and disability? These are questions that are part of a more general question, namely what should the functions of the health care system be? 16 These questions are not new. But I would argue, they have recently become more pressing for the following four reasons. First, in this century we have witnessed a dramatic increase in average life-expectancy in both industrialized and nonindustrialized countries. This has widened the range of life-expectancy and of the prospects for disability-free life within societies. Second, the potential for helping those who are threatened by premature death and disability has greatly increased, in particular through advances made in medical care, epidemiology, and health policy. Third, the potential costs of prevention and treatment have increased through the availability of new and better technology. And finally, we have only recently become able to identify beforehand those who are at the highest risk for developing diseases leading to premature death and disability. This not only increases our potential to help those at risk but also transforms their status from a statistical bearer of risk to an identifiable individual. This makes a difference from a moral point of view, because if we could have or have identified an individual as risk bearer, without doing anything about this risk, we might be acting wrongfully 16 Daniels (1985) 15 against this particular individual. How severe are the resource constraints for avoiding or postponing premature death and disability? It is often asserted that prevention and early treatment averting premature death actually save money which would otherwise be spent in the treatment of advanced disease stages. If this were generally true, spending for the prevention of premature death and disability might pay for itself. Although cost saving does occur in some cases, it is not generally the rule and there are some cases that are extremely expensive to address. 17 Such cases include, for example, those that can only be successfully treated if they are detected through screening programs which are relatively inefficient because few test as true positives and many test as false positives. This is the case for breast cancer screening and cholesterol screening in some relatively young age brackets. 18 Other cases of premature death prevention that are extremely costly involve safety-regulations injury prevention measures which seem to be more expensive as a group than medical care in terms of dollars per life-years saved. The costs for safety-regulations can be as high as an 17 Weinstein (1990) 18 Tengs (1994) 16 estimated 100 billion per life-year saved. 19 Thus we could spend 10% of the current estimated annual expenditures for health care in the U.S. on saving one statistical life-year. Clearly therefore, industrialized nations could almost certainly devote a much larger share of their GNP to the prevention of premature death and disability than they do now and still get some additional benefits. This is especially so since, I will argue below, we should regard prematurity in death and disability at least in part as dependent on the average life expectancy in a society. This would imply that the definition of premature death is dynamic, and some deaths will always have to be regarded as premature. Justice and the Functions of Health Care There is no scarcity of proposals about what justice demandswith respect to the structure of health care systems. 20 Most of the proposals made rightly focus on issues of distributional justice because of the fact that there is a wide range of what kind of health care people enjoy (in particular, but not only in the U.S.), and health 19 (ibid) (1993) 20 Buchanan (1983) 17 care costs are rising in all industrialized countries.21 One way to explore justice in health care is to ask whether there is a right to health care. This is an important question because of the political power rights claims do enjoy in western democracies. We should realize however that the nature of our obligations to provide health care for others ultimately determines what kind of health care services someone could claim as a right and what the limits of those claims are. Still it is useful to explore what a right to health care could mean according to defenders of the most widely held theories of justice. The theory which is most closely linked to health since economics as practiced in the U.S., and also to the use of modern techniques of policy analysis, is utilitarianism.22 In utilitarianism there are no deontologically justifiable obligations or rights. It is an important theoretical question if utilitarianism is compatible with the institution of rights at all, but to the extent that it is, it can be said to advocate only those rights that in the long run tend to maximize utility.23 The moral obligation of an individual to support such rights would follow from a more general obligation, for example deriving from universal benevolence 21 U.S. Congress, OTA (1993) 22 Brock (1993) Lyons (1994) 18 or mutually advantageous conventions. A right to health care would follow from the empirical assumption that extending such a right would contribute to the maximization of utility. The services covered, as well as the budget set for such a right to health care, would likewise be regulated by the utility maximization rule. Alternatively, communitarian theories of justice would, simplifying enormously, grant a right to health care for all members of the community if doing so would express the shared understanding of what justice in health care means for the community in question. 