Search Results

This chapter focuses on one of the most important dimensions of the diffusion of the health agenda: the opening up of the ‘ends’ of health policy. It discusses the concept of health and considers the ways in which various conceptions of health or other health-related goods are, or ought to be, embodied in policies and practices, as self-consciously chosen ends or as elements built into the value field. The second part of the chapter asks some more direct questions about the nature and boundaries of healthcare and health policy, about the difficulties of isolating health from health-related goods, or health-related goods from other goods, and about some of the value tensions inherent in health-related discourses.

This introductory chapter begins with a brief discussion on the purpose of the book, which is to provide readers with the ‘hands-on’ knowledge, skills, and attitudes needed to deliver research for health policy, in the government, not-for-profit, and private sectors. It focuses on describing research for health policy in a heuristic, practice-based way. The chapter then discusses two assertions underpinning the approach in the book and three different kinds of sources used throughout the volume.

This introductory chapter discusses the ‘diffusion of the health agenda’ and its implications for healthcare and healthcare ethics. It begins with a thumbnail sketch of some fundamental shifts in modern health policy and services, and looks briefly at some of the philosophical changes that underpin these shifts — the so-called ‘social turn’ in healthcare. The chapter then reflects upon some of the implications of this diffused agenda for healthcare ethics.

This chapter introduces the concept of health-policy ethics by exploring the nature and ethics of health promotion. The main concern is to highlight the implications of the issues reviewed for the theory and practice of healthcare ethics when it shifts from a clinical to a more societal focus. It begins by identifying generalizations about health promotion broadly conceived and some of the distinctive features of health-promotion ethics. Some of the fundamental continuities between health promotion and more conventional healthcare are discussed.

This chapter begins by briefly reflecting on some of the different senses of responsibility. It then considers the relationship between specific examples of questions about health responsibilities and the more overarching questions. It is argued that for healthcare ethics, diffused responsibility means combining ethical analysis of policy contexts and institutions with work on individual professionals and citizens. We must examine and find ways of appraising the ethical bases and effects of the social and institutional arrangements which shape the production of health experiences and the distribution of health-related entitlements and obligations. Policy-making has to be evaluated through this lens, and the actions of individuals judged within this context. Each of these layers of appraisal is only relatively autonomous. Overall, the judgements made at each level determine the judgements we make at the others.

This chapter looks at the shape of the health agenda. In other words, it considers some of the health-policy choices we face, whether as legislators, managers, health professionals, or as individual citizens. Topics discussed include the drive of globalization, the drive of biomedicine, competing ideas in healthcare, and realizing health as a social good.

This chapter demonstrates how the coalition of insurance companies, managed-care firms, and small businesses destroyed a proposal for home care for disabled people in the 1980s, and notes that the same coalition also attacked President Clinton's plan for universal health care in the 1990s. It begins by discussing long-term care for the weak elderly, then looks at another revival of the national health insurance and introduces the Consolidated Omnibus Reconciliation Act of 1985, which tried to fill the gaps within the private health insurance system. The chapter then studies health policy making after the Health Security failed.

This chapter focuses on one of the most important dimensions of the diffusion of the health agenda: the opening up of levels of ‘involvement’ in healthcare and policy. It reviews the nature and ethical significance of participation in both healthcare and health policy. It considers the relationship between participation at the levels of care and policy, including the relationship between people participating as patients and as citizens. The discussion is designed not only to highlight the central ethical importance of participation, but also to specify the reasons it falls far short of an ‘ethical panacea’. Participation has to be understood as only one element in a complex nexus of competing healthcare goods.

This chapter examines the emergence of market ideology and how it has reshaped understanding of the nature and import of inequality within the American health-care system. It describes four changes that have dramatically altered the politics of inequality in medical care. First, the introduction of markets to medical care exacerbates unequal health outcomes. Long-standing differences in health-care utilization and health outcomes are likely to grow under market reforms. Second, market arrangements promoted the growth of large health-care corporations. Their political power may circumscribe government policy making that could limit health inequalities. Third, market frames are associated with different standards of fairness for assessing the performance of the health-care system. This changes the outcomes seen as inequitable, and hence suitable, for government intervention. Fourth, market schemas have transformed prevailing discourse around important perspectives on health policy, including the rights of citizens and the responsibilities of local communities.

This chapter provides a workable operationalization of health capabilities, and seeks a shared standard of health based on the demands of social justice and the right to health in terms of health equity. The health capability paradigm offers a trans‐positional conception of health that reflects the ‘view from everywhere’. This chapter delineates the relationship between health capabilities, health functionings, health needs and health agency, introducing shortfall in equality —— deviations of individuals or groups from a standard —— as a means for judging public policies affecting health. It emphasizes that although many factors influence health, health policy is one of the most important determinants; thus there is need for efficiency in health policy, and for joint clinical and economic solutions to achieve optimal levels of health and reduce inequalities in individuals' capabilities to be healthy. It argues for a differential allocation of resources to mitigate shortfall inequality. It critically analyzes the ethics of the social determinants of health and surveys and responds to criticisms of the capability approach.

The most important ethical implication of the diffusion of the health agenda is the growth in salience of health inequalities. Taking a broad social perspective on health opens up the consideration of patterns of determinants and patterns of health experiences. This chapter addresses the following issues: (i) What they might entail in practice, in other words: ‘What would a more equal health polity have to aim at?’ and (ii) How far should health or public policy be led by a concern with equity where this comes into conflict with other relevant values? The first part of the chapter sets out the rationale for thinking that health inequalities are ethically important. The chapter later places more emphasis on the problems of interpreting the implications of this ethical significance.

This chapter seeks to pull together the arguments and implications of the book. In particular, it wants to ask how we — individually and collectively — ought to understand and debate the major questions of public-health policy. It focuses on the methodological implications of the arguments, i.e., their implications for the direction of healthcare ethics. It is argued that we each have some responsibility to divide our attention between our immediate ‘role-related’ obligations and the wider evaluation and construction of the social frameworks that define these roles and associated ‘ethical positions’. One aspect of this broader responsibility is seeking to understand the value field of health-related action: of the ways in which health-related goods are socially constructed and produced, and of the scope for changing these things.

This chapter discusses some of the key policy issues related to health systems that public health managers face. This is important both in terms of understanding the ‘bigger picture’ and in seeing how they can get involved in influencing them. Having given this broad overview of global policies, the chapter then looks at what is meant by a health system and what are its key elements.