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1. In the modern world health care is provided to people in order to obtain the better possible quality of life, firstly for individuals, secondly for families and, finally, also for the human life in the society.
This statement means that health care cover not only therapeutic interventions over individual patients, but other actions which can protect everyone us society from being sick, the so-called actions on Public Health; the education for health, the vaccinations, the secreening tests on apparently healthy people as well as the improving of the sanitation of the towns, are the more relevant of these actions in the protection of individuals and families from preventable diseases.

Unfortunatelly individual care of patients in Hospitals and clinics is generally considered as the key action in health care not only by the public opinion in general but also by financing institutions and governments. The preventing medicine, which can contribute, powerfully, to the welfare and to the quality of life of the citizens, is not favoured by politicians or investors and in consequence, is not viewed as a priority by medical doctors. Certainly, a political programme in preventine medicine, even if well organised and well financed, demands many years to produce a consistent change in the epidemiologie figures of preventable diseases, if we exclude the vaccination against certain viral and infections diseases of children. In this way a strict economic balance of cost/benefice don’t recommended the implementation of such political programmes at national level.
In the beginning the National Health Service of the U.K. was created to assist the pregnant women in order to avoid the dangers to the mother and to the children, before and after delivery. After the Second World War the U.K. has recognized the need to protect pregnancy and child birth, as well as child development, to compensate the lost of men and women during the war. This kind of preventive medicine was directed to a national and general good and not to the quality of life of women and families; consequently the costs of the programme were paid from the national budget according to the ethical principle of solidarity.

2. Quality of life is a personnal feeling not a factual situation which the doctor can evaluate in an objective way. When anyone decides to see a doctor he or she feels some personal symptons, as we doctors call it, but the consultation is essentially a narrative of a bad quality of life, Doctor, I cannot support this headache, says the person, and I’m seeking for your help. In fact, the wellfare is a very important component of the quality of life; anyone can feel, subjectively, a very bad quality of life beeing not sick, surely, but with an overt disease is very dificult to have a good quality of life.

The dilemma between provision of health care and restoration of a good quality of life with medical care measures, of good quality themselves of course, is on the costs of medical interventions, is an economic dilemma, is the dilemma of economy versus quality of life. As the quality of life is linked with the quality of health care medical interventions, the costs of medical activities are of a paramount importance. The modern high technology, currently used in diagnostic and therapeutic procedures, is progressively more expensive, the intensive care units are very expensive, the treatment of cancer patients is progressively more expensive as well as AIDS and chronic diseases of the elderly treatments.
If the patient can pay, out of pocket, the bill of the health care services the quality of life and its cost is a personal decision and a personal free choice.

However, when the expenses of health care are paid by a social system, based on solidarity of a group of persons or of the entire tributable population of a nation, like the National Health Services in U.K. and others countries, the decision of the dilemma is not only financial or economic, but also ethic. Here the key notion is justice as equity and fairness. The benchmarks of fairness of Norman Daniels will be presented and fully discussed in order to delineate the main lines of a just health care system.

3. Benchmarks of fairness for health care.
Norman Daniels, discussing the meaning of fairness in the health care field, stresses that fairness cannot be confused with fair deals. There is an inclination to think that the process of political “dealing” of arriving at compromises reflecting the competing interests of the big players in the health care field, is a way of arriving at a fair outcome that is, one to which all the big players can agree. But fairness is not whatever emerges from the deals. There are deeper issues of fairness, reflected in notions like a “right to health care” or meeting the range of health care needs people have, and these concerns about fairness should act as constraints on the acceptable outcomes of making political deals. Confusion of “fair deals” with fairness reflects our cynicism: politics is not ethics; it is power. Politics may displace ethics, but it cannot replace it. It is crucial when addressing fundamental issues of the structure of our society that we insist that justice regulates politics.” End of citation of Daniels.

This is the philosophical position with which I agree and is the foundation for my discussion of relationship between economy and quality of life. If quality of life is affected by disease and if our society has decided to offer the best quality of life to all citizens, than the provision of health care of good quality to all citizens is mandatory.
The point is the fairness of this provision and this is an ethical and economic issue.

How to evaluate the fairness of a health care system?
Daniels has proposed, with great success, a methodology of evaluation based on ten points, he called benchmarks.
I will present to you, synthectically, the ten benchmarks of Norman Daniels, which were applied to the evaluation of the fairness of the portuguese health care systems and of the other countries like Mexico and Pakistan.
I consider here the benchmarks not as a tool to achieve a health care reform but as marks of fairness of an ideal health care system in a modern democratic society.
The first one is the Universal access which means that any fair health care system must make a reasonable carray of needed and efective health case services available to everyone, regardless of their health conditions, risks, or ability to pay. Universal access means universal inclusion in an insurance scheme.

