Health and resource allocation

 Issues regarding the allocation of resources are among the most controversial in the field of bioethics. First of all, there is a debate about whether the various forms of rationing or priority allocation are actually inevitable: some argue that resources could be sufficient if unnecessary benefits were eliminated, while others believe that this strategy is only partially resolved. Furthermore, as DW Light points out, the modalities of this division influence in themselves the perception of adequacy of the financing itself (Light, 1997). However, whatever their scarcity, resources must in any case be divided and therefore the question arises of who should take decisions in this regard and according to what criteria.

Healthcare delivery and purposes

The first problem concerns the comparison between public health care and private insurance. One argument in favor of public health care is that it is, by its nature, more fair and equitable than private insurance, which is more likely to be available only to wealthy members of society.

State health care policies have the overriding aim of ensuring that, in all forms of state-provided health care and assistance for the disabled, the principle of public service replaces commercial profit objectives (Lopez, 1997). In a system where health care is the prerogative of private insurance, not only the poorest sections of society, but also groups with special needs, such as people with a mental illness or a mental handicap are likely to be discriminated against. J. Lopez goes so far as to argue that the private option can be seen as an infringement of the principle of solidarity, understood as "the propensity of citizens to contribute to the social assistance of others with the aim of improving the general level of well-being" (Light, 1997). For Lopez, in contrast, a public system "has the capacity to place greater emphasis on prevention and health promotion in the broadest sense, developing community control as well as effective participation" (Light, 1997). .

Even in a publicly funded system, however, there can be controversy about what the aims of the service should be. In Great Britain for example, AJ Culyer has argued that one of the main objectives of the NHS is to raise the health of the whole community as much as possible. According to Culyer not only does this occur, but it should be so. In general, health is a necessary condition for well-being, which is a fundamental good (Culyer, 1997). l Harris, however, has criticized this position, arguing that raising the level of health of the entire community as much as possible could have the effect of systematically disadvantaging some of its segments. For example, public health could be significantly improved by letting some people die (Harris, 1997).

The right to health care

Problems of various kinds arise when trying to uphold the universal right to health care or, within a given society, the right to health care for all members of that society. First of all, the concept of right is very complex, and it is still the subject of debate whether the right to social assistance, as opposed to the right to freedom, is a right or not. There is debate about the consequences of the fact that those who have a capacity, such as that of providing health care, have the right to sell it at will. Secondly, even if it were accepted that there is a social right to health care, this does not solve the problem of defining exactly what this right consists of and how extensive the provision of services should be.

The decision levels

Usually a distinction is made between macro-, meso- and micro-levels of decision making. At the macro level there is the government, which allocates the overall funds for the delivery of health care; at the mesolevel local administrators, who determine which services should be offered and how much funds should be allocated to each service; at the micro level the individual doctors, who establish which services to offer, to which patients, and which patients should have recourse to specialists. At each level there are ethical problems to be solved.

Consultation of public opinion

Public opinion has often been consulted on the allocation of funds for health care, such as the famous experiment carried out in Oregon: extending free assistance to the poor by abandoning the organ transplant program. This collides with what has been called the problem of democracy (Daniels, 1993), namely the possibility that the results may not be liked. One study has shown that the public is less sensitive to equity issues than are professional health care professionals (Stronks et al., 1997). The problem therefore arises of finding a theoretical justification for consulting public opinion in this context; in fact, such a consultation on resource allocation does not occur in other fields.

A good reason for consulting public opinion could lie, as mentioned above, in the particular importance that is attached to health. However, it is not only healthcare that plays an important role for public health. Decisions about traffic regulation and environmental planning can be just as important to people's health. Therefore, the primary importance of health cannot be considered an answer. Another point of view could be to consider consulting public opinion as a means of educating it. In countries where health care is public, there has been a growing expectation that health protection will continue to be comprehensive. Consulting the public on priorities in the Allocation of funds is a way to make people understand that, given the exponential growth of healthcare costs, continuing on this path is simply impossible. Even in countries where total health protection is not the norm, the need to contain costs has been recognised; the most striking example is offered by the United States.

Another reason, of a theoretical nature, for consulting public opinion could be based on a community vision of ethics. As H. Zwart has pointed out, this has to do with the question of setting limits on medicine. Zwart contrasts the liberal perspective, which tends to emphasize not only personal autonomy, but also the right to choose health services, with the community perspective which, in his opinion, should aim to develop a consensus on the objectives of medicine. From this point of view "those who act according to morality should not be seen in an atomistic way, but rather as placed in a moral community from which they derive their moral identity, their substantial moral convictions and the direction to follow" (Zwart, 1993).

Thus, a consensus is obtained from the community on when, in the case of health care, action should be taken and when it is preferable to accept the situation instead. A community consensus, however, does not equate to a majority vote, which could be prejudicial to the interests of minority groups. H. ten Have suggests that a community approach depends on a normative and deontological framework that defines the meaning of community interests (ten Have, 1993). He clarifies the presuppositions of the Dutch position, for example, in terms of the fundamental equality of people, the fundamental right to the protection of human life and solidarity.

It could be argued, however, that in a postmodern pluralist society such a communal consensus is not possible and the concept of community has weakened (Poole, 1991). T. van Willigenburg further argued that the effectiveness of the community-oriented criterion is based on its ability to exclude, to silence some voices (van Willigenburg, 1993). In this case, therefore, one wonders whether it is possible to achieve some kind of consensus (Moon, 1993) through the continuous dialogue between different groups. It can be argued that bioethics is a field in which, in part because of the overriding importance of health and health care, consensus is particularly desirable.