24 This would lead to quite different health care entitlements in different societies, since different societies live by distinctly different sets of shared values. It would imply no right to any kind of health care if that is what best expressed the values of a particular community. Finally, for liberal theories of justice, a right to health care is not automatically included in any just society either. Liberal theories do, indeed, grant certain rights to the individual that neither utilitarian nor communitarian considerations can overturn. The question is, should health care be part of the set of rights granted to everyone. Libertarian liberals deny this, claiming that doing so would 24 Walzer (1983) 19 either violate more central rights of tax-payers or of health care professionals. 25 They may regard enforced taxation for the purpose of granting health care rights as a form of forced labor. Likewise, forcing the medical profession to provide health care services to all members of society has been regarded as a significant infringement on their personal liberty to treat whom they want. Among those liberal theories that do support a right to health care one can distinguish between two groups. On the one hand there are those who claim that health care is a right that follows from our more general obligation to provide every citizen with a fair share of resources or what Rawls has called "primary goods". The term refers to all- purpose resources and privileges that would be desired by those who knew what is typically required for pursuing a wide variety of life-plans. 26 On the other hand are those who claim that the nature of the obligation to provide health care is different than the obligation to provide resources or primary goods and should be prior to the rights following from that obligation. The best example for this kind of insulation of health care from other social goods was developed by Norman Daniels. He argues that a right to health care follows from our obligation to provide everybody with 25 Nozick (1974) 26 Dworkin (1993) 20 equal opportunities before we start distributing primary goods or resources.27 All of these approaches have been criticized from wards various perspectives, and I will not repeat these criticisms here.28 Instead I want to put forward one particular kind of criticism that appears to apply to all of the theories surveyed above and offer my own suggestion how we could make progress in clarifying our intuitions about justice in health care by avoiding this problem. This kind of criticism also provides us with some important concepts for how we should think about the problem of preventing premature death and disability specifically, and can explain why those comprehensive theories of justice in health care which are open to this criticism cannot give us a satisfying answer to that problem. What all the above theories share is the assumption that our obligation to provide any particular form of health care can only follow from a more general obligation to provide other quite different forms of health care. Utilitarians believe that obligations to provide any form of health care could only follow from a quite general obligation to maximize utility. Communitarians hold that the obligation to provide 27 Daniels (1985) 28 Buchanan (1983); Emanuel (1991) 21 any form of health care would follow from a general obligation to share and express the values of a particular community. Among liberals there are those who hold that health care obligations are part of the obligations towards assuring fairness in the distribution of resources and those who argue they follow from our obligations to provide everybody with equal opportunities. I want to challenge this central assumption, namely that all forms of health care are covered by one kind of obligation, and will do so from a broadly Kantian point of view. Instead, I claim that there is a specific type of obligation concerning what I propose to term the central functions of health care that is different from our obligations with regard to other, non-central types of health care. None of the general obligations, derived from the other theories, does justice to the reasons why, I believe, we have a particular obligation to prevent premature death and disability. Premature death prevention and the protection against severe disability, I contend, are obligations we have as part of respecting others as moral agents. Thus, avoiding premature death and disability are the central functions of health care, since they follow from an obligation more important than utility considerations, the expression of 22 shared values, equality of opportunity, or fairness in resources. For purposes of justice, therefore, we should not regard health care as a single social good, and should regard our obligations to provide everybody with the services needed for the central functions of health care as prior to providing any other set of services. For other functions of health care there are other general obligations which provide a more plausible reason to provide the corresponding health care services. It is often claimed that Kantian ethics lacks the resources needed for practical ethics or "real life" policy issues and it has been criticized as an empty formalism devoid of defensible practical implications.2 Although I think that this criticism has been successfully rebutted by Kantian moral philosophers, it is somewhat surprising that in the current Anglo-American debate about justice in health care there exists so far no comprehensive Kantian theory of just health care. Although my effort is not such a theory either, it is guided by the conviction that Kant's moral philosophy does have a lot to contribute to this debate. I believe that broadly Kantian reasoning can help us to understand the special moral importance of the obligation to save lives from death and severe disability while it also allows us to limit the costs of this central function of 29 Mill (1994) 23 health care in a principled way. In looking at justice in health care from from a Kantian point of view I also hope to stimulate the debate about how Kantianism can be used to understand specific matters of social justice. It has been been argued that Kantian ethics provides the most secure foundation for liberalism. 