Book Review

Back to Reform: Values, markets, and the health care system

N Engl J Med 1996; 335:1540November 14, 1996

Article

Back to Reform: Values, markets, and the health care system
By Charles J. Dougherty. 179 pp. New York, Oxford University Press, 1996. $29.95. ISBN: 0-19-510397-1

Dougherty's stated goal in this book is to “identify key moral values, display their roots and general structures, and apply them to the health care system.” He seeks to critique the vast power of market forces in health care and provide a normative framework for future reform. The seven values he discusses are human dignity, caring, protection of the least well-off, the common good, cost containment, responsibility, and excellence. Dougherty believes that a health care system ordered by these values would be very different from the increasingly market-driven one we now have. It would, for example, guarantee access for all to a basic package of benefits and require the federal government to have a more vigorous role.

Dougherty seems ambivalent about what will count as reform. In the first chapter he asserts that to be worthy of being called “reforms,” changes in the system must demonstrate that they improve health statistics for the nation as a whole, and especially for those with the highest rates of mortality and morbidity. At the end of chapter 4, however, he adopts a more qualitative criterion, saying that reform “may” improve delivery and health status, but “must” ensure that Americans care about and for each other.

Each chapter explicating one of the seven key values discusses the foundations of that value, along with its implications for health policy. For example, the chapter on human dignity discusses its roots in Judeo–Christian tradition and the Enlightenment and then explores its meaning in terms of a right to receive health care, give informed consent, and refuse treatment. In general this approach is successful, although some chapters are stronger than others.

One of the strengths of the book is its succinct summaries of moral concepts, with useful indications of how the concepts play out in health care. Yet the brevity is sometimes a liability, because it can entail a lack of precision. Occasionally, important ethical ideas are mentioned without being systematically discussed. For example, the otherwise excellent chapter on human dignity contains a sweeping critique of autonomy. This broad critique is especially puzzling because Dougherty stresses the subject of provider and patient choice very strongly in the chapter on excellence. He writes from a Christian perspective and identifies some of his key values as rooted in what he calls “the Judeo–Christian tradition.” This phrase, especially, calls for more precise explication. “Judeo–Christian” is a contested term, with colonizing overtones. Perhaps the strongest chapter is the one on cost containment, which describes eight criteria for a morally acceptable policy of rationing.

Finally, one has to admire the hopefulness of this book. To talk seriously about the common good and the welfare of the least well-off is an expression of hope. We clearly need such expressions, if only to remind us of what is being lost in the current fixation on costs, the fetish of reform through market forces, and the crippling political inertia regarding health policy. At stake is not only the health of millions of Americans, but also the values that make America a humane and viable society.

Larry R. Churchill, Ph.D.
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599