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The American Journal of Bioethics, 11(7): 32–45, 2011Copyright c Taylor & Francis Group, LLCISSN: 1526-5161 print / 1536-0075 onlineDOI: 10.1080/15265161.2011.568577 Target Article
Health and Social Justice (Ruger 2009a) developed the “health capability paradigm,” a conception of justice and health in domestic societies. This idea undergirds an alternative framework of social cooperation called “shared health governance” (SHG). SHG puts forth a set of moral responsibilities, motivational aspirations, and institutional arrangements, and apportions roles for implementation in striving for health justice. This article develops further the SHG framework and explains its importance and implications for governing health domestically.
Keywords: health governance, health ethics, social cooperation, self-interest, shared health governance
Health and Social Justice (Ruger 2009a) advances a series of approaches, but in both, narrow self-interest is a chief goals for domestic societies. It envisions societies in which motivation. Some have sought to merge the study of game all people can realize central health capabilities—to avoid theory with that of ethics. These efforts, however, have premature death and escapable morbidity. While no society focused primarily on formalizing social contract theory and can guarantee good health, societies can, if they will, create demonstrating the rationality of acting morally in accord the conditions—effective institutions, social systems, and with particular principles agreed upon through bargaining practices—to support all members as they seek to achieve or negotiation (Gauthier 1986). The underlying premise here is still primarily narrow self-interest. Few applications This article continues this journey by considering who of economic game and social contract theories in health is responsible for various aspects of these social objectives and health care exist and focus on distributing societal and how societies might make this vision a reality. Societies responsibility and benefits for the wider common good differ significantly in the way in which they make decisions and individual good simultaneously. Also, a growing body and take actions regarding health and health care. Some see of research “eschews a narrow conception of rationality” governments as primarily responsible, setting up central- altogether (Levitt and List 2008, 909).
ized national health systems. Others emphasize personal This article takes a broad view of health governance.
responsibility, relying heavily on the free market and indi- To create conditions in which all have the ability to be vidual choice, as in the United States and most developing healthy, the shared health governance (SHG) model sets countries. Scholarly discourse maps these trends, ranging out allocations of responsibility, resources, and sovereignty from collective to individual responsibility, but the focus to national and state governments and institutions, non- has tended to be more general than health care specific.
governmental organizations (NGOs), the private sector, In health care particularly, efforts toward responsibility communities, families, and individuals themselves. In assessment and assignment tend to be ad hoc, judging the this view of health governance, ethical commitments are ethical behavior of individuals and particular institutions fundamental, in conjunction with institutions and policies.
like managed care organizations, for-profit hospitals, or the SHG focuses on the alignment between the common good medical profession (Wikler 2002; Buchanan 2009). This nar- and self-interest: It seeks societal conditions to achieve row approach diverts attention from the harder problem, common and individual goods concurrently.
mapping the interdependent and shifting roles of different Shared health governance is a more normatively appeal- actors in fostering health at both individual and societal ing and effective approach to governing health domestically levels. Individual and population health require shared re- as compared to existing alternatives. It asserts that as a so- sponsibility, individual and collective. Social cooperation is ciety we’re all responsible for doing our fair share to seek health justice. Because health production at the individual Economic cooperation theory offers both noncoop- and population levels demands resources and public envi- erative game theory and more cooperative game theory ronments that are beyond any one individual’s or group’s The author thanks the Patrick and Catherine Weldon Donaghue Medical Research Foundation, the Greenwall Foundation and the Yale Center for Faith and Culture, and the McDonald Agape Foundation for financial support, and Jarrad Aguirre, Christina Lazar, Nora Ng,and Betsy Rogers for research and editing assistance. Thanks also go to participants at the Greenwall Faculty Scholars bi-annual meeting,the American Society for Bioethics and Humanities (ASBH) Annual Conference, the Workshop on Desire and The Common Good atYale Divinity School, and Wendy Farley, Jennifer Herdt, John Hare, David Kelsey, Alonzo McDonald, Russell Reno, Theodore Ruger, andMiroslav Volf for helpful comments.
