Ruger J P
Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA.
Glob Public Health. 2007;2(1):78-96. doi: 10.1080/17441690600911480.
In 2005 the Global Health Council convened healthcare providers, community organizers, policymakers and researchers at Health Systems: Putting Pieces Together to discuss health from a systems perspective. Its report and others have established healthcare access and quality as two of the most important issues in health policy today. Still, there is little agreement about what equal access and quality mean for health system development. At the philosophical level, few have sought to understand why differences in healthcare quality are morally so troubling. While there has been considerable work in medical ethics on equal access, these efforts have neglected health agency (individuals' ability to work toward health goals they value) and health norms, both of which influence individuals' ability to be healthy. This paper argues for rethinking equal access in terms of an alternative ethical aim: to ensure the social conditions in which all individuals have the capability to be healthy. This perspective requires that we examine injustices not just by the level of healthcare resources, but by the: (1) quality of those resources and their capacity to enable effective health functioning; (2) extent to which society supports health agency so that individuals can convert healthcare resources into health functioning; and (3) nature of health norms, which affect individuals' efforts to achieve functioning.
2005年，全球健康理事会召集了医疗服务提供者、社区组织者、政策制定者和研究人员，参加“卫生系统：整合各方力量”会议，从系统角度探讨健康问题。其报告及其他相关报告已将医疗服务可及性和质量确立为当今卫生政策中两个最重要的问题。然而，对于平等可及性和质量对卫生系统发展意味着什么，人们的共识甚少。在哲学层面，很少有人试图理解为何医疗质量差异在道德上如此令人困扰。虽然医学伦理学在平等可及性方面已经开展了大量工作，但这些努力忽视了健康能动性（个体朝着他们所重视的健康目标努力的能力）和健康规范，而这两者都会影响个体保持健康的能力。本文主张从另一个伦理目标的角度重新思考平等可及性：确保所有人都有能力保持健康的社会条件。这种观点要求我们审视不公正现象时，不仅要看医疗资源的水平，还要看：（1）这些资源的质量及其促进有效健康机能的能力；（2）社会支持健康能动性的程度，以便个体能够将医疗资源转化为健康机能；（3）健康规范的性质，这会影响个体实现机能的努力。
