Health Care: The Health Care Future: Defining the Argument, Healing the Debate

doi:10.1001/jama.280.22.1961

1998-12-09 00:00:00

In the fierce and continuing battles about health care in the United States, the conflicts have centered on such specific, practical, and detailed matters as fee-for-service vs managed care, the role of government, and access to emergency rooms. The Health Care Future undertakes to reframe the policy debates about health care in the United States in terms of underlying value-laden ethical and cultural issues. The initial section sets out some of these issues. It asks, for example, to what extent individuals are entitled to make claims on society's resources and how far society is obligated to meet such claims. It notes the potential tension between the role of physicians as caregivers to individuals and as citizens responsible for using society's limited resources optimally. It summarizes key ethical concepts such as justice and equity in allocating resources. The second section reviews the ideas of several leading figures in organizational theory and management. It emphasizes the continuous quality-improvement concept of W. Edwards Deming and the dynamics of "learning organizations" laid out by Peter Senge of the Sloan School of Management at the Massachusetts Institute of Technology. In a brief final section, the authors propose to use these and other management techniques to resolve the philosophical, ethical, and practical issues that underlie the ongoing health care debates in the United States. The attempt to move from fractious arguments about the details of our nonsystem for delivering medical care to reasoned dialogue about broad underlying principles is a noble goal. Unfortunately, this book fails to show how it can be done. The authors summarize the basic ethical principles and the key ideas of Deming, Senge, and others clearly. Regrettably, they give no examples of how these concepts can be applied to the specific issues that are being debated today in the United States. Agreed, the ethical basis for distributing whatever resources society decides to allocate to medical care is a critical issue. Should all US citizens be entitled at least to basic medical care regardless of ability to pay? The authors suggest that groups of citizens should be discussing and resolving these broad ethical issues, rather than stakeholders and politicians maneuvering to create or to block one or another specific national scheme for health insurance for all. They imply that application of the management techniques they espouse so enthusiastically (Deming's "14 points" are summarized twice in this short book) will somehow help to solve the problem. However, they offer no specific description of how their proposal might work to resolve this or any other contentious issue. Without examples of how their ideas might help us to reach agreement on specific issues, the book does not succeed in making its case. Its goal of reconsidering medical care from the perspective of "our most basic notions of who we are as individuals and what we wish to become as a society" is laudable. The authors would have made an important contribution had they demonstrated how consideration of moral principles and application of management techniques could combat the devils that are in the details of medical care issues. As it stands, their book is a clear, concise presentation of their ideas but fails to show that the ideas offer a new way to deal with the key issues regarding health care in the United States.

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JAMA American Medical Association

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$In the fierce and continuing battles about health care in the United States, the conflicts have centered on such specific, practical, and detailed matters as fee-for-service vs managed care, the role of government, and access to emergency rooms. The Health Care Future undertakes to reframe the policy debates about health care in the United States in terms of underlying value-laden ethical and cultural issues. The initial section sets out some of these issues. It asks, for example, to what extent individuals are entitled to make claims on society's resources and how far society is obligated to meet such claims. It notes the potential tension between the role of physicians as caregivers to individuals and as citizens responsible for using society's limited resources optimally. It summarizes key ethical concepts such as justice and equity in allocating resources. The second section reviews the ideas of several leading figures in organizational theory and management. It emphasizes the continuous quality-improvement concept of W. Edwards Deming and the dynamics of "learning organizations" laid out by Peter Senge of the Sloan School of Management at the Massachusetts Institute of Technology. In a brief final section, the authors propose to use these and other management techniques to resolve the philosophical, ethical, and practical issues that underlie the ongoing health care debates in the United States. The attempt to move from fractious arguments about the details of our nonsystem for delivering medical care to reasoned dialogue about broad underlying principles is a noble goal. Unfortunately, this book fails to show how it can be done. The authors summarize the basic ethical principles and the key ideas of Deming, Senge, and others clearly. Regrettably, they give no examples of how these concepts can be applied to the specific issues that are being debated today in the United States. Agreed, the ethical basis for distributing whatever resources society decides to allocate to medical care is a critical issue. Should all US citizens be entitled at least to basic medical care regardless of ability to pay? The authors suggest that groups of citizens should be discussing and resolving these broad ethical issues, rather than stakeholders and politicians maneuvering to create or to block one or another specific national scheme for health insurance for all. They imply that application of the management techniques they espouse so enthusiastically (Deming's "14 points" are summarized twice in this short book) will somehow help to solve the problem. However, they offer no specific description of how their proposal might work to resolve this or any other contentious issue. Without examples of how their ideas might help us to reach agreement on specific issues, the book does not succeed in making its case. Its goal of reconsidering medical care from the perspective of "our most basic notions of who we are as individuals and what we wish to become as a society" is laudable. The authors would have made an important contribution had they demonstrated how consideration of moral principles and application of management techniques could combat the devils that are in the details of medical care issues. As it stands, their book is a clear, concise presentation of their ideas but fails to show that the ideas offer a new way to deal with the key issues regarding health care in the United States.$

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Health Care: The Health Care Future: Defining the Argument, Healing the Debate

Health Care: The Health Care Future: Defining the Argument, Healing the Debate

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Health Care: The Health Care Future: Defining the Argument, Healing the Debate

Health Care: The Health Care Future: Defining the Argument, Healing the Debate

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