Resource constraints and moral pressures: can we still afford ourselves?

M Little
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引用次数: 3

Abstract

We have reached a phase of diminishing returns in medicine. Increasing costs produce smaller and smaller incremental benefits in health status. Medical scientists continue to work within the ideology of the Enlightenment, whereby advances in knowledge will eventually lead to control of health and welfare. The enormous costs of this ideology have led to two new ideologies: those of economic rationalism and managerialism. At the public level, the Western liberal emphasis on the value of individual life is generally held to justify the amount of public money spent on health. Those who frame health policy are influenced to some extent by this ideal, but we cannot continue to develop costly interventions without constraint. To overcome this impasse, we might accept that economic rationalism provided a proper base for health care; or we might redefine disease so that more people were excluded from treatment programmes; or we might agree to limit medical research in costly areas; we might change our ethical thinking to emphasize classical utilitarianism; or we might undertake systematic studies of community values and opinions to find out what people really want from their health and welfare services. There are serious ethical problems with each of these solutions, except for the last: the idea of modifying services to take note of community values. Testing community values is difficult, but there are ways of doing it, and there have been some exercises in which the process has been undertaken with some success. The recent Constitutional convention suggests that it may even be possible in Australia.

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资源约束与道德压力:我们还能养活自己吗?
我们已经进入了医学收益递减的阶段。增加的成本在健康状况方面产生的增量效益越来越小。医学科学家继续在启蒙运动的意识形态中工作,据此,知识的进步将最终导致对健康和福利的控制。这种意识形态的巨大代价导致了两种新的意识形态:经济理性主义和管理主义。在公共层面上,西方自由主义者对个人生命价值的强调,通常被用来证明公共资金用于健康的合理性。制定卫生政策的人在某种程度上受到这一理想的影响,但我们不能继续不受限制地制定昂贵的干预措施。为了克服这一僵局,我们可能会承认,经济理性主义为医疗保健提供了一个适当的基础;或者我们可以重新定义疾病,让更多的人被排除在治疗计划之外;或者我们可以同意限制在昂贵领域的医学研究;我们可以改变伦理思想,强调古典功利主义;或者我们可以对社区价值观和意见进行系统的研究,以找出人们真正想从他们的健康和福利服务中得到什么。这些解决方案都存在严重的道德问题,除了最后一个:修改服务以注意社区价值的想法。测试社区价值是困难的,但是有一些方法可以做到,并且已经有一些实践在这个过程中取得了一些成功。最近的制宪会议表明,这在澳大利亚甚至是可能的。
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