Table Of ContentHealth Policy and Ethics
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Health Policy
and Ethics
A Critical Examination of Values
from a Global Perspective
ROGER WORTHINGTON PhD
Assistant (Adjunct) Professor of Medicine,
Department of General Internal Medicine, Yale University
Honorary Associate Professor, Medical Ethics and Law,
Faculty of Health Sciences and Medicine, Bond University (Australia)
Lecturer and Law and Ethics Lead,
School of Medicine, Keele University (UK)
and
ROBERT ROHRBAUGH MD
Professor of Psychiatry
Deputy Chair for Education and Career Development,
Department of Psychiatry
Director, Offi ce of International Medical Student Education
Yale University
Radcliffe Publishing
London (cid:129) New York
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Radcliffe Publishing Ltd
33-41 Dallington Street
London EC1V 0BB
United Kingdom
www.radcliffepublishing.com
Electronic catalogue and worldwide online ordering facility
© 2011 Roger Worthington and Robert Rohrbaugh
Roger Worthington and Robert Rohrbaugh have asserted their right under the Copyright,
Designs and Patents Act 1998 to be identifi ed as the authors of this work.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner.
British Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
ISBN-13: 978 184619 310 1
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certifi ed. FSC® (The Forest Stewardship Council®)
is an international network to promote responsible
management of the world’s forests.
Typeset by KnowledgeWorks Global Ltd, Chennai, India
Cover design by Cox Design Ltd, Witney, UK
Printed and bound by TJI Digital, Padstow, Cornwall, UK
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Contents
Foreword vii
About the authors ix
Contributors xi
Part 1
1 Introduction 3
2 Why ethics and health policy 11
3 Health policy and rationing: in search of reason 27
4 Policy success and failure: causes, remedies and methods
of analysis 41
Part 2
5 Ancient origins and modern approaches to health care
delivery in China
a) M edical ethics, policy and health care delivery in
modern China 55
Kwok-Yin Chan
b) Accessing psychiatric treatment in China 63
Carla Marienfeld
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6 Medicine, ethics and professionalism in modern India
a) I ndian philosophy and bioethics 71
Roger Worthington
b) Health care in the Himalayas 76
7 Health and social policy trends in Malaysia 81
Noor Sulastry Yurni Ahmad
8 Pharmaceutical industry, medicine and questions of ethics
a) Industry and the physician-investigator in the USA 89
Jaazzmina Hussain
b) Postgraduate medical education in the USA 98
Caroline Broughton
9 Geneva to Guantanamo and the ethics of interrogation 103
Maya Prabhu
10 Risk and shared decision-making: questions of medical
practice and social policy in the UK 117
Sarah A. Lee
11 Italian policy and the ethics of ECT 127
Anthony Marfeo
Part 3
12 Comparative analysis and future health care decision-making 137
Index 153
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Foreword
The authors of Health Policy and Ethics believe that something fundamental about
the ethical values of a society can be learned by understanding its health policies.
Through the use of several examples from various societies, they demonstrate the
point nicely. We can learn much about our values by examining our healthcare
policies and professional standards. Perhaps even more importantly, however, it
is essential that those who create policy ensure that this thesis is true. That is, it is
essential that our health policies (indeed all of our public policies) refl ect our values
and priorities. This is not a simple matter, and as various options are considered
and various moral arguments are brought to bear in the development of health-care
policy and professional standards, sound ethical analysis is needed. To best accom-
plish this, ethicists must have a seat at the table.
Though much of the terminology is relatively new, medical ethics has been a
subject of consideration and scholarship since antiquity, and has informed medical
practice for as long. The past several decades, however, have seen a great expansion
of scholarship in this fi eld, and it is now considered an essential part of the medi-
cal school curriculum. It is widely accepted within the medical profession that one
cannot and should not practice medicine without grounding in at least the funda-
mentals of medical ethics. And, given the complexity of many of the questions we
physicians now face, it is increasingly accepted among our profession that ethicists
have something valuable to contribute. As we navigate the diffi cult waters of medi-
cal care, their insight and analyses of the diffi cult questions often prove helpful. As
regional, national, and even international health policy continue to play an increas-
ing role in the delivery of health care, it is essential that those crafting the policies
reach the same understanding about the value of ethical analysis.
Healthcare policy has been a major subject of controversy in many places for
many years. In the United States, at the time of this writing, it has been at the very
forefront of our national conversation for years. Complex problems are unlikely to
lend themselves to easy solutions. A thoughtful approach requires input from those
with expertise in economics, medicine, nursing, law, politics, life sciences, research,
history, epidemiology, technology and yes, ethics. In Health Policy and Ethics the
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viii FOREWORD
authors provide an excellent illustration as to how an understanding of ethics can
inform the ongoing development of health policy. They also show the value of a
broad, global perspective. By considering the history and current status of health-
care and medical ethics in cultures from China to Italy, and many others, we reach
a better understanding of things both there and here (wherever ‘here’ happens to
be for the reader).
While physicians are mindful that ethical analysis is often essential with regard
to individual patient decisions, we also recognize that ethically sound decisions on
an individual level can be greatly augmented, or be negated, by policy decisions
made on a regional or national level. The basic premise of Health Policy and Ethics
is that including ethical analysis will lead to more effective and successful policies.
This seems clearly to be so. We need to understand what we truly value before we
can effectively establish priorities. And, as this book nicely illustrates, it often proves
interesting and helpful to consider what others value, and what others have done,
even if we choose a different path.
As the authors have shown, examination of professional standards and policy
can facilitate analysis of ethical issues in healthcare. Conversely, ethical analysis can
and should inform ongoing policy development. Policies should be continually
assessed in light of societal values through ethical analysis, and something akin to
John Rawls’ refl ective equilibrium should continually be sought; when our policies
are found to be inconsistent with our principles, one or the other (or perhaps both)
should be revised. Ethical analysis in this domain is not easy, as things held sacred
will at times confl ict, and of course within a given society there will be variability in
values and priorities between individuals and over time. The anticipated diffi culties
serve to further emphasize that the ongoing ethical analysis should include input
from those with experience and skill at that task. This book successfully demon-
strates that point. In addition, Health Policy and Ethics is a welcome bridge between
these two fi elds, and a very worthwhile read for individuals whose primary interest
lies in either one.
Mark R. Mercurio, M.D., M.A.
Director, Program for Biomedical Ethics
Yale University School of Medicine
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About the authors
Roger P. Worthington, MA, Ph.D.
Roger Worthington is an Assistant (Adjunct) Professor of Medicine at Yale University
(USA), and Honorary Associate Professor of Medical Ethics and Law at Bond
University (Australia) leads on health care law and ethics at Keele University School
of Medicine (UK). He co-runs a student exchange program between Keele and Yale
with Robert Rohrbaugh; he works as an adviser in the public sector and provides
continuing medical education and training programmes for the National Health
Service (NHS) and he is a former consultant at the General Medical Council (UK).
His MA in medical ethics is from Keele, and his doctorate in philosophy is from the
State University of New York at Buffalo.
Robert M. Rohrbaugh, MD
Robert Rohrbaugh is Professor of Psychiatry and Deputy Chair for Education and
Career Development in the Department of Psychiatry at Yale University School of
Medicine. He also directs the Offi ce of International Medical Student Education
where he oversees the global health curriculum, develops international clinical elec-
tives for Yale students and brings international students to Yale for clinical electives.
He consults to the Xiangya School of Medicine in Changsha China on the develop-
ment of post-graduate medical education programs. His medical doctorate is from
Yale University.
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