30 The question is, is it also capable of specifying reasonable solutions to specific questions of justice such as justice in health care. I believe it is. 30 Rosen (1994) 24 https://www.karllauterbach.de/wp-content/uploads/2019/07/dissertation/Chapter%202%20Kantian%20Ethics%20And%20The%20Functions%20Of%20Health%20Care.pdf Chapter II: KANTIAN ETHICS AND THE FUNCTIONS OF HEALTH CARE Kant's Ethical Theory Kant offered three different formulations of the categorical imperative which he considered to be the only moral norm that all human beings must observe. 31 All three express the same idea, albeit with different emphasis. The following presentation is adapted from Sullivan: 32 Formula 1: Formula of Autonomy: "I ought never to act in such a way that I could not also will that my maxim should be a universal law." Formula 2: Formula of Respect for the Dignity of Persons: "Act so that you treat humanity, whether in your own person or in that of any other, always as an end and never as a means only." Formula 3: Formula of Legislation for a Moral Community: "All maxims that proceed from our law ought to harmonize with a possible kingdom of ends as a kingdom of nature." 31 Kant (1788) 32 Sullivan (1994) 25 For the purpose of my discussion it is not important if the three formulations are exactly compatible or what the limits of their application are. Instead I want to highlight the key ideas behind them and apply them to the question of just health care. The first formulation expresses the idea that we should not act in ways that are intended for reasons. that when expressed as a principle, cannot be universalized. Killing, violence, coercion, and deception are examples for actions which cannot be universalized in that way. 33 This formula- tion is particularly important for justifying the negative rights that every human being should enjoy, such as freedom from harm and interference. But the first formulation does not only secure the negative rights of people. It also is a compelling foundation of the basic entitlements people have in any society and a rejection of libertarianism, which denies such entitlements. The argument is that a principle of nonbenevolence cannot become a maxim that can be willed as a universal law. This is so because it is part of the human condition that we are vulnerable to diseases, accidents, impoverishments, and many other threats to our agency as rational beings. We, in principle, can at any time become dependent on the help of 33 O'Neill (1989) 26 others in order to pursue any rational goal at all, and would will the help of others in such circumstances. Since we cannot consistently will a principle of nonbenevolence and, at the same time, understand this aspect of the human condition, a principle of nonbenevolence cannot become a universal law. It would involve us in a contradiction between the willing of a principle and the willing which is natural under circumstances when the principle is suposed to be applied. From this follows that its opposite principle, benevolence, must be regarded as a universal law. Since diseases and accidents are typical threats to rational agency for humans, any account of what follows from a law of benevolence should justify at least the public provision of some forms of health care. However, for the purpose of applying Kantian ethics to justice in health care the second formulation is equally or even more instructive. According to Kant, respect for the dignity of persons is considered to be an important justifi- cation for the positive rights people enjoy. This comes from their being rational agents, rather than from any other contingent feature of themselves, a particular society, or tradition. Positive rights include, among others, property rights, freedom of expression, political participation, welfare rights, and rights to mutual aid. As I will argue 34 O'Neill (1989); Herman (1993); Rosen (1994) 27 below, the second formulation also gives a direct justifi- cation for securing access to some forms of health care through public provision. The third formulation concerns Kant's notion of an ideal community in which there would only be free and equal citizens.35 This is the most comprehensive way to express Kant's ethics and has found wide application in the work of John Rawls. To simplify, one may say that Rawls' work, well as that by many other liberal political philosophers, represents a comprehensive and explicit interpretation of what it would mean to live in a community of free and equal citizens, or as Kant would put it, in a Kingdom of Ends. For my purposes this third formulation is somewhat less important since I will not be concerned with an ideal community or a complete set of just institutions. Formulation 1 and 2 both include the key idea on which I will build when formulating the central functions of health care. What do these formulations tell us about just health care? In what follows I will argue that they imply: a) We have an obligation to be concerned with at least some aspects of our health and the health of others, 35 Sullivan (1994) 