NOTE: To view the article
with Web enhancements, go to:
http://www.medscape.com/viewarticle/564144
Comparing Healthcare Systems: Outcomes, Ethical
Principles, and Social Values
Eike-Henner W. Kluge, PhD
Medscape General Medicine. 2007;9(4):29.
©2007 Medscape
Posted 11/07/2007
Abstract
The question of how healthcare should be structured has been at the
forefront of public debate for quite some time. In particular, debate has
raged over the acceptability of socialized and rights-oriented approaches
to healthcare as opposed to privatized and commodity-oriented approaches.
The present discussion looks at the underlying logic of the debate and at
the use of outcome measures as a primary determinant. It suggests that
outcome measures are of limited use in deciding the issue because they
ignore important variables and further suggests that outcome measures are
inappropriate tools when comparing distinct healthcare systems because
they ignore valuational components that are integral to deciding whether a
healthcare system is consistent with a society's principles and
values.
Key Words: healthcare systems, values, health outcomes, health-
definition
Reader
Comments on: Comparing Healthcare Systems: Outcomes, Ethical Principles,
and Social Values
See reader comments on this article and provide
your own.
Readers are encouraged to respond to the author at ekluge@uvic.ca or to
Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's
eyes only or for possible publication as an actual Letter in MedGenMed via
email: pblumen@stanford.edu
Introduction
The question of how healthcare should be structured has been at the
forefront of public debate for quite some time. There are literally
hundreds of commissions, reports, studies, learned papers, and policy
initiatives that deal with the subject in countries all over the world. No
country appears satisfied with the healthcare system it currently has in
place, yet all seem to believe that proper health is integral to the
maximization of individual human potential and that finding the right way
to deliver healthcare is the key to ensuring individual and social
well-being. Healthy people are productive people, and productive people
make for a happy, harmonious, and successful society. The search for the
right model of healthcare, therefore, has become something like the modern
equivalent of the search for the philosopher's stone -- something that
will transmute ailing healthcare systems into perfect vehicles for
producing healthy persons.
As we all know, the search for the philosopher's stone was the search
for an illusion. There is nothing that will magically transform base
materials into gold -- and there is no social service that will ensure a
happy, harmonious, and successful society. Healthcare is no exception.
Healthy people have the potential for happiness, harmony, and
success, and to that degree, access to healthcare lays the foundations for
a happy, harmonious, and successful society, but whether that potential is
realized still depends on the people themselves. It also depends on
whether the structures that are in place are consistent with the resources
that are at society's disposal. And above all, it depends on the values
and principles that are integral to the moral fabric of that
society.
Health System, Ethical Principles, and Social Values
A society that values autonomy and equality and that considers the
ethical principles that are integral to the "Universal Declaration of
Human Rights"[1] as fundamental to its moral framework will
design its healthcare system differently from a society that considers
utility and efficiency as primary values and whose ethical perspective is
driven by the principle of the greatest good for the greatest number. Both
of these, in turn, will take a different approach to healthcare from a
society that believes that what is right or wrong has nothing to do with
individual rights or the greatest good for the greatest number but instead
is relative to each individual and depends on her or his personal
principles and values -- in a word, a society that has an egoistic ethical
orientation.
The first kind of society will structure its healthcare around the
notion that there is a social duty to level the playing field in terms of
access and use of health services and that each person has the right to a
basic level of healthcare but that this right is limited by the equal and
competing rights of others. By contrast, the second kind of society will
reject the notion of a basic individual right to healthcare. Instead, it
will structure its system of healthcare solely with an eye to maximizing
the health status of society as a whole, and the balancing of individual
access rights will not even enter the picture. Finally, the third kind of
society will reject both the notion of a basic right to healthcare and the
ideal of maximizing the health status of society as a whole. Instead, it
will structure its healthcare on a free-enterprise model and treat
healthcare as a commodity. The delivery of healthcare will be designed on
a competition approach, and the determinants will be neither individual
nor collective rights but the ability of the members of that society to
assert their individual claims.
