Goold S D
University of Michigan, USA.
J Health Polit Policy Law. 1996 Spring;21(1):69-98. doi: 10.1215/03616878-21-1-69.
Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.
假设医疗资源配给不可避免，且需要进行道德推理，那么我们应如何分配有限的医疗资源呢？这个问题很棘手，因为我们多元、自由的社会在分配正义的概念上没有达成共识。在本文中，我关注另一个问题：应由谁来决定如何进行医疗资源配给，以及如何在尊重自主性、多元性、自由主义和公平性的前提下做到这一点？我探讨了三种做出配给决策的过程：成本效用分析、明智的民主决策以及无知之幕的应用。我将这些过程作为程序正义的示例进行评估，假定不存在被认为是最公正的结果。我以同意作为评判相互竞争过程的标准，以便配给决策在某种程度上是自我施加的。我还考察了这些过程在我们当前医疗体系中的可行性。成本效用分析不符合实际同意或假定同意的标准，即便成本和与健康相关的效用能够被完美衡量。现有的政府结构无法可靠地吸纳做出合理配给决策所需的信息，而基层努力又缺乏代表性。无知之幕的应用在确定与医疗资源配给相关的原则方面比做出具体的配给决策更有用。我概述了一个专门针对医疗保健的决策过程，该过程依赖于实质性的、经过挑选的代表制，尊重多元性、自由主义和协商民主，并且可以在社区或组织层面实施。
