Bloche M Gregg
Calif Law Rev. 2003 Mar;91(2):247-322.
By default, the courts are inventing health law. The law governing the American health system arises from an unruly mix of statutes, regulations, and judge-crafted doctrines conceived, in the main, without medical care in mind. Courts are ill-equipped to put order to this chaos, and until recently they have been disinclined to try. But political gridlock and popular ire over managed care have pushed them into the breach, and the Supreme Court has become a proactive health policy player. How might judges make sense of health law's disparate doctrinal standards? Scholars from diverse ideological starting points have converged toward a single answer: the law should look to deploy medical resources in a systematically rational manner, so as to maximize the benefits that every dollar buys. This answer bases the orderly development of health care law upon our ability to reach stable understandings, in myriad circumstances, of what welfare maximization requires. In this Article, I contend that this goal is not achievable. Scientific ignorance, cognitive limitations, and normative disagreements yield shifting, incomplete, and contradictory understandings of social welfare in the health sphere. The chaotic state of health care law today reflects this unruliness. In making systemic welfare maximization the lodestar for health law, we risk falling so far short of aspirations for reasoned decision making as to invite disillusion about the possibilities for any sort of rationality in this field. Accordingly, I urge that we define health law's aims more modestly, based on acknowledgement that its rationality is discontinuous across substantive contexts and changeable with time. This concession to human limits, I argue, opens the way to health policy that mediates wisely between our desire for public action to maximize the well being of the many and our intimate wishes to be treated noninstrumentally, as separate ends. I conclude with an effort to identify the goals of health law, so constructed, should pursue and to suggest how a strategy of accommodation among these goals might apply to a variety of legal controversies.
默认情况下，法院在创设卫生法。规范美国卫生系统的法律源自法规、条例以及法官创制的原则的杂乱混合，而这些法规、条例和原则在制定时，主要并未考虑医疗保健因素。法院没有能力对这种混乱局面进行梳理，并且直到最近，它们也一直不愿意尝试。但是政治僵局以及民众对管理式医疗的愤怒促使它们挺身而出，最高法院已成为积极参与卫生政策的角色。法官如何才能理解卫生法中各不相同的教义标准呢？来自不同意识形态出发点的学者们已趋向于一个共同的答案：法律应以系统合理的方式调配医疗资源，以便使每一美元所带来的效益最大化。这一答案将卫生保健法的有序发展建立在我们在无数情况下对福利最大化要求达成稳定理解的能力之上。在本文中，我认为这一目标无法实现。科学上的无知、认知局限以及规范性分歧导致对卫生领域社会福利的理解不断变化、不完整且相互矛盾。如今卫生保健法的混乱状态就反映了这种无序性。将系统性福利最大化作为卫生法的指导原则，我们可能会远远达不到理性决策的期望，从而引发对该领域任何形式的合理性可能性的幻想破灭。因此，我敦促我们更适度地界定卫生法的目标，基于这样一种认识，即其合理性在不同的实质背景下是不连续的，并且会随时间而变化。我认为，这种对人类局限性的认可为卫生政策开辟了道路，该政策能够在我们希望通过公共行动使众多人的福祉最大化的愿望与我们希望被作为独立个体而非工具性对待的内心愿望之间进行明智的调和。我最后努力确定如此构建的卫生法应追求的目标，并提出这些目标之间的调和策略如何可能适用于各种法律争议。