In other words, there is no right model of healthcare. There is only a
right model for a particular society's ethical
orientation.
Funding Schemes, Outcome Measures, Principles, and Values
The relevance of these considerations to the debate on how healthcare
should be structured cannot be overestimated. It means that any attempt to
assess the appropriateness of a given healthcare system simply by looking
at whether healthcare is provided by the private or the public sector, or
to evaluate its success by looking at outcome measures, is wrongheaded
because it uses the wrong tools to measure the wrong things. It confuses
principles with process, ideals with commitment, and perfection with
reality.[2]
Let us assume that there is a society that values people as persons and
believes that every member of society has the same rights as every other
person and deserves the same treatment and respect. In other words, let us
assume the first kind of society, a society that accepts the "Universal
Declaration of Human Rights" and therefore believes in the principle of
the inherent dignity and equality of all persons. Laws aside, health is
the greatest single determinant of whether someone can compete on an equal
footing with everyone else for the opportunities that exist within that
society.[3] The society's acceptance of these fundamental
principles therefore entails a duty to guarantee its members equitable
access to health services to minimize health-based differences.
Ideals, Principles, and Funding
However, the fact that the society is committed to providing healthcare
as a matter of social obligation does not mean that it must provide this
healthcare in a specific way. If the society can somehow guarantee that
all of its members have sufficient access to healthcare to minimize
health-based differences and that all members are therefore able to
compete equitably for the opportunities that exist within that society,
then it does not matter whether healthcare is delivered in a public,
private, or a mixed public-private setting. The key is equal opportunity
of access. How this is achieved is logically irrelevant.
For example, suppose that rather than turning healthcare into a state
institution, the society decided to dissociate itself entirely from the
actual delivery of healthcare and leave it to the private sector. At first
glance, this might suggest that the society was merely paying lip-service
to equality, dignity, and justice because not everyone has the same
resources; therefore, not everyone would be able to purchase the
healthcare that would allow each individual to compete on an equal
footing.
However, suppose that the society also decided to give each of its
members a guaranteed basic income that was sufficient to cover the cost of
accessing any healthcare that was necessary, thereby removing
health-related differences. To illustrate the point further, let us make
this case a bit extreme. Let us also suppose that the society attached no
strings to how the guaranteed income could be spent because it believed
that all persons, as autonomous beings, have the right to
self-determination and should be able to decide how they will spend the
resources they have at their disposal. With this approach, it could very
well happen that some people would decide not to spend their guaranteed
income on healthcare but instead would choose to use the money to live in
more comfortable surroundings or to access consumer goods and services
that they might otherwise not be able to enjoy.
This would of course mean that health-related differences would still
exist, which in turn, would mean that as a matter of actual fact the
playing field would not be level. Nevertheless, the society would not have
failed in its ethical duty to level the playing field because, by
providing each person with sufficient resources to purchase appropriate
healthcare if they so wished, it would have honored its basic principles
and values. The mechanism that it had put in place would have a leveling
effect if it were used properly. The fact that some people might decide to
act foolishly and not use the resources properly would say something about
those persons, not about the society.
The point is not that this would be a particularly good way for society
to honor its commitment to level the healthcare playing field and treat
healthcare as a right. Clearly, structuring health as a publicly funded
service available to everyone on an equal footing but on a per-need and
per-use basis would prevent the potential misuse of funds that would be
possible with the approach just discussed. Providing healthcare directly
as a government service would also avoid the problem. Rather, the point is
that treating healthcare as a right and being committed to leveling the
playing field does not entail removal of healthcare delivery from the
private sector. In fact, one can think of still other scenarios. For
example, one could keep healthcare delivery in private hands but place use
conditions on individual publicly funded healthcare accounts. So to
reiterate, the point of the example is merely that whether a society's
approach to healthcare access is consistent with its principles and values
is logically independent of the question whether healthcare should be
delivered by the private or the public sector.
