Reason Papers The Moral Foundations of Health Services Reform

I write this criticism of H. Tristram Engelhardt's The Foundations of Bioethics ' not fiom the perspective of a philosopher, but fiom that of a physician with a long-time interest in health policy issues as they relate to bioethics. I hold Engelhardt in high regard: among philosophers currently active in bioethics, he is one of the few who are deeply committed to freedom as the primary requirement of social life, and to liberty as its primary political manifestation. In this commentary, I will focus on his view of health services r e f ~ r m. ~ Few would disagree that our health services system is troubled. High costs and their uncontrolled escalation in recent decades are undoubtedly the driving force behind reform of the system. But a variety of other problems, like unequal access and uneven quality of care, have often been a central concern in the design of reform measures. Profound differences in visions of an ideal health services system were highlighted in the intense national debate over health care reform early in the first Clinton administration. The failed attempt to produce a consensus justification on ethical grounds for the American Health Security Act has made it clear that a monolithic, bureaucratic health services system of the sort designed by the Clintons will not come about soon. The differing moral vision