Benchmarks of Fairness for Health Care Reform By Norman Daniels, Donald W. Light, and Ronald L. Caplan (review)

BOOK REVIEWS Benchmarks ofFairness for Health Care Reform. By Norman Daniels, Donald W. Light, and Ronald L. Caplan. Oxford; Oxford University Press, 1996, vii, 198 pages, $29.95. Benchmarks ofFairnessfor Health Care Reform seeks to "put fairness on the table as an issue in the national debate about health care reform and the design of our health care system (p. 3)." The authors maintain that the American commitment to fair equality of opportunity creates a commitment to "normal functioning"; that is, to treat disease and dysfunction that would restrict access to life's opportunities. The value of focusing on equality of opportunity and not arguing for a right to health care (which the authors argue is a conclusion from this premise) is to gather greater acceptance of their theory. It is an idea that Professor Daniels has espoused in previous works at greater length. As the authors realize, it is necessary but not sufficient. Unless there is reform in other institutions, particularly education, fair equality of opportunity cannot be achieved. The authors propose ten benchmarks to assess the fairness in health care offered by various health care reform proposals. Some of these benchmarks derive directly from their commitment to fair equality of opportunity; others from a broader account of fairness. The authors even suggest that the benchmarks can be accepted by those who reject their underlying premises as the benchmarks "capture widely shared values in our society (p. 34)." The authors use these ten benchmarks for two related tasks. First, they analyze four health care reform bills from the 103rd Congress—the Michel bill, the Cooper bill, the Clinton bill, and the McDermott/Wellstone bill. The idea was to look at actual legislation rather than hypothetical constructs to test the ten benchmarks. The authors give a short summary of each bill, although if one is unfamiliar with the actual bills, many of the criticisms that the authors offer must be taken on face value. The authors then assign a numeric value to quantify how much each bill promotes or detracts from fairness. Second, the authors modify the benchmarks to analyze six major trends in U.S. health care: cost cutting in government programs, the expansion of managed care, the corporatization of health care, the increasing numbers of uninsured and underinsured, rising out of pocket expenditures, and the move from inpatient to outpatient services. The interdisciplinary development of these benchmarks is laudable. Too often, sociologists, philosophers, and economists fail to share in dialogue despite the fact that all are interested in the same issue. The result is that 1) we fail to develop public policy that serves the needs of the population for whom it is designed; 2)we develop policy that lacks sound theoretical justification and motivation, or 3)we develop policy that is economically or politically infeasible. The irony is that the authors may have produced a book that will frustrate all Perspectives in Biology and Medicine, 41, 4 ¦ Summer 1998 | 605 three audiences. Philosophically, I am frustrated by the authors' decision not to give a theoretical justification for why they chose these ten benchmarks and not others. The theoretical underpinnings of this project are also incomplete. For example , the authors do not explore what "normal functioning" entails. Depending on how this is defined will have wide impact on the degree of health care services that would be required to achieve "normal function" as well as to determine whether medicine or another institution is better adept at addressing the inequalities that derive from it. I am also frustrated by the authors' decision to give each benchmark equal weight, although this is partially corrected by the fact that there are two benchmarks to address some issues such as universal access and equitable financing, but only one benchmark to address other issues such as public accountability and degree of consumer choice. The benchmarks are then subdivided into a varying number of subdivisions , and each subdivision is counted equally. For example, under public accountability , the authorsjudge the value of the four reform proposals on the basis of whether they include 1) explicit and public procedures for evaluating services, 2) explicit democratic procedures for resource allocation, 3) fair grievances procedures , and 4) adequate...