28 b) We should not make central aspects of the health of others a means to fulfilling specific individual or communal c) There are limits to our obligations to be concerned with our health and the health of others, and d) The different functions of health care are supported by different kinds of obligations and principles. Why Should We Be Concerned with our Health and the Health of others? As explained above, the most obvious Kantian justifi- cation for being concerned with the health of others is that a principle of complete nonbenevolence cannot be universa- lized for human beings who are rational and vulnerable from internal and external causes.36 The first formulation above is the basis for such a justification. I believe, however, that the second formulation is a richer and more direct source for an obligation to be concerned with the health of others and of ourselves because of the direct importance of health care for respecting others as rational agents. 36 O'Neill (1989) 29 To respect others as ends in themselves implies a concern with sustaining their capacity for the kind of reasoning and action which is constitutive of their status as ends in themselves. We do not owe the same respect to animals or lifeless objects because they are not capable of the same kind of rational agency. What is distinctive about rational agency in humans is that it not only includes the satisfaction of the basic needs of survival or short term goal-directed action, but also allows for the autonomous choice of broader goals and life-plans. These broader goals are often motivated by moral ideals about how we should live, and for most people are an important source of finding meaning in life. For humans, therefore, rational agency always has the dimension of moral agency. I regard this moral agency as the most distinctive and important characteristic of human rational agency. In what follows, I will speak of human beings as moral agents rather than rational agents, putting emphasis on this part of rational agency as the foundation of our dignity. All this, in turn, has broad implications for the distribution of health care resources. The key idea behind our obligation to make sacrifices for the health care of others is this: It is inconsistent to say that I respect a person as a moral agent and have no concern for the kind of mental and physical functioning of that person which is needed to sustain their moral agency. 30 And to have such a concern implies to be prepared to make a sacrifice to sustain this functioning, since otherwise the concern is not sincere. Here we confront a critical difference between basic mental and physical functioning and a person's happiness. I can, without inconsistency, say that I respect a person as a moral agent without having much of a direct concern for their happiness, depending on the many reasons why that other person might be unhappy. But to respect other human beings as moral agents directly implies that we should also be concerned with the conditions they need to be and to remain moral agents. This is so because I cannot plausibly say that I respect you as a moral agent only as long as you happen to remain one. In particular, my concern with your basic capabilities for moral agency may well have an impact on whether or not you can continue to act as such an agent. In our world this, in fact, is often the case. Small sacrifices by ourselves often can sustain the moral agency of others. I believe that any substantively plausible interpretation of the second formulation of the categorical imperative requires us to make such sacrifices. The same holds for our own basic health, since as part of our self- respect as moral agents we cannot plausibly be indifferent about what sustains our own moral agency. 31 The respect for others as moral agents, however, also implies that we should have an interest in their having available a minimum of those other means which they need to act as moral agents. Any pursuit of life plans is only possible with a minimum of means such as income, education, and other opportunities, means that Rawls has called "primary goods". This is important since it implies, I will argue below, that we are under a moral obligation not to exceed a certain budget for health care. Health Care and the Ends of the Individual and the Community Respect for the dignity of moral agents further implies that we should not reduce others to merely being the means for fulfilling our, or the community's, ends. A comprehen- sive interpretation of what it means not to do that, and the implications of such a principle for limiting paternalistic actions and actions intended to avoid great evil cannot be attempted here. However, it is clearly impermissible, for example, to harm others for the sake of personal happiness or to advance the specific ideals of the community. Any such harm would have to be justified by something of higher moral importance, since in this sense the "right is prior to the happiness it could good", as Rawls has stated it. 37 Rawls (1971) 32 For health care, this argument implies that the state, for example, cannot unrestrictedly use the health care system to maximize human happiness or welfare as it would appear to be morally mandated by utilitarianism. A potential organ donor, for example, may not be sacrificed for the health of several potential recipients, even if this would maximize utility. Not sacrificing the basic liberties of individuals for community ends also rules out forms of eugenics, even if such practices were part of the shared values of a particular society. These are important arguments since they provide an unconditional protection for