Just Caring: Oregon, Health Care Rationing, and Informed Democratic Deliberation

Abstract

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, but it is mostly hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels.

Local Food Innovation in a World of Wicked Problems: The Pitfalls and the Potential

“…That is, the DTM could be a venue for more deliberative and experiential processes of learning by trying; as various small start-ups and programs initiate new practices with community input in mind and as these programs evolve in order to better meet the needs of the community, more effective and just practices are likely to emerge (Fleck, 2009;Norton, 2005). Programs that utilize cooperative, experiential learning strategies with a diverse range of stakeholders can open space within which participants can together modify current, dominant, unjust systems (PolicyLink, 2014).…”

Deliberative Bürgerbeteiligung in der Priorisierungsdebatte: Welchen Beitrag können Bürger leisten?

“…Auch im US-Bundesstaat Oregon wurden deliberative Methoden angewandt, um Bürger aktiv in die Debatte um Priorisierung und die Erstellung des sogenannten Oregon Health Plan einzubeziehen (vgl. [8,9]). Das National Institute für Health and Clinical Excellence (NICE) in Großbritannien bemüht sich ebenfalls um die Einbindung von Bürgern in dort parallel diskutierte Fragen der Priorisierung und Rationierung.…”

Talking with Patients about Cost Containment

“…2 There are various mechanisms for engaging members of the general public in ethical deliberations about health policy matters such as cost containment and equitable access to care. 8,9 However, in developing sound ethical policies for cost containment, it will be necessary to distinguish carefully between the rationing problem posed by low-benefit, high-cost interventions and the rather different issues raised by interventions that effectively offer no benefit, whatever the cost. 6,7 As the headache-imaging scenario illustrates, it is important to keep these two different problems straight, whether the physician is responding to patients' questions and concerns in the clinical encounter, or whether citizens are meeting to plan sound public policy.…”