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The Goals of Medicine: The Forgotten Issue in Health Care Reform
  1. Richard Ashcroft
  1. Lecturer, Centre for Ethics in Medicine, University of Bristol

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    Edited by Mark J Hanson and Daniel Callahan, Washington, DC, Georgetown University Press, 1999, 239 + xiv pages, $55 hb.

    The dominant theme in health care and its ethics as we move into into the new century looks likely to be how to allocate scarce health care goods fairly. Many ingenious proposals have been devised for determining how to choose between funding service A and service B, how to fix on appropriate levels for funding individual services, and how to decide who will receive a service and to what extent. Yet it would not be controversial to assert that none of these proposals has met with wide acceptance and trust. One of this remarkable book's premises is that the reason for this general failure is that rationing proposals duck the question: “What is medicine for?” To pursue this question seriously is to sail into waters less familiar to Anglo-American readers than those of medical ethics, namely, those of philosophy of medicine. The idea is that by obtaining some (or a better) answer to this question we will be in a much better position to prioritise services, that is to say, to determine which of two services better fulfils the purpose or purposes of medicine.

    This strategy has obvious interest. Yet it has an equally obvious difficulty. While medical ethics has by now a relatively stable set of methods and perhaps some results which claim moderate public acceptance, philosophy of medicine is more varied and contentious, both as to method and results. This being so, it might be thought perverse to seek solutions to a problem, even a large and diffuse one, by translating it into a harder one that is still less definite in its scope. The ground-breaking work of Norman Daniels arguably suffers from this defect, in that having determined that needs are the fairest basis for allocating health care, his account of need has defeated attempts to operationalise it.

    If one considers the history of medicine, and if one compares the diversity of health care systems and “philosophies”, it could be that much of what passes for philosophy of medicine rests on a confusion between exegesis of the goals of medicine as historically and culturally constructed and the attempt to divine the trans-historical essence of medicine. We think we are doing the latter, when in fact we are generally able to do only the former. This insight has proved very useful in the historiography of science and in political philosophy, and so I think it would prove in the theory of medicine.

    This volume reports on a Hastings Center-coordinated international project to devise a core set of goals of health care which would better answer the question: “what is medicine for” in a way that would make health care reform able to proceed along humane and rational lines. The book opens with a description of the project by the editors, and is followed by a consensus statement on the values, and their meaning, of contemporary health care; the description summarises the views of the project participants. This statement is followed by the position papers prepared by each participant group in the project. Participants were drawn from 14 countries, including the UK, the USA, China, Chile, Sweden and Germany. Predictably, most of the papers are American, but the volume is pleasing in not being merely a reflection on the failed Clinton health reforms. However, while careful and interesting consideration is made of the diversity of European views, and of the relations between different medical traditions (notably Western allopathic medicine and Chinese medicine), little attention is paid to the philosophical issues thrown up by medicine in the poor world. This is the only weakness—and it is a considerable one—in the volume. Given that Callahan's critics have often argued that his attempts to place limits on medical need are unwittingly complicit with attempts to limit care given to the poor, this omission is surprising. One cannot, I suggest, have a philosophy of medicine without a political economy to match.

    Overall, however, this is a remarkable volume: rich, of high scholarly standard, intriguing, and readable. The strengths of the book —philosophical and cultural sophistication, a clear eye as to the applicability of its proposals, and a strong sense of the historical and political nature of medicine—make it a book which should be read with profit by anyone interested in this area. In particular, it would make a useful textbook for a graduate seminar on philosophy of medicine or health care reform.

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