This afternoon I'm speaking to members of the ethics committee (and interested others) at Tan Tock Seng Hospital in Singapore. The hospital was founded in 1844 by Mr. Tan, a wealthy Chinese businessman, who donated $7,000 to found a hospital for the "diseased of all nations." It's a large hospital, with 460 emergency visits and more than 2,000 specialty clinic visits every day.
I've been asked to speak about "Accountability for Reasonableness," the framework for setting limits that Norman Daniels and I described in our book Setting Limits Fairly. From a combination of conceptual analysis and field work done in the U.S. at not-for-profit organizations like Kaiser Permanente, and in Canada and the UK, we concluded that health care limit-setting required a fair process, which the book explicated. The framework emphasizes the role of relevant reasons, transparency about policies and their rationales, and processes for appeal and revision.
The framework has been found useful in liberal western democracies like Canada, the National Health Service in England, and the Scandinavian countries that have universal coverage under publicly established budgets. Singapore is decidedly "first world" in its remarkable economic achievements since independence (1965) - its per capita GDP in 2011 was approximately the equivalent of US$50,000, and the unemployment rate was 2.1%. From talking with Singaporeans and reading, my impression of the society and its governance is that it is much readier to accept expert authority than the US and liberal western democracies.
The ethics committee has asked me to discuss the case of a middle aged man with severe rheumatoid arthritis, for whom a costly new medication has been recommended. In the US context there would be no question as to whether insurance would cover the medicine if the clinical reasoning behind the recommendation was sound. Any debate about coverage would be expected to be open to public scrutiny. From what I learned from my colleagues in rheumatology, a patient in his condition would expect to have access to the medication in the US, and would certainly expect to be able to challenge a decision not to be given access.
But as a visitor here I'm acutely aware of what a terrible example the US sets as a health system. Our costs are strangling other important societal investments, and because of our out of control costs we've left 50 million to be uninsured. So while I'm proud of the work Norman Daniels and I have done on fairness, I'm agnostic about its relevance for another society with (a) different moral and political traditions and (b) excellent overall health outcomes. I'll be introduced as a visiting expert, but before meeting with a group that provides clinical care and is concerned with ethics, I feel more like a learner than like someone ready to pronounce the truth about setting limits in a society significantly different from my own.
I've been asked to speak about "Accountability for Reasonableness," the framework for setting limits that Norman Daniels and I described in our book Setting Limits Fairly. From a combination of conceptual analysis and field work done in the U.S. at not-for-profit organizations like Kaiser Permanente, and in Canada and the UK, we concluded that health care limit-setting required a fair process, which the book explicated. The framework emphasizes the role of relevant reasons, transparency about policies and their rationales, and processes for appeal and revision.
The framework has been found useful in liberal western democracies like Canada, the National Health Service in England, and the Scandinavian countries that have universal coverage under publicly established budgets. Singapore is decidedly "first world" in its remarkable economic achievements since independence (1965) - its per capita GDP in 2011 was approximately the equivalent of US$50,000, and the unemployment rate was 2.1%. From talking with Singaporeans and reading, my impression of the society and its governance is that it is much readier to accept expert authority than the US and liberal western democracies.
The ethics committee has asked me to discuss the case of a middle aged man with severe rheumatoid arthritis, for whom a costly new medication has been recommended. In the US context there would be no question as to whether insurance would cover the medicine if the clinical reasoning behind the recommendation was sound. Any debate about coverage would be expected to be open to public scrutiny. From what I learned from my colleagues in rheumatology, a patient in his condition would expect to have access to the medication in the US, and would certainly expect to be able to challenge a decision not to be given access.
But as a visitor here I'm acutely aware of what a terrible example the US sets as a health system. Our costs are strangling other important societal investments, and because of our out of control costs we've left 50 million to be uninsured. So while I'm proud of the work Norman Daniels and I have done on fairness, I'm agnostic about its relevance for another society with (a) different moral and political traditions and (b) excellent overall health outcomes. I'll be introduced as a visiting expert, but before meeting with a group that provides clinical care and is concerned with ethics, I feel more like a learner than like someone ready to pronounce the truth about setting limits in a society significantly different from my own.
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