How best shall we serve? Case study.

KIE: Four disparate proposals for hospital programs, varying in their funding requirements and revenue-generating capacity, have been made to the chief executive officer (CEO) of a metropolitan nonprofit general hospital that has always prided itself on being responsive to community needs. Although the hospital faces severe financial pressures, the CEO has determined that one of the proposals can be supported. Three commentaries on this case discuss what ethical criteria should be considered in evaluating the four proposals, and what role the hospital ethics committee should play in the decision.^ieng

Universal health care, American style: a single fund approach to health care reform.

With increasing momentum for health care reform, attention is shifting to finance reform that will provide for direct methods for controlling health care spending. This article outlines the two principal paths to direct cost control and outlines a national plan that retains our multiple sources of payment, yet also contains a powerful direct cost control technique: a single fund to finance all health care.

Universal New York Health Care. A single-payer strategy linking cost control and universal access.

Now that universal access to health care is back on the governmental agenda, elected officials are faced with the dilemma of expanding our present pluralistic system of numerous private and public payers, with its built-in administrative inefficiencies and inflationary pressures, or scrapping the present system of financing and moving to a tax-based scheme like the Canadian Medicare program, an option fraught with political difficulties. There is, however, a third option. The New York State Department of Health has developed a proposal for universal access--Universal New York Health Care, or UNY-Care--that would retain the existing payers, including employer-based insurance coverage, but combine them in a one-payer framework. Providers would no longer have to interact with the many public and private payers, each with its own rules, criteria, and levels of payment. The single payer would serve as the only payer for most health care services and would also negotiate reimbursement rates. The single-payer framework should bring savings in administrative and billing costs and should move government closer to the goal of buying health care services--getting good value for payment rendered--rather than simply paying bills as they are submitted. Although the single-payer strategy could be implemented at either the state or the federal level, it seems ideal as the principal responsibility of the states in a national plan for universal coverage.

Morality and the health of the body politic.

KIE: Although acquired immunodeficiency syndrome (AIDS) is clearly a public health threat, Beauchamp contends that the view that it is also a threat to the majority's values is a form of potentially counterproductive legal moralism. Social discrimination against homosexuals both directly threatens the health of homosexuals and impedes changes in their sexual practices that could lessen the risk of transmitting AIDS. Sodomy statutes contribute to the poor health of homosexuals by discouraging them from seeking treatment for sexually transmitted diseases. Success in the battle against AIDS depends on replacing old images of the tightly bound community based on sodomy statutes with a complex public health policy that combines the right to be different with the view that, in matters of the common health and safety, we are "one body" with a common good.^ieng

Community: the neglected tradition of public health.

The dominant language of politics in the United States has been political individualism, with minimal restrictions on property and personal, voluntary conduct. But there are second languages of community that stress cooperation and group action. These second languages include the constitutional tradition for public health. Public health offers a community justification for paternalistic measures that, for example, discourage smoking or require seatbelts.

KIE: The political focus in the United States has been on individualism with minimal restrictions on property and personal conduct. Government regulation or paternalism has been accepted, however, in the area of public health. Political thought has embraced the concepts of common or group interests which must be protected and which legitimize the police power of the state. Contemporary public health problems such as fluoridation, alcoholism, the wearing of motorcycle helmets, and the discouragement of smoking are discussed in terms of constitutional rights and the collective good.

Alcoholism as blaming the alcoholic.

Theories of alcoholism tend to blame the alcoholic by implying that most American drinkers have an ability, which the alcoholic lacks, to drink without problems. The presence or absence of this ability or capacity presumably accounts for the incidence of alcohol problems in society. But we normally apply the idea of an ability or a capacity only after an individual has been exposed to the risk of problems from a hazard or difficult task, and when an individual avoids these problems by their efforts. On this point survey data reveal that most American drinkers have a rather limited exposure to alcohol and are not at risk for problems. It is likely that it is this low exposure to alcohol-rather than some drinking ability-that accounts for the absence of problems. Moreover, the entire practice of treating drinking and the occurrence of problems in the idiom of individual abilities, capacities, or control can be shown to be incorrect and is systematically misleading. A public health approach to alcohol problems is needed that identifies the risks for all associated with hazardous intakes of alcohol and that seeks to reduce these hazards chiefly by reducing the overall consumption of alcohol.

Exploring new ethics for public health: developing a fair alcohol policy.

Alcoholism policy since the repeal of Prohibition has been largely based on the assumption that alcohol problems are the result of the failure of a small minority to "control" their drinking. Thus, in sharp contrast to the approach to other drug policies, the problem of alcohol abuse has been viewed as one of "bad users" rather than "bad substances." This regard of alcoholism has helped exonerate the majority of drinkers and the alcohol industry from responsibility. However, mounting epidemiological evidence demonstrates that a primary factor in rates of diseases such as cirrhosis is the per capita use of alcohol and suggests that alcohol problems can be controlled or reduced only if all involved in the manufacture, sale or consumption of alcohol accept the burdens of restrictions over its availability and use. This acceptance will not be forthcoming, however, unless the prevailing market ethic of individual responsibility and minimal collective obligations to protect and preserve life is replaced with a new public health ethic rooted in social justice. This new ethic would assign the highest priority to life and would stress the obligations of all citizens to share the burdens of reasonable restrictions over all health hazards. In this paper a new alcohol policy is outlined based on just and reasonable limits on the availability, marketing and consumption of this substance.