One could also make the point by considering the third kind of society
mentioned at the beginning of this article: the kind that believes there
are no fundamental human rights and what is right or wrong has nothing to
do with the greatest good for the greatest number but instead is relative
to each individual and depends on her or his personal principles and
values. Again, at first glance, it might seem that this ethical
perspective locks the society into a particular mode of healthcare
delivery; , specifically, that the society would be logically committed to
staying out of the healthcare field itself and leaving it entirely to the
private sector, which would supply health services on a commodity
basis.
However, again, this is not necessarily the case. The society could,
without contradicting its basic values and principles, treat healthcare as
a source of revenue and make it a government service on the model of a
government-owned corporation such as Singapore Airlines, the Saudi Arabian
Oil Company, or the United States Postal Service. With this approach,
access to healthcare would still be determined by the ability to pay, the
market place would still rule, and healthcare would still be a matter of
individual responsibility, not a matter of right. However, the delivery of
healthcare would become a socially controlled function and healthcare
itself would not be in private hands.
Of course one might well ask whether a government-owned corporation
would be successful in an economic sense. However, in this connection it
might be useful to reflect on 4 considerations. First, government-owned
corporations such as Singapore Airlines have shown that they can compete
extremely well in the business arena if they are run using an appropriate
business model. Second, there are many countries in which healthcare is
delivered by publicly owned corporate entities. Canada, where these
corporations are usually referred to as health authorities or districts,
and the United Kingdom, where they are usually referred to as health
trusts, here provide good examples. Third, these government-owned health
corporations have shown that they can compete extremely well with the
private business sector. Thus, on average, they are up to 12% more
efficient administratively than private healthcare corporations in the
United States.[4,5] Finally, that government-owned health
corporations are currently not being run with the intent of generating
revenue does not mean that it could not be done. It merely means that, for
political reasons, governments have not decided to do so.
Resources, People, and Outcome Measures
Just as there is no logically necessary connection between the
fundamental ethical principles and values of a society on the one hand and
the mechanism that it chooses for delivery of its healthcare on the other,
there also is no logically necessary connection between the
appropriateness of a particular healthcare system and the outcomes that
are provided by that system. To put it more concretely, it does not follow
that a society that believes in a right to healthcare has failed in its
social obligations and that it has chosen the wrong kind of healthcare
system just because overall health status, life -expectancy, morbidity,
and other health measures of its citizens -- including their
satisfaction-ratings -- fall below a certain level ( and in that sense the
system is less than ideal).
The reason is simple. There is a fundamental logical disconnect between
the fit of a society's principles/values and the system it puts into place
to operationalize these principles on the one hand and the successful
operation of the system on the other. There are all sorts of factors that
are entirely independent of the nature of a particular healthcare system
but that nevertheless determine whether an otherwise appropriate system
functions optimally and produces ideal outcomes. Two factors that
immediately come to mind are resource limitation and the attitudes of
healthcare professionals and patients. (I hesitate to use the currently
popular phrase 'healthcare consumer' because it already prejudges the
issue whether healthcare is a right or a commodity.)
Resource size will critically affect whether a particular service can
be successfully put into place and operated.[6] This is true in
all sorts of endeavors, not only healthcare. For example, both
manufacturing and marketing require a certain level of investment to
develop and produce a quality product that will be successful in the
marketplace. Healthcare is no exception. Healthcare also requires a
certain threshold level of funding before it can be effective and achieve
its intended outcome. Public health measures and preventive health
measures are particularly well-known examples in this regard. Public
health measures such as sanitation and preventive health measures like
immunization will be ineffective unless they are funded sufficiently to
serve, if not everyone, then at least the majority of the population. To
fund it below a certain threshold level is to set the stage for an
epidemiologic disaster. In fact, this holds true even in the acute care
sector.[7-9] Thus, one of the best indicators of successful
pediatric cardiac interventions is not only the qualifications of the
cardiologists and their support staff but also the size of the support
staff and how frequently the cardiac team performs the relevant
procedures[10] -- all of which are functionally related to the
level of funding.
