摘要：I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination. IN THIS ARTICLE, I OFFER AN alternative approach to health system reform in the United States, which I call shared health governance, that is part of an alternative theory of health ethics. 1 – 5 The basic ethical commitment to “human flourishing” 6 – 10 underlies society's obligation to maintain and improve health, under this paradigm. 5 Public policy should focus on individuals' ability to function. 11 – 13 Health policy should support individuals' health capabilities by enabling them to meet their health needs and by fostering what I call health agency (i.e., people's ability to make health decisions and pursue health goals). 14 This ethic encompasses several key principles for health policy and reform. First, it assigns special moral importance to, what I call, health capability, a person's ability to be healthy. 1 , 5 This contrasts with the view that health care is special because of its impact on equality of opportunity 15 and the utilitarian view that health care is important for maximizing social welfare. Equality of opportunity, for example, results from “[a] time or condition [favorable] for a particular action or aim,” 16 (p2009) as when individuals have equal access to employment opportunities, 17 and utility connotes desire or pleasure. Second, this paradigm argues for valuing “central health capabilities” above those that are secondary. 3 , 5 Agreement on such core health capabilities can provide guidance in prioritizing health care goods and services. 3 , 5 This approach can help determine whether a particular medical intervention or technology merits societal resources. Third, this paradigm proposes a joint scientific and deliberative approach to evaluating public health and health care interventions. It combines the evidence base of medicine and public health, expert opinions from health professionals, and input from individuals. Individuals, as change agents for their own behavior and for public policy at large, must be able to participate in deliberations and decisionmaking and must be informed of the risks, benefits, and costs of various health policy, prevention, and treatment options. This view contrasts with paradigms in which health care decisions are made by consumers, physicians or public health experts, or third parties such as insurers alone, as well as with paradigms in which such decisions are made via strict algorithms, cost–benefit calculations, or shared decisionmaking within an informed consent model. 18 In shared health governance, individuals, providers, and institutions work together to empower individuals and create a positive environment for all to be healthy. 4 , 19 This approach also differs from efforts to develop a decisionmaking process designed “to set fair limits [on] health care.” 20 (p2) It calls for consensus on substantive principles and procedures of distribution and offers a method for achieving such consensus, 1 , 5 one that places importance on the results (costs and effectiveness) of health policies and promotes collaborative problem solving. Fourth, shared health governance argues for equal access to high-quality care and expanded health agency. Individuals, providers, and institutions should share responsibilities in achieving health goals. Fifth, shared health governance requires universal health insurance coverage via shared costs and risk pooling, with health care funded through community-rating and progressive financing. 21 Sixth, evaluations of health policies and technologies must consider costs. Every resource has an alternative use, so its expenditure represents an opportunity cost. Individuals and society must use resources parsimoniously by evaluating the efficiency of those resources. Finally, this paradigm aims to protect disabled people from discrimination while limiting exorbitantly costly care that would deprive others of health resources.
