摘要：I trace the evolution of ethical approaches to health policy in the United States and examine a number of critical unresolved issues pertaining to the current set of frameworks. Several themes emerge. First, fair procedures claim more attention than substantive and procedural principles. Second, in the case of public deliberation, more focus has been placed on factors such as procedural mechanisms than on understanding how individuals and groups value different aspects of health and agree on health-related decisions. Third, the nation needs workable frameworks to guide collective choices about valuable social ends and their trade-offs; purely procedural strategies are limited in illuminating overarching health policy and ethics questions. There is a need to integrate consequential and procedural approaches to health ethics and policy. IT IS AGAIN TIME FOR A debate on health care reform in the United States. A major paradox of the American health care system is the existence of dramatic therapeutic gains alongside large discrepancies in access to quality care. The United States spends more than 14% of its gross domestic product on health care, yet more than 41 million Americans are uninsured. Efforts to achieve universal health insurance in the United States have never succeeded; the failure of the Clinton administration's 1993–1994 health reform efforts illustrates the problem's intractability. Explanations for policy failures typically focus on economic and political factors and the failure of different political parties and interest groups to strike a bargain on comprehensive reform. In this article, I trace the evolution of ethical approaches to health policy and examine a number of critical unresolved issues pertaining to the current set of frameworks. In the companion to this article, 1 I present an alternative framework, taking as its premise that an ethical vision resting on explicitly articulated values and norms is critical for health reform and that comprehensive reform requires a consensus on the public good, transcending self-interest and narrow agendas. What is needed for universal health reform is a moral vision underpinning collective action for universal coverage. The companion article presents such a vision, offering an ethical paradigm to guide health sector reform that is part of an alternative approach to health and social justice. 2 – 6 This paradigm calls for a reasonable consensus justified by appeal to a particular ethical vision of the good life. It envisions what I call shared health governance, in which individuals, providers, and institutions work together to enhance individuals’ health agency and create a social environment that enables all to be healthy.