individuals against being sacrificed wrongfully through the health care system, protections, which neither utilitarianism nor communitaria- nism can provide.38 What I want to argue here, however, is that the non- instrumentalization of others, as part of mutually respecting our status as moral agents, also has implications for our positive obligations in health care. It implies not only that we should not cause harm for others in order to advance personal or community projects in health care, but also that we should not sacrifice the morally important positive entitlements of individuals for such projects. It is incon- sistent to argue that we should never impose even a slight harm on an individual no matter how much happiness it could 38 Lyons (1994); Holmes (1989) 33 bring to the community, if at the same time we generally allow individuals to die because we do not provide them with the resources needed for health care, in order to spend them instead to further our own happiness. The restriction on harming others for our own ends can easily be supposed to be stronger than the obligation to help others in need, but this can be wrong. Harming others intentionally cannot be universalized and is therefore not permissible. Helping others in severe need is on the first formulation only covered through a duty of mutual aid, because we cannot consistently will principles of complete non-benevolence. The principle of not willfully harming others is a perfect obligation, meaning that it applies to all individuals whom I meet. This is not the case for the principle of benevolence, since I am not under an obligation to help every single person I meet. This is so because I cannot do this as human being with limited means. The obligation of benevolence is, thus, an imperfect obligation, since it does not always apply. It is fallacious, however, to think, that a principle that does not always apply is weaker than one that does always apply in cases in which both principles apply. In such instances, the obligation to help can be stronger than the obligation not to harm, depending on the consequences the 34 failure to meet each of these obliagtions would have. On this account of Kant's ethics, negligence with great consequences to another individual can be a morally greater wrong than causing more modest direct harm. I will argue below that this interpretation of Kant's ethics is a compelling account, on reflection, of how we conceive of our obligations to others with regard to the fulfillment of the basic needs of people and the basic liberties. I cannot attempt here any discussion whether this interpretation of Kant's ethics is one he would have endorsed himself, and I, therefore, also do not assume this to be the case. My aim is rather to show that the consequences of such an interpretation are intuitively appealing and important for justice in health care and would result from Kant's account of moral reasoning. For health care this interpretation of Kant's ethics istpractically very important because implies that there may be some medical needs of others that we cannot ignore for the sake of projects of the community or ourselves. This includes projects that are neither hedonistic nor self-interested, although these obviously come to mind. It also includes projects of an explicitly moral status, such as those that advance religious or secular perfectionist ideals. 35 The Limits to Our Obligations Respecting oneself and others equally as moral agents implies that we cannot be under an obligation to sacrifice our own moral agency for the sake of saving that of others even above the level of functioning that would put our survival at risk. The primary reason to prolong or improve the life of others is to allow them to remain moral agents, not survival per se. This means that we cannot be under an obligation to reduce ourselves to the level of mere survival, having sacrificed the means needed to function as moral agents. There is, therefore, clearly a limit to what we as individuals owe to others in order to meet the medical needs that unmet would doom the potential beneficiary. On the other hand, as discussions of our obligations for mutual aid have shown, the sacrifices we can owe to others can be quite substantial. An individual can indeed come upon a situation where moral obligations rightfully demand great sacrifices. The limits of the sacrifices that we are under an obligation to make is best expressed through Amartya Sen's concept of "basic capabilities". 40 The basic capabilities 39 Herman (1993) 40 Sen (1992) 36 are a mixture of our internal functional characteristics as individuals and the external means we command to function. For meeting some of the morally most important medical needs. of others we may appear to be obliged to make sacrifices to the point where our own basic capabilities as moral agents are threatened. This would clearly imply bad moral luck for the individuals who have to make such sacrifices but would not reduce them to anything less than full moral agents. I will argue below that we are under an obligation to live by a set of principles that distributes such sacrifices in a fair way. This implies that we are under a moral obli- gation to create institutions that on the one hand meet those medical needs that are morally central, and on the other hand avoid requiring individuals to make overly substantial sacrifices. If this effort is successful, it would imply the important conclusion that we have moral obligations towards both those who stand to receive the benefits of the central functions of health care as well as towards those who capable of making the sacrifices required