Address correspondence to Jennifer Prah Ruger, Yale University, 60 College Street, PO Box 208034, New Haven, CT 06520, USA. E-mail:jennifer.ruger@yale.edu 32 ajob
Electronic copy available at: http://ssrn.com/abstract=1752295 ability to provide, it necessitates shared resources that are There are contrasts between NCGT and a cooperation distributed fairly and efficiently. Because generating and model such as SHG. For one, NCGT says little about val- distributing resources fairly and efficiently require the at- ues (except maximizing one’s own utility). Second, in NCGT tention of us all—individuals, groups and institutions—we each player makes her own decision, so there is no mutuality are all responsible for steering such efforts. While the gov- or shared deliberation. Third, classic NCGT games involve ernment may assume the role of redistribution, regulation, two players, so coalition building and group inclusion are and oversight, we all must govern ourselves to ensure wise absent, although group games have similar results (Bowles and Gintis 2008). Fourth, under certain circumstances peo- Health and health care decision making calls for in- ple have an incentive to cheat or defect from cooperation in put from both experts (e.g., medical professionals) and one-time interactions or in instances when they can elude laypersons (e.g., patients). Thus SHG involves shared punishment, potentially leading to “a sequence of succes- sovereignty—inclusive decision making and shared author- sively higher order punishments” (Fudenberg and Maskin ity. But the corollary to this privilege is the obligation to make wise health decisions and take prudent health actions A second class of economic cooperation theories is co- operative game theory (CGT), which also presumes self- Mutual collective accountability is the coin of the realm interested rationality. CGT can describe either cooperative in the SHG framework. Thus, consensus and congruence on or competitive environments. CGT concentrates on possibil- values and goals are important among government, health ities for agreement, as well as on outcomes resulting from providers, groups, and individuals, as is a shared under- player cooperation in different combinations. By contrast with NCGT, CGT places greater emphasis on coalition for- Finally, SHG recognizes that while regulations and laws mation and on promising and threatening behavior (Au- are of great consequence to social cooperation, alone they mann 2008). Common characteristics of CGT situations are are not enough; although monitoring is important, no gov- participants who can achieve benefits (such as power or ernment agency can micromanage and police everyone in money) from cooperation but who are in conflict over the every situation. Thus, SHG relies on a specific type of social division of benefits since each desires the greatest share for norm—a public moral norm—and its correlative social sanc- herself (Lemaire 1984). Participants (all or as subgroups) ne- tions as a motivation and authoritative standard for action.
gotiate, bargain, and form coalitions in pursuit of gains, and Internalized public moral norms convey society’s shared will not accept less benefit than what can be attained alone.
values and goals and are important to making shared health The division of group benefits ultimately depends upon the relative power of participants. Players perceived as weak orof little value to the coalition may receive few if any benefitsin the final allocation scheme (Lemaire 1984; Arce M. andSandler 2003).
THEORIES OF COOPERATION
Unlike SHG, the bargaining and division of benefits un- An alternative model of social cooperation must situate it- der CGT are based at least in part on “layers” of power and self within the contours of existing work in cooperation marginal contribution, which means that CGT is unlikely to theory. Although an exhaustive review of the literature is meet SHG’s goals of shared sovereignty or shared resources.