Therefore, the fact that a healthcare system does not achieve optimal
outcomes because the allocated resources are insufficient to allow its
various services to be successfully implemented does not in itself mean
that the healthcare system is inappropriate and should be replaced. That
would be like saying that if immunization efforts are not funded
sufficiently to achieve global immunity, then public health measures
should be abandoned entirely and immunization should be left to the
financial capabilities of the individual citizen. Instead, one should
reconsider the level of funding, and that of course, raises the question
of whether society really believes in public health measures or merely
pays lip service to an ideal. "By their fruits ye shall know them!"
(Matthew 7:20) In other words, outcome measures are meaningful only once
it has been determined that society has allocated sufficient resources to
implement the services it has instituted.
Of course no society has unlimited resources, and diverse demands are
made on these limited resources, each with its own legitimate
considerations. Genuine resource limitations impose constraints that no
social structure can overcome and that no person can transcend. Moreover,
one cannot be obligated to do the impossible. Therefore the demands of
competing social endeavors must be balanced. Even for a society that
believes in an individual right to healthcare, healthcare is only one of
several socially mandated endeavors, and it may be that the funding that
can be allocated to healthcare is insufficient to produce the desideratum
of a completely healthy society. In fact, that will probably always be the
case.
However, this does not mean that if the outcomes are less than optimal
the society should change its approach to healthcare, that is, that it
should abandon its belief that healthcare is an obligation and switch to
the view that it is an individual and private matter. Instead, it means
that society should re-examine the level of resources that it allocates to
healthcare compared with other social services. For instance, does defense
really require the proportion it receives? If not, does a re-apportionment
bring healthcare funding to the level of threshold effectiveness? At a
more particular level, is the distribution of funding within the system
itself appropriate? Is the acute care sector receiving more than its fair
share, with diminishing returns? As McKeown and Lowe[11,12]
showed years ago, if one is interested in improving longevity, morbidity,
and life expectancy, then the thing to do is invest resources in
nutrition, public housing, sanitation, and diverse other public health
measures, not in acute care medicine.
The society might also wish to develop an equitable mechanism for
balancing the competing right claims of individual healthcare users. As
the Oregon experiment recognized,[13,14] and as has been made
very clear in the relevant ethical literature with respect to
smoking-generated needs, some preventable health conditions are linked to
immoderate or imprudent lifestyle.[15,16] In other words, not
all healthcare claims have equal merit. Moreover, allowing the system to
be used in hopeless cases (eg, treating inoperable metastatic cancer
acutely instead of palliatively) also exacerbates resource limitations and
guarantees that threshold-sensitive interventions that might produce
better outcomes if they were better funded will have low outcome
quotients. Therefore the effects of resource limitation may be exacerbated
because there is no mechanism to evaluate the appropriateness of certain
procedures or to evaluate the moral legitimacy of healthcare claims for
self-induced conditions. That such mechanisms are not generally in place
or that they might be resisted by members of the public does not mean that
they are unworkable or unethical.
The Notion of a Positive Outcome
One might also want to ask what constitutes a positive outcome and,
perhaps more importantly, whether it is always reasonable to expect a
positive outcome. For example, suppose that a society that believes in a
right to healthcare has a high incidence and prevalence of infectious
diseases and an average life expectancy of approximately 37 years. It is
tempting to suggest that the society should restructure its healthcare
system from a rights-oriented approach to an individual commodity-oriented
approach. Not only, it is alleged, would that make the healthcare system
more efficient because it would then be run on a business model, but it
would also result in better outcomes because everyone would have to assume
ownership of healthcare issues on an individual basis, which in turn would
result in better aggregate performance outcomes.