The second benchmark refers to the non-financial barriers to the universal access, like shortage of personnel educated and trained, equipment and others facilities, as well as the barrier of language, culture and class backgrounds.
The benchmark three requires equitable access to an appropriate set of health care services, which means that the services must be comprehensive and produce uniform benefits. Here we have room for a discussion of the difference between desired benefits and needed benefits and on the fixation of a basic package of uniform needed services and benefits.
The next benchmark open the great problem of how to achieve a equitable financing by community-rated contributions, because fairness concerns not only the benefits – equitable access to an appropriate set of services as defined in the first three benchmarks – but how we share the burden of meeting that obligation.
Rating money from the community to pay health care services to all citizens poses a tremendous question of fairness and is the central debate of economy versus quality of life.

Many people accept that social fairness and community rating are the right principles but make an exception for self-induced risks. As a citizen I can accept to be obliged to protect the access to medical assistance when people are ill to no fault of their own. But it is different have to bear the burden of deliberate choices others make to engage in risks behaviours.
The most debated topic is the case against smokers and, in a certain way, the case against skiing, tennis or runing, as self-induced risks by free and informed people. The principle of solidarity on the costs of health care services will be applied, many people says, only to the situations of diseases due to natural risks and not to risky lifestyle choices.

However, for the individual person, to smoke or to practise risky sports is considered as an important component of his or her quality of life, in the present, even if, in the future, it cans provoque serious diseases. Consider unfair to pay by solidarity the costs of the treatment of the diseases of a smoker will be a paternalistic restriction of the lifestyle choices made by competent people, and a way of coercing them to behave in ways we think is in their best interest.
In my view the principle of community rating means that society should not address the risks of behaviour, work and environment by reducing access to needed health care, but by dealing with them directly. Restrictions on advertising alcohol or tobacco or taxing them directly are much more fair (and apparently more effective) than discouraging them through the exclusion of the access to health care services when they became sick.

As a consequence the benchmark five says that the community rating must be based on the ability to pay as is the case of taxing proportionally to the income of each cytizen. The progressive taxing for health costs as well as for other social services in a community is ethically correct if we consider basic health care as a personnal and civilisational right and not a commodity.
The counterparts are benchmarks six and seven which deal with value for money. The first related to clinical efficacy the second one with financial efficiency about clinical efficacy. The Cochrane test stresses the well known six points, namely consider in priority any treatment that is effective, reduce or eliminate less effective treatments, intervene at the most cost-effective times and treat at the most cost-effective places.
The financial efficiency to save the most value for money includes minimizing layeres of bureaucracy, installing efficient management systems exercising financial discipline, minimizing cost shifting, bargaining hard for maximum value in contracts, and preventing fraud and abuse.
The benchmark number eight is, for me, the most importan one. It refers to public accountability.

Public accountability about decisions on, for instance, how to allocate funds and how much money to spend on what types of treatments and services, means that the decisions on health are democratic processes, publicy accountable, in order to verify if they are fair.
The benchmark nine recomends a comparability between the health care budget and the budgets of comparable social services like education, job training and job creation. When making the comparision we will consider that health care is a good of special moral importance, because of its impact on opportunities, but not the only important social good.
It is not possible to find a magic number which constitutes a reasonable level of expenditure on health care. This number is situate somewhere between six and ten percent of gross domestic product but the point is not the number but the outcomes obtained in terms of mortality in general, infant mortality and morbidity statistics. The better outcomes at european level are related mainly with the organization of the health care system and with the way of spend the money afforded to the system.

Finally the degree of choice by citizens is the last benchmark of fairness. The evaluation will be refered to four ways of choice: choice of primary-care provider, choice of specialist, choice of alternative health care providers and choice of procedures.
This is the most sensitive benchmark in the topic of autonomy versus quality of life. The right of free choice is a basic element of subjective quality of life in reference to health care, even if you are well aware that the criteria by which most patients judge quality differ from the criteria of clinical effectiveness. Of course people cannot always have their first choices and a fair system cannot simply promise that all choices will be satisfied, because satisfying choices in some cases leads to less value for money and less effective care. Choice is an important device for making the health care system better and is the best way to assure that patient choice works to support concerns about clinical effectiveness and quality, is to provide patients with excellent information about outcomes and performance of practitioners, care system and procedures. The informed consent for medical interventions is a good way of disclosement of the information needed to a free and reasonable choice, appropriate for the wellfare of the patient and economically acceptable.

4. In the debate, economy versus quality of life, I find a tension between personnality rights, social and financial capacities and justice.
Rawls proposed, in 1971, that the good way to discover the fundamental principles of justice is to make us choose principles from behind a “veil of ignorance” that keeps us from knowing what our individual traits are and where we will end up in life. This stipulation forces us to make rules that we would have to live by and find acceptable, regardless of whether we were a medical doctor, a poor farm worker, an unemployed young or the president of a big company. We want provisions and rules that would be fair regardless who we turn out to be.
The provision of equality of opportunity as a requirement of justice is a basic rule in a modern and democratic society.

If we are dealing with a just society, the question of economy versus quality of life is not a question of individual free choices versus social ability to pay those choices but a splendid opportunity to find the criteria of fairness and to decide in conformity with those criteria.
In a just society, the aged population has the right to be medically assisted, wih fairness, in order to achieve the best quality of life.
Bucarest, 26 May 2003

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