beyond this article’s scope, most economic theories of co- For example, the distribution of gains from cooperation un- operation, whether noncooperative or cooperative, rest on der CGT could exclude weak, vulnerable, or marginalized the premise of Homo economicus, that cooperation or lack groups. Unlike SHG, CGT places little or no emphasis on thereof involves strategic interactions among self-interested public moral norms; a CGT bargain holds if it serves the and rational individuals (e.g., individual utility or payoff parties’ self-interest, not if it achieves an overarching social objective. Finally, in the CGT model there is conflict among Economic noncooperative game theory (NCGT) is un- players over the division of benefits, reflecting a lack of con- appealing for social cooperation in health even though gruence on values and goals (except the goal of maximizing it does not preclude cooperation. In NCGT, each player one’s own utility or gains). SHG is more closely aligned makes unilateral decisions driven by self-interest; coopera- with cooperation models including other-regarding prefer- tion must be self-enforcing—achieved and maintained only ences and social norms (Ullmann-Margalit 1977) leading to if each player cannot do better on her or his own. The Pris- cooperation (Bowles and Gintis 2008). Moreover, additional oner’s Dilemma (PD) is a classic example. In the one-shot PD work on cooperation theory and empirical social science re- game, each player maximizes her own payoff according to search, particularly evolutionary game theory and biology the PD payoff matrix without regard to the other player, and and behavioral economics (Levitt and List 2008), provides defection becomes the dominant strategy for each player empirical evidence of the role of morality in solving recur- even though cooperation between players would yield a ring social problems, consistent with SHG.
better final outcome. In indefinitely iterated PD games, us- A third general category of cooperation theory stems ing a “tit-for-tat” strategy, players are able to punish each from the social contract theory tradition. Social contractari- other for defection in previous rounds, reputation matters, anism is a major model and relates to CGT and bargaining and there is a tendency toward cooperation.
theory. However, it assumes a “fundamental connection ajob 33
Electronic copy available at: http://ssrn.com/abstract=1752295 between rationality and morality”—“moral norms . . . are ers who have their own interests to pursue” (Ashford and rationally acceptable . . . if . . . there is no feasible alternative arrangement where all parties concerned would be better Models of contractualism vary. Kantian forms seek prin- off” (Verbeek and Morris 2010). Under social contractarian- ciples expressing freedom and equality to which every agent ism, individuals are mainly self-interested; they don’t neces- would rationally agree (Rawls 1971). Though Rawls’s form sarily have regard for others’ well-being. A reasoned pursuit also seeks principles to which everyone would agree, the fo- of self-interest leads to moral behavior, and moral norms are cus is on political principles, not necessarily moral ones, and based on maximizing interests jointly. Social contractarian- principles of justice are chosen by self-interested agents act- ism theories presume that the initial bargaining position is ing behind a veil of ignorance (Rawls 1971). Thomas Scan- characterized by scarcity or other cause for competition, and lon’s version of contractualism bases morality on mutual that social interaction and cooperation can produce gains respect and looks for principles that “no one can reason- (Cudd 2008). Social contractarianism also includes an ele- ably reject” (as opposed to those on which everyone would ment of power, since parties to a contract must have the agree) under free and voluntary conditions (Scanlon 1998).
capacity to contribute to the product of social interaction Scanlon does not propose a veil of ignorance; instead, in- or at the very least pose a threat to it (Hartley 2009). In this dividuals account for the interest of others through their sense, social contractarianism is similar to CGT and exhibits own desire to justify themselves to everyone else. Scanlon the same differences from an SHG model in potentially leav- places a more stringent criterion on how we live with oth- ing certain groups—the severely disabled and other weak ers: The fact that a principle negatively affects oneself is and vulnerable groups—outside the realm of justice. The insufficient reason for rejecting it. Individuals must rather contract requires a “rationally acceptable” and “impartial” ask how that principle affects others. In an interesting twist starting point and procedures (e.g., no coercion or decep- on the Pareto principle, Scanlon argues that the true test in tion) to secure social cooperation (Gauthier 1986). Under so- assessing moral principles from the agent’s point of view is cial contractarianism, then, justice is possible where all those not whether a principle imposes a burden on the agent, but who are able to contribute benefit from the social contract.
whether the alternatives would place a heavier burden on In Morals by Agreement, David Gauthier discusses “con- others; if so, the agent cannot reasonably reject the principle strained maximization,” in which players may actually do (Scanlon 1998). Under this view, both self-interest and re- better in many situations by eschewing “straightforward” spect for others motivate actors, who owe it to one another maximization and do not maximize self-interest (utility) at to promote each other’s interests (Scanlon 1998). Thomas every decision point, given the expectation of cooperation Nagel, among others, has criticized Scanlon’s idea of prin- from others (Gauthier 1986). Rationality can encompass in- ciples no one can reasonably reject as impracticable, given dividual decisions deemed suboptimal at the point of action.
the conflict of values in pluralist societies (Nagel 1991).