to provide these benefits. This would constrain the institutional design of this part of health care because it would limit, based on justice, the extent to which we could pursue utilitarian or perfectionist points of view. It will turn out that our 37 obligation to provide others with the health care they need to function as moral agents has unexpected and wide-ranging implications for socio-economic justice in society. Different Kinds of Health Care are Covered by Different Obligations The last conclusion I want to draw from my interpre- tation of Kant's ethics is that we do not have the same kind of obligation to support morally peripheral medical needs that we have for morally central needs. I regard as central that which underlies our functioning as moral agents, and define peripheral health care needs as those that concern the quality of functioning that is clearly above the level of functioning which allows us to act as moral agents. The distinction is socially constructed, as it needs to be to take into account important differences in the functional requirements for moral agency in different cultures and socio-economic contexts. This is a point to which I will return when I define moral agency in more detail below. An example of a peripheral need is the desire for cosmetic surgery in order to look younger in a society that places some value on looking young. If one looks older, some life-plans may not be available in such a society. But the remaining available range of plans may well be broad enough 38 to not justify any entitlement to surgical intervention. That is, we may generally understand ourselves as respecting others as moral agents without being prepared to make sacrifices to provide others with cosmetic surgery against the signs of aging. From a moral point of view, the peripheral functions of health care clearly have a lower priority than the central functions of health care. This is so even if, as is frequently the case, some individual's desire for some of the peripheral functions of health care is stronger than their desire for the central functions. We do not owe others health care because they desire it but because they need it to remain functioning moral agents. This rules out a direct obligation to provide them with those services that constitute peripheral functions. How should we provide those peripheral functions? Their fair distribution should be taken care of by insuring every- one a fair share of resources or of Rawlsian primary goods. But since even a fair distribution of resources or of primary goods would not address all of the important morally arbi- trary comparative differences in life prospects between people, those who face premature death or disability have further entitlements. These, from a Kantian point of view, have their foundation in what it means to respect people with 39 whom we interact as moral agents. Moral Agency and Capabilities I now come back to the claim I made above, that there are two distinct functions of health care which we should separate for moral reasons. I argued that we cannot, when we interact with others, consistently hold that we respect them as moral agents without at least having some concern about their survival, or their risk of becoming severely disabled, either mentally or physically, and that this should guide the definition of the central functions of health care. What does it exactly mean to be a moral agent and how can this definition be used to define the central functions of health care? What it practically means to respect others as moral agents cannot be deduced from any definition of the term moral agency or from linguistic analysis. Even if it were possible to use such means of analysis to establish the correctness of the Kantian categorical imperative (another matter beyond the scope of this effort), such an analysis would not decide about how that imperative should be applied in a specific case. Such applications always are a matter of interpretation rather than deduction and rely in part on 40 information about the context of their application.41 In that spirit I want to make a proposal about how we should conceptualize the notion of respecting others as moral agents in the context of the circumstances of: 1) very large differences in health and life-expectancy, 2) a distribution of income that would be fair if no differences in health existed, and 3) limited resources so that we cannot afford to eliminate all of the differences among individuals in health status and life-expectancy. The first step in this interpretation is that respecting others as moral agents means respecting others for their capacity to make autonomous moral choices, and not because they might advance some specific ideals of the good. Beings that are not capable of making such choices we are not supposed to treat as ends in themselves, such as animals. To treat animals respectfully involves e.g. that we do not inflict pain or discomfort on them without appropriate reasons. But it does not involve that we respect the choices that they make about their lives. Thus the kind of choices that it is particularly important for us to allow other human beings to make for themselves, are moral choices. Such choices are distinctively human. We cannot even conceive of human beings without at the same time conceiving of them as 41 O'Neill (1989) 41 individuals who can make choices with a moral component. Moral agency is not an empirical concept, since it involves a perspective that can only be approached by an interpretation of what actions mean to the subject involved. It presupposes intentionality, meaning that someone (at least potentially) at