However, that is not necessarily the correct response. The claim about
greater efficiency is highly dubious,[4,5] and there are no
studies that show that primary payers take greater ownership in their
health. In addition, the reason for the low life expectancy and high
morbidity in this society is a high prevalence and incidence of
antibiotic-resistant tuberculosis and opportunistic infections associated
with HIV/AIDS. Moreover, this is a very patriarchal society whose belief
system demands open-faced communication between persons as a matter of
respect, and where unprotected intercourse (and intercourse with multiple
partners) is part of the patriarchal value structure. The high incidence
and prevalence of antibiotic-resistant tuberculosis and other
opportunistic infections (and therefore of high morbidity and low life
expectancy) is therefore not something that can be attributed to the
society having a rights-oriented healthcare system or not operating on a
business/commodity model. It is a function of the values and the overall
belief system of that society. Nothing short of changing the values and
the belief system will produce better health outcomes no matter what
ethical orientation is adopted or what healthcare system is put in
place.
In other words, the same outcomes would exist even if the society had
privately structured healthcare or defined the right to healthcare in
terms of overall utility. Therefore to automatically characterize a
less-than-ideal health outcome in terms of overall health status,
longevity, or even user satisfaction as a failure of the rights-oriented
healthcare system is logically unwarranted. Instead, what has to be
determined is whether, within the valuational (and resource) constraints
that exist, the system is functioning as well as can be expected. In more
general terms, outcome measures are appropriate only when they measure
outcomes relative to existing constraints, and these constraints may
include principles and values that lie entirely outside the realm of
healthcare.
Moreover, it is quite unclear, rationally speaking, whether outcome
measures such as morbidity and life expectancy are the right measures to
use. Living to 87 years of age with incurable and irremediable
schizophrenia or living to 45 years of age with cystic fibrosis may
improve the statistics for a given healthcare system, and reducing the
infant mortality rates from incurable and irremediable inborn errors of
metabolism will certainly count as an improvement in outcomes; however, it
is questionable whether this is really desirable. Prolonged suffering may
look good from the perspective of longevity, but it palls under the
perspective of humanity.
In other words, an increased rating for a particular type of
intervention may be a positive outcome in numeric terms but may not in
fact be a positive outcome in any other sense. Quality of life is
important and has to be factored into any meaningful evaluation.
Unfortunately, there is no single quality-of-life measure that is
validated and appropriate for healthcare outcomes in general. This means
that there is no way to evaluate the success or failure of healthcare
systems as systems, which in turn means that, in the absence of any
consistent and valid tool for rating healthcare systems, comparisons
between types of approaches is inherently meaningless.
The immediate response to this, of course, is that there are
quality-focused tools for measuring outcomes. For example, measures such
as the Health-Related Quality of Life (HRQOL) developed by the Centers for
Disease Control (CDC),[17] when combined with life-expectancy
and other measures, provides clear and unbiased information. Not only does
it allow the identification of "health disparities" within a given
healthcare system, but it also allows a comparison across
systems.[17] Therefore outcomes can be used to assess
healthcare systems after all.
However, this is more illusion than reality. No matter how quality of
life is measured, and no matter whether the relevant measure includes only
objective components or subjective parameters as well, what is measured is
the quality relative to the embedding of the individuals whose quality of
life is being measured. That means that if a population has conditions for
which there is no treatment or for which the treatment has reduced
effectiveness, then the quality of life of the affected population will be
reduced.[2]
Moreover, whether a particular treatment is available or effective
depends not merely on the condition itself but also on research and
development. Unfortunately, research for and development of treatment
modalities -- particularly those that involve the use of pharmaceuticals
-- is not determined by an individual healthcare system but by industry.
This means that if there is insufficient profit in developing a particular
treatment, then either there will be no treatment at all or treatment will
be insufficiently developed -- the Orphan Drug Act[18]
notwithstanding. Therefore, basing an assessment of a healthcare system on
any measure that involves quality-of-life considerations will incorporate
a hidden but profound bias, and rejecting a particular approach to
healthcare because quality-of-life measures are not sufficiently high may
be to reject the approach for the wrong reason.