Moral constraint on pursuing self-interest is necessary be- Contractualism actually shares some SHG elements.
cause individuals can almost always do better by cheating Like SHG, it requires individuals and groups to consider in cooperative activities while others keep to the bargain others in their moral calculations, and demands that persons promote others’ interests. Scanlon’s contractualism, in par- Because social contractarianism shares many features ticular, rejects self-interest maximization with an emphasis with CGT, its contrasts with SHG are similar. Gauthier’s on narrow individual rational agency. By focusing primarily version, however, does introduce an element of normative on individuals as they relate to each other, however, contrac- constraint on “straightforward” self-interest maximization tualism, unlike SHG, does not provide adequate scope for that may be conducive to larger social interests. Moreover, aggregate or societal concerns. Moreover, unlike contractu- the element of conditioning oneself to restrain self-interest alism, SHG recognizes that there may be some actions that for the sake of keeping an agreement is appealing, although, do impose greater burdens on others (e.g., requiring others like SHG’s public moral norm internalization, likely difficult to pay more for health insurance so the agent at hand has coverage) that are still justified as long as the sacrifice of Social contractualism is another idea stemming from others does not interfere with their own ability to ensure this tradition. Under contractualism, the rationality condi- central health capabilities. Nor does it offer a sufficiently tion takes a slightly different twist: We must respect per- comprehensive approach to encompass shared sovereignty, sons, which entails that moral principles be justifiable to shared responsibility, and shared resources.
each person. Individuals are thus motivated by a commit- A final category of social cooperation to assess in ment to being able to justify their actions to others, rather conjunction with SHG is utilitarianism. While there are than by self-interest (Scanlon 1998). The principle of persons many varieties of utilitarianism, some main features in- having equal moral status grounds social contractualism.
clude grounding individuals’ moral status in happiness, Moral behavior results from agreements that bind free and desire fulfillment, and well-being, allowing interpersonal equal moral agents. Comparing social contractarianism and comparisons and aggregation of welfare and burdens, and contractualism, the former describes a society in which in- an overall social goal of maximizing utility for all (aggregate dividuals aim to maximize self-interest in bargaining or ne- utility), or in “average utilitarianism,” a goal of the highest gotiating with others, whereas under contractualism, each average level of utility (e.g., Bentham 1961). Utilitarianism individual pursues her interest by means justifiable to “oth- demands impartiality such that everyone’s utility is counted 34 ajob
equally in the aggregation scheme, although some have in- that caused 500 deaths. It paid civil penalties to avoid crim- troduced equity weights to modify this requirement (e.g., inal charges, but then lobbied to ban future lawsuits against manufacturers of such devices (Palast 2002). Another com- Utilitarianism contrasts with SHG in this particular pany introduced a heart device (Prizm 2 DR) that malfunc- impartiality requirement because the SHG framework in- tioned in more than 33% of patients over a 19-month period, volves special efforts to include weak and vulnerable and failed to report to the U.S. Federal Drug Administration groups; utilitarianism does not give these groups special (FDA) the resulting 57 emergency surgeries and 12 deaths consideration. Moreover, the goal of maximizing overall utility does not address the distribution of utility. “Aver- The FDA itself is not immune to these concerns. Many age utilitarianism” might mitigate this concern, but does assert that its funding structure renders it vulnerable to con- not really solve the problem of addressing those with the flict of interest. Half of the FDA’s budget for reviewing mar- greatest needs. Utilitarianism, unlike SHG, lacks emphasis keting applications comes from the drug industry (Willman on individual agency or autonomy; collective interest may 2000). Ten of 32 members of the FDA advisory committee override individual interest. But utilitarianism does require deliberating Vioxx and Bextra withdrawal had conflicts of actors to consider the impact of actions on others, because interest with drug companies (Harris and Berenson 2005).
the goal is to maximize overall utility. Maximization of indi- Of the 13 drugs removed from the market since 1997, at least vidual self-interest cannot be the coin of the realm; trade-offs 7 had been approved despite the objections of FDA safety among individuals are required, as in SHG.