perceives a choice as a free choice, and furthermore as a choice with normative implications. For this reason it is not possible to give a purely biological or psychological interpretation of moral agency. Moral agency cannot be equated with a certain mode of brain functioning or physical functioning in the absence of an interpretation of what that brain functioning or physical functioning signifies. We, therefore, need to refer to commonly used criteria to determine if someone is a moral agent in everyday life rather than trying to derive the meaning of moral agency from biology or psychology. What I conceive of as a typical moral agent is a human being who self-consciously pursues an ideal of the good life. Although moral agency involves many choices with limited scope and impact, such as helping someone in need or simply going to a movie, these limited choices are best interpreted as constitutive of a larger narrative which I propose, fol- lowing Rawls, to call "the ideal of the good" of an 42 individual. The paradigm case of moral agency is the pursuit of such ideals of the good over a normal life-time. What counts as an ideal of the good or as a normal life-time is again a matter of interpretation that is only possible in a specific context. But, I contend, it is part of our notion of human beings per se to conceive of them as beings that pursue life-plans, which are constitutive of their moral agency and rationality. However, the notion of the value of having individuals choose and pursue ideals of the good should not be regarded as such an ideal itself. Moreover, the construction of justice in health care I am attempting here should not seen as contingent on the acceptance of any such specific ideal. To use O'Neill's terminology, to conceive of others as moral agents is not an idealization of human beings but just an abstraction. The liberalism that follows from such a construction is not dependent on a specific ideal of how to live (such as the ideal of "autonomy"), nor on a political compromise between such ideals. It rather puts constraints of reason on the use to which alternative moral ideals of the good can be employed in the political realm. The specific constraint in question here is that ideals of the good cannot be used to justify institutions that allow certain avoidable threats to the moral agency of some to persist, since the justification of such institutions would be inconsistent with 43 the mutual respect of moral agents. One must be careful not to confuse the typical charac- teristics of a moral agent and moral agency itself. For example, a minimum life-expectancy may be necessary to be regarded as a typical moral agent, but to live that long is not automatically to be a moral agent. Thus, despite a normal life-span, moral agency may not be possible in the face of severe mental retardation. Also, if someone can conceive of ideals of the good but, through severe poverty, does not have the means to live them, she also cannot be regarded as fully-functioning moral agent. Thus, moral agency involves internal and external requirements, requirements about the person and her circumstances. I believe a promising way to conceptualize moral agency is provided by Sen's notion of "capability", although the concept seems to be quite complex. 42 The space of capabili- ties is defined through the so-called "functionings" that an individual actually can achieve. Such possible functionings include those that actually are achieved, as well as those which could be achieved given the personal characteristics, situation, and means of the individual. The functionings themselves may be further grouped into the two broad categories of well-being and agency. Thus, there can be four 42 Sen (1985), (1992); Nussbaum & Sen (1992) 44 forms of functionings: well-being and agency functionings as achieved and well-being and agency functionings as freedoms ro achieve. The ability to function as a moral agent may then be thought of as involving a particular important subset of functionings. this subset of functionings constitutes the freedom to choose and pursuer ideals of the good and includes well-being functionings as well as agency functionings. Important well-being functionings may include freedom from pain or discomfort, mental health, and being well-nourished. Agency functionings may include the physical, emotional, and cognitive ability to choose and to pursue such ideals how to live like doing meaningful work, making friends, establishing a family, and participating in culture and politics. The focus on functionings rather than income or resources allows us to see the different effects the same income, resources, or Rawlsian "primary goods" can have on different human beings, including those with different genetic endowments or disadvantages incurred earlier in life. For example, a person who is mentally retarded does not have the same level of capabilities that a person without such a handicap has, even if both enjoy the same level of resources of income. Differences in capability can be the result of many reasons, not all related to health. Thus, a person with better education may have a higher level of capabilities than a person with the same resources but little education. 