People as Confounding Variables
Moreover, the ethos of the people who are involved in implementing an
enterprise is crucial to whether the enterprise will succeed and achieve
the desired outcome.[19] That is why corporations engage in
team building, why they encourage their employees to develop an esprit
de corps, and why they try to motivate their employees to adopt and
share the values of the corporation itself. As the expression has it,
throwing sand into the gears can bring an engine to a halt. However, that
does not mean that there is something wrong with the engine itself.
Research has also shown that managerial attitudes have a profound effect
on work outcomes[20] and can affect staff turnover, which
itself contributes significantly to less-than-optimal
outcomes.[21-25] Therefore, unless the human variables are
controlled for, outcomes will provide a very insecure basis for evaluating
the appropriateness and effectiveness of a given approach to healthcare.
Currently there are no tools that evaluate outcomes and include these
considerations. Therefore to use outcome measures to judge the
appropriateness or acceptability of a particular approach to healthcare,
or for accepting or rejecting a particular way of implementing a
particular healthcare philosophy, is to make a decision using inadequate
tools.
Finally, there is this to consider. A totalitarian regime may set up
health services that are entirely successful in achieving the desirable
outcome of a healthy population. However, it does so by strictly
regulating the interaction of its citizens with healthcare providers, by
instituting and enforcing medical surveillance standards and behavior
patterns that regiment the daily lives of its citizens, and by enforcing
healthy habits and lifestyles that leave no choice to its individual
members. Such an approach to healthcare could certainly boast excellent
outcome measures in terms of average health status, life expectancy,
morbidity, quality-adjusted life years (QALYs), disability-adjusted life
years (DALYs), HRQOLs, and any other health-related quality-of-life
measures that one might care to name. For all that, however, such a
healthcare system would not be in keeping with the principles of respect
and equality that underlie the Universal Declaration of Human
Rights.
The Definition of Health
There is a further flaw that besets current comparison between
healthcare systems, and indeed the evaluation of any healthcare system on
its own. It has to do with the definition of health. To appreciate the
depth of the problem and its insidious nature, it is perhaps best to begin
in general terms.
No matter what the structure of a particular healthcare system, the
reason for the system is to provide healthcare and to advance the health
of its target population. One might therefore naively suppose that when it
comes to evaluating a particular healthcare system or when comparing the
effectiveness of one healthcare system with another, the common measure is
the health status of the relevant populations.
The problem is that there is no consistent and usable definition of
health.[26-29] As has been pointed out, the World Health
Organization (WHO) definition of health as "a state of complete physical,
mental and social well-being" is hopelessly flawed, even though the
definition was accepted by the CDC and other organizations.[2,
30-34] Although various other definitions have been attempted, none
has received general acceptance. In real terms, this means that all of the
measures that have been developed for evaluating individual healthcare
systems or for comparing one healthcare system to another measure
something that is in fact undefined or that is defined in such general and
ambiguous terms that the resultant quotients are effectively meaningless.
This is not to say that there are no specific measures for evaluating the
effectiveness of a particular treatment modality within a given context or
for comparing the resources that are being spent to bring about certain
specific outcomes within distinct healthcare systems. However, it does
mean that it is currently impossible to evaluate the success of a given
healthcare system as healthcare system. It also means that the
claim that a particular approach to delivering healthcare is better or
more effective than another approach is mere "puffery" because what would
turn such a claim into a meaningful assertion, namely a consistent and
usable definition of health, is missing.
Conclusion
The debate over the correct model of healthcare delivery has been at
the forefront of public and professional debate for quite some time.
