What does it mean to be a "just" and "caring" society when we have only limited resources to meet unlimited health care needs? Do we believe that all lives are of equal value? Is human life priceless? Should a "just" and "caring" society refuse to put limits on health care spending?
In Just Caring, Leonard Fleck reflects on the central moral and political challenges of health reform today. He cites the millions of Americans who go without health insurance, thousands of whom die prematurely, unable to afford the health care needed to save their lives. Fleck considers these deaths as contrary to our deepest social values, and makes a case for the necessity of health care rationing decisions. The core argument of this book is that no one has a moral right to impose rationing decisions on others if they are unwilling to impose those same rationing decisions on themselves in the same medical circumstances. Fleck argues we can make health care rationing fair, in ways that are mutually respectful, if we engage in honest rational democratic deliberation. Such civic engagement is rare in our society, but the alternative is endless destructive social controversy that is neither just nor caring.
1. Just Caring: An Introduction ; 1.1 The Just Caring Problem: Core Argument ; 1.2 Rationing Justly: The Moral Challenge ; 1.3 Applications of the Deliberative Model ; 2. Just Caring: The Ethical Challenges of Health Care Rationing ; 2.1 The Story of Coby Howard and Its Lessons ; 2.2 Why Health Care Rationing is Inescapable ; 2.3 Renal Dialysis and the Medicare End-Stage Renald Disease [ESRD] Amendments ; 2.4 The Totally Implantable Artificial Heart [TIAH] ; 3. Pricing Human Life: Getting Beyond Tragic Choice ; 3.1 Is Human Life Priceless? ; 3.2 Tragic Choices or Tragic Disingenuousness: Invisible Rationing ; 3.3 Invisible Rationing and the Publicity Condition ; 3.4 Managed Care and Health Rationing: ; 4. Elements of Health Care Justice ; 4.1 Is Health Care Morally Special? ; 4.2 Non-Ideal Justice: A Moral Analysis and Defense ; 4.3 Pluralism, Justice, and Rational Democratic Deliberation ; 5. Rational Democratic Deliberation: Scope and Structure ; 5.1 The Scope of Rational Democratic Deliberation ; 5.2 Fair Health Care Rationing: Not Markets, Not Physicians, Not Bureaucrats ; 5.3 Rational Democratic Deliberation: Taking Seriously the Tragedy of the Commons ; 5.4 Rational Democratic Deliberation: Key Structural Features ; 5.5 Rational Democratic Deliberation and Fair Health Care Rationing ; 5.6 Wide Reflective Equilibrium and Just Health Care Rationing ; 5.7 Priority-Setting, Wide Reflective Equilibrium, and Democratic Deliberation ; 5.8 Facts, Wide Reflective Equilibrium, and Democratic Deliberation ; 5.9 Constitutional Principles of Health Care Justice and Rational Democratic Deliberation ; 5.10 Evaluating the Deliberative Process ; 5.11 Objections and Responses ; 6. Just Caring: Setting Limits for Effective Costly Therapies ; 6.1 Problem Introduction ; 6.2 Setting Limits: Options in the ESRD Program ; 6.3 Setting Limits: Options for HIV/AIDS Patients ; 6.4 Setting Limits: The Case of Artificial Hearts ; 6.5 Setting Limits: Concluding Comments ; 7. Just Caring: Last Chance Therapies ; 7.1 Introduction: Scope of the Problem ; 7.2 Why Last Chance Therapies? Weak Moral Arguments ; 7.3 Last Chance Therapies and Rational Democratic Deliberation ; 7.4 Futility and Last Chacne Therapies ; 8. Just Caring: Rationing, Catastrophically Ill Patients, and Patients with Disabilities ; 8.1 Introduction: The Scope of the Problem ; 8.2 Needs Are Not Enough: Effectiveness Must Matter ; 8.3 The Oregon Plan and the Disability Critique ; 8.4 Health Care Justice and the Disability Critique ; 8.5 Defining the Disabled: Ethical Implications ; 8.6 Conclusions ; 9. Is Age-Based Rationing Ever 'Just Enough'? ; 9.1 Defining the Problem: Can We Accept Natural Limits to Life? ; 9.2 Justice and Age-Based Rationing: Fair Innings ; 9.3 The Prudential Life Span Account ; 9.4 Age-Based Rationing: Major Objections ; 9.5 Age-Based Rationing: Responses to Objections ; 9.6 Age-Based Rationing and the Duty to Rescue ; 9.7 Conclusions ; 10. Just Caring: Do Future Possible Children Have a Just Claim to a Sufficiently Healthy Genome? ; 10.1 Introduction ; 10.2 Framing the Issue ; 10.3 Preimplantation Genetic Diagnosis [PGD]: A Historical Side Note ; 10.4 Does Justice Require Public Funding for Limited PGD? ; 10.5 Concluding Comments: Justice and Genetic Enhancement ; 11. Organ Transplantation: When is Enough Enough? ; 11.1 Scope of the Issue ; 11.2 The Maximization Argument: A Critical Moral Analysis ; 11.3 The Pittsburg Protocol: How Dead Must Donors Be? ; 11.4 Organ Procurement and Financial Incentives: A Critical Assessment ; 11.5 Presumed Consent/Duty to Donate: Critical Remarks ; 11.6 Justice and Multi-Organ Transplants or Retransplants ; 11.7 Concluding Comments ; 12. Just Caring: The Liberalism Problem ; 12.1 Justice, Health Care Needs and Morally Controversial Interventions ; 12.2 Liberal Communitarianism: Is It Just Enough? Is It Liberal Enough? ; 12.3 Resolving the Liberalism Problem: Public Reason and Public Interests ; 12.4 Concluding Reflections ; 13. Just Caring: The Ethical Challenges of Priority Setting in Public Health ; 13.1 Defining the Problem ; 13.2 The Scope of Public Health: Challenges and Choices ; 13.3 Health Care Justice and Public Health: When is Enough Enough? ; 13.4 Setting Public Health Priorities Justly: The Limits of Moral Theory ; 14. Just Caring: Financing Health Care Fairly ; 14.1 Why National Health Insurance? ; 14.2 Why Health Reform? ; 14.3 Assessing Competing Proposals for Health Reform ; 14.4 Health Savings Accounts: A Critical Assessment ; 14.5 Health Care Vouchers: A Critical Assessment ; 14.6 Single-Player Reform: A Constructive Proposal