45 The value of mny functionings cearly depends on the ideal of the good that a person has chosen or may choose. Only the lack of the most general functionings should count as morally significant disadvantages for the puropose of conceptualizing moral agency. These are the kind of function- ings one needs to have in order to choose among a variety of ideals of the good and to pursue them, rather than the functionings which are specific to some particular ideals of the good. To illustrate that point, consider someone with a high level of achieved functionings and freedom functionings, which in this case depend for their value on the ideal of the good the person has chosen. Such a person, for purposes of justice, may be more disadvantaged than someone who has achieved less and is free to achieve less from the perspective of the ideal of the good life he has chosen,if the second invididual could, in contrast to the first, also have substantive achievements in case th she adopted other ideals of how to live. To give a specific example, for purposes of justice, what do we owe in the way of health care support to a happy and successful wheelchair-bound mathematician compared to an unhappy limping, uneducated, and unsuccessful factory worker? Suppose they enjoy comparable total sets of achieved functionings (although achieved functionings do not seem to be easily comparable), since the 46 mathematician enjoys highly valuable and sophisticated special functionings, whereas the factory worker has a wider range of more basic funtionings available. I argued that for justice in health care we should be concerned with maintaining or restoring each individual's capacity to formulate and implement a broad range of life plans. This would imply that the mathematician in the wheelchair should have greater health care entitlements than the limping factory worker, since the former suffers a more significant restriction on his moral agency. In Sen's terms, we shold regard him to be more entitled to health care since he has lost more basic capabilities. If this analysis of the space of capabilities does not interpret this difficult concept, it seeems to me possible to conceptualize moral agency in the following way: To have, as a matter of fact, that level of capability, that allows one to choose and pursue ideals of the good. Capabilitiey levels are determined by a mixture of internal and external characteristics of a person. Part of the external characteristics is the level of resources and income a person enjoys and whether the basic liberties are 47 available. If a just distribution of these external characteristics has been achieved in society, no one would fail to be a moral agent as long as they are not internally handicapped. Such internal handicaps concern the functional characteristics of a person, such as his mental and physical health and his life-expectancy. A person's health or life- excpectancy can be such that the ideals of the good that are commonly puersued in society are not open, even with an otherwise fair share of resources of income. Some-one's disadvantages may be so great that no amount of additional resoures or income would permit them to make such choices. In a society with a fair distribution of resources and income those with such internal limitations on their capabi- lities may be the only group which does not achieve full moral agency. This is the case in a society in which the dis- tribution of resources, income, or primary goods allows those members of the least advantaged socio-economic group who are not internally handicapped at least that level of resources which is adequate to pursue some of the ideals of the good that are typically pursued in such a society. For example, in a society in which having a family with children and being able to choose among a varietly of employments are typical ideals of the good, the question is whether or not the members of the lowest socio-economic group de fact have such a choive. If this is the case, their moral agency appears not 48 to be impaired since they have the necessary capability level. If in contrast they have to accept any forms of employment and risk starvation if unemployed then full moral agency would not yet be achieved for this group. In the United States, Germany and other democratic industrialized countries, most external limitations on moral agency have been overcome even for the socio-economically worst-off groups. This is certainly the case for the other West Euopean countries, since they have put in place large welfare systems. In these countries, as well as in Canada, Japan, New Zealand, and Australia, only those with internal limitations on their most basic capabilities do not enjoy full moral agency. In the next chapter I will argue that the central forms of health care, to use Daniel' phrase, are a "special social good", which are in moral importance comparable to the basic liberties and basic welfare. These special goods we owe to others as part of respecting them as moral agents, rather than as a matter of distributive justice. I will then turn to the implication of the status of central care for its total budget. [Satzfehler behoben. Van] |
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on: May 04, 2023, 01:53:54 PM
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Started by Brioclin Zelltek - Last post by Brioclin Zelltek | ||
Karl Lauterbachs Dissertation ist bloß als eine Sammlung von Scans online. Die Bilder sind kapitelweise in PDFs zusammengetragen. Lauterbach hat die online, aber nicht richtig lesbar. Scans United und Anonymaus Gutenberg sind der Sache nachgegangen und haben die Scans zu edierbarem Text übertragen.
Ob die Übertragung an allen Stellen fehlerfrei ist, können wir nicht garantieren. |
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on: May 04, 2023, 01:34:55 PM
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Started by RUEBENKRAUT - Last post by Brioclin Zelltek | ||
Hallo, das mit der Mail. Ich habe in die eine reingesehen. Dauert noch etwas. Einräumen müßt ihr dann. Ich kann das nicht.
CU |