Comparisons are drawn with respect to cost, public satisfaction,
professional satisfaction, and outcomes to mention but a few of the
variables that have figured in the debate. In one sense, however, the
debate has been curiously unscientific. It has ignored the fact that
measures are relevant only when they are standardized and validated, when
they measure the same things, and when the variables that affect what is
being measured are controlled in a rigorous fashion. Above all, however,
comparison measures are meaningful if and only if they measure the right
things and when what is being measured is clearly and consistently
defined. The current debate fails on all of these counts. It also ignores
the more central issue: does the healthcare system honor the fundamental
principles and values of the society itself? As Croesus found to his
regret, a philosopher's stone that turns base materials into gold can kill
you. A healthcare system that is effective in producing a materially ideal
outcome but violates its basic principles will spell the death of that
society as a moral community.
What does all of this mean? Two things. First, it may be appropriate to
view with extreme caution any claim that a particular approach to
healthcare is better than another. Second, it may be appropriate to
restructure the entire debate over which approach to healthcare is ideal
by paying more attention to a society's fundamental principles and values.
If a society's approach to healthcare is consistent with its principles
and values, then the issue is not whether that system should be replaced
but how to make it more efficient or more effective -- which has nothing
to do with the healthcare system itself but has to do with its
implementation. (And here the preceding comment will once again be
germane.) Of course it is an entirely different matter whether the
society's principles and values themselves are ethically defensible; that
is a subject for another debate.
References
- United Nations General Assembly. Universal Declaration of
Human Rights. Available at: http://www.un.org/Overview/rights.html
Accessed October 23, 2007.
- Reidpath DD, Allotey P, Kouame A, Cummins RA. Social cultural
and environmental contexts and the measurement of burden of
disease: an exploratory study in the developed and developing
world. Melbourne, Australia: Key Centre for Women's Health in
Society, University of Melbourne; 2001.
- President's Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research. Securing Access
to Health Care. 3 vols. Washington, DC: US Government Printing
Office; 1983.
- Woolhandler S, Campbell T, Himmelstein DU. Costs of health
care administration in the United States and Canada. N Engl J Med.
2003;349:768-775. Abstract
- Woolhandler S, Campbell T, Himmelstein DU. Health care
administration in the United States and Canada: micromanagement,
macro costs. Int J Health Serv. 2004;34:65-78. Abstract
- Evans DB, Tandon A, Murray CJL, Lauer JA. Comparative
efficiency of national health systems: cross national econometric
analysis. BMJ. 2001;323:307-310. Abstract
- Park JS, Kang SB, Kim SW, Cheon GN. Economics and the
laparoscopic surgery lLearning curve: comparison with open surgery
for rectosigmoid cancer. World J Surg. 2007;31:1827-1834. Abstract
- Forbes TL, Chu MW, Lawlor DK, DeRose G, Harris KA. Learning
curve analysis of thoracic endovascular aortic repair in relation
to credentialing guidelines [published online ahead of print June
27, 2007]. J Vasc Surg. 2007;46:218-222. Abstract
- Tseng JF, Pisters PW, Lee JE, et al. The learning curve in
pancreatic surgery. Surgery. 2007;141:694-701. Abstract
- Report of the Manitoba Pediatric Cardiac Surgery Inquest: An
inquiry into twelve deaths at the Winnipeg Health Sciences Centre
in 1994. Available at
http://www.pediatriccardiacinquest.mb.ca/pdf/pcir_chapter10.pdf
Accessed October 24, 2007.
- McKeown T, Lowe CR. An Introduction to Social Medicine.
Oxford, UK: Blackwell Scientific; 1974.
- McKeown T. The Role of Medicine Dream, Mirage of Nemesis.
Oxford, UK: Blackwell; 1979.
- Nelson RM, Drought T. Justice and the moral acceptability of
rationing medical care: the Oregon experiment. J Med Philos.
1992;17:97-117. Abstract
- Crawshaw R, Garland MJ, Hines B, Lobitz C. Oregon health
decisions. An experiment with informed community consent. JAMA.
198513;254:3213-3216.
- Veatch, RM. Voluntary risk to health: the ethical issues.
JAMA. 1980;243:50-55. Abstract
- Moss AH, Siegler M. Should alcoholics compete equally for
liver transplantation? JAMA. 1991;265:1295-1298.
- Centers for Disease Control. Origins and use of CDC HRQOL
measures and data. Available at
http://www.cdc.gov/hrqol/methods.htm#origins and
http://www.cdc.gov/hrqol/index.htm Accessed October 24, 2007.
- US Food and Drug Administration. The Orphan Drug Act, 1983 (as
amended). Available at http://www.fda.gov/orphan/oda.htm Accessed
October 24, 2007.
- Hollingsworth B. Productivity changes in the NHS internal
market [Rapid Response]. BMJ. Available at
http://www.bmj.com/cgi/eletters/315/7116/1126 Published September
2, 1999. Accessed October 24, 2007.
- Carmeli A. The relationship between emotional intelligence and
work attitudes, behavior and outcomes: an examination among senior
managers. J Managerial Psychol. 2003;18: 788-813.
- Jayaratne S, Chess WA. Job satisfaction, burnout, and
turnover: a national study. Social Work. 1984;29:448-453. Abstract
- Gray A, Phillips V, Normand C. The costs of turnover: evidence
from the British National Health Service. Health Policy.
1996;38:117-128. Abstract
- Howard B, Gould KE. Strategic planning for employee happiness:
a business goal for human service organizations. Am J Ment Retard.
2000;105:377-386. Abstract
- Knudsen HK, Johnson JA, Roman PM. Retaining counseling staff
at substance abuse treatment centers: effects of management
practices. J Subst Abuse Treatment. 2003;24:129-135.
- Aarons GA, Sawitzky AC. Organizational climate partially
mediates the effect of culture on work attitudes and staff
turnover in mental health services. Adm Policy Ment Health.
2006;33:289-301. Abstract
- Callahan D. The WHO definition of health. Stud Hastings Cent.
1973; 1: 77-87 Abstract
- DeVito S. On the value-neutrality of the concepts of health
and disease. J Med Philos. 2000,25: 539-567.
- Nordenfeld L. On the Nature of Health: An Action-Theoretic
Approach. Dordrecht, Holland: Reidel; 1987.
- Whitbeck C. A theory of health. In Caplan AL, Engelhardt HT
Jr, McCartney JJ, eds. Concepts of Health and Disease:
Interdisciplinary Perspectives. Reading, Mass: Addison-Wesley;
1981:611-626.
- Kass LR. Regarding the end of medicine and the pursuit of
health. The Public Interest 1975;40:11-42.
- Garcia D. What kind of values? A istorical perspective on the
ends of medicine. In: Hanson MJ, Callahan D, Kaebnick GE, eds. The
Goals of Medicine: The Forgotten Issue in Health Care Reform.
Washington DC: Georgetown University Press; 2001.
- Daniels N. Just Health Care. Cambridge, UK: Cambridge
University Press; 1985.
- Richardson J, Robertson I, Wildman J. A Ccritique of the World
Health Organisation's evaluation of health system performance.
Monash Centre for Health Program Evaluation, working paper 125.
Available at
http://www.buseco.monash.edu.au/centres/che/pubs/wp125.pdf
Accessed October 24, 2007.
- Bok S. Rethinking the WHO Definition of Health. Harvard Center
for Population and Development Studies, Working Paper Series.
2004;14(7). Available at
http://www.globalhealth.harvard.edu/hcpds/wpweb/Bok_wp1407_3.pdf
Accessed October 24, 2007.
Eike-Henner W. Kluge, PhDDepartment of
Philosophy, University of Victoria, Victoria, British Columbia,
Canada
Email:
ekluge@uvic.ca
Disclosure: Eike-Henner W. Kluge, PhD, has disclosed no
relevant financial relationships.