van Schie T, Seedhouse D
Westmere Physiotherapy Clinic, Auckland, New Zealand.
Health Care Anal. 1997 Dec;5(4):283-91. doi: 10.1007/BF02678526.
This paper is in three parts. In Part One we briefly explain that an unsophisticated form of utilitarianism--economic rationalism (ER)--has become dominant in many health systems. Its proponents argue that one of ER's most important effects is to increase consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, the logic of ER requires the construction of systems which tend to restrict individual participation. In Part Two we argue that although some have advocated an 'ethic of care' in an attempt to counteract ER's utilitarianism, two decades of campaigning have had little influence on health policy. ER's pro-care adversaries have failed to make an impact because they have not developed a taxonomy of care--they have not established a language compatible with, or as powerful as, ER's. In Part Three, in an attempt to raise the conceptual and practical status of caring in contemporary health systems, we distinguish four different forms of care. In opposition to those who believe the 'ethic of care' can adequately direct health care practice, we demonstrate that care is a secondary notion. We show that in order for a carer to decide which form of care to adopt in different situations she requires a more powerful idea. We contend further that health care ought to be governed by a theory of health, and suggest that 'the foundations theory of health' should be adopted by planners searching for a more humane alternative to ER. We conclude that ER's dominance can and must be challenged. However, only those arguments which offer detailed theoretical analyses of health care, as well as meticulously derived practical policies, have any chance of success.
本文分为三个部分。在第一部分中，我们简要解释了一种简单形式的功利主义——经济理性主义（ER）——在许多卫生系统中已占据主导地位。其支持者认为，ER最重要的影响之一是增加消费者选择。然而，来自新西兰的证据并不支持这一说法。此外，ER的逻辑要求构建倾向于限制个人参与的系统。在第二部分中，我们认为，尽管有些人倡导一种“关怀伦理”以试图对抗ER的功利主义，但二十年的倡导对卫生政策几乎没有影响。ER的支持关怀的反对者未能产生影响，因为他们没有建立一种关怀分类法——他们没有建立一种与ER兼容或同样强大的语言。在第三部分中，为了提高关怀在当代卫生系统中的概念和实践地位，我们区分了四种不同形式的关怀。与那些认为“关怀伦理”可以充分指导医疗实践的人相反，我们证明关怀是一个次要概念。我们表明，为了让护理者决定在不同情况下采用哪种关怀形式，她需要一个更强大的理念。我们进一步认为，医疗保健应该由一种健康理论来指导，并建议寻求一种比ER更人道替代方案的规划者应采用“健康基础理论”。我们得出结论，ER的主导地位可以而且必须受到挑战。然而，只有那些对医疗保健进行详细理论分析以及精心推导实际政策的论点才有成功的机会。