Even the research and academic community faces con- cerns about integrity of research and reporting due to in- SELF-INTEREST MAXIMIZATION AND SUBOPTIMAL
dustry ties. For example, a 2000 New England Journal of OUTCOMES IN HEALTH AND HEALTH CARE
Medicine article omitted some risks of Vioxx; all 13 authors Self-interest (e.g., individual utility or payoff) maximization were connected with the Vioxx maker Merck, through em- is at the heart of most theories of cooperation. From the per- ployment or other financial relationships (Bombardier et al.
spective of social cooperation in health and health care, nar- 2000). Suppression of damaging results also occurred in the row self-interest maximization alone produces suboptimal case of the drug Synthroid (Rennie 1997) and a drug for results. In U.S. health care, there are examples of medical thalassemia major (Baird et al. 2002).
providers (doctors), drug and medical device businesses, in- Both providers and patients commit Medicaid and surance companies, and patients maximizing their own in- Medicare fraud. Providers bill for services not ren- terests without internalizing system-wide effects. Geyman dered, double-bill to both Medicaid/Medicare and to pa- (2008) compiled an extensive collection of examples from tients/private insurance, upcode, and use unauthorized the United States. Some doctors receive kickbacks from re- service suppliers but bill at authorized supplier rates, ferrals, refer patients to medical facilities in which they have among other tactics. Patients loan Medicaid/Medicare ID financial stakes, recommend and perform unnecessary pro- cards to others, deliberately receive duplicate or excessive cedures, and collect payments and gifts from hospitals and services and/or supplies, and sell Medicaid/Medicare sup- medical suppliers. In-depth studies of high-cost communi- ties confirm many of these trends (Gawande 2009). Even Such corrosive behaviors are not unique to the Ameri- doctors’ choice of specialties is affected by material con- can health care system. Health worker absenteeism, nepo- cerns, as they avoid lower paying but crucial fields like fam- tistic hiring, medical supply theft, and corrupt procure- ily medicine, internal medicine, and pediatrics. Only about ment are significant problems in countries such as Uganda, 10% of American medical students choose one of these fields Bosnia, Dominican Republic, Argentina, and Venezuela, just for residency training (Pugno et al. 2005); meanwhile, 70% to name a few (Lewis 2006). Staffing shortages are some- of the doctors in the United Kingdom and 50% in Canada times further exacerbated by professional turf protection, are in primary care (Starfield 1994). A weak primary care where higher level professionals resist delegation of tasks base renders the U.S. system excessively specialized and to lower ones. One example is Botswanan doctors resisting blood drawing by phlebotomists even in the face of staff Many for-profit entities boost profits by various means.
shortage, thus hindering the scale-up of antiretroviral ther- For example, one for-profit hospital chain was found to apy (Swidler 2006). There are a number of structural factors have inflated operating room charges by more than 800% contributing to these practices and they undermine health and collected fees more than 17 times that of public hospi- efforts and waste scarce public health resources.
tals for blood tests (Benda 2003; Lagnado 2004). Diagnostic, The starkness of these examples does not necessar- screening, and imaging centers often have arrangements in ily represent universal behavior but serves to highlight which they charge discounted prices to doctors (e.g., $400 the underlying importance of working within a frame- per scan, $850 per MRI), while doctors receive $2,300 from work of shared and individual goals simultaneously. The insurers for each MRI (Armstrong 2005). Such practices lead idea is not to deny or eliminate altogether self-interest to overuse of needless services. Medical suppliers have been as a human motivation; rather, it is to recognize it, align known to market and sell defective or unapproved medical with shared goals, and create conditions (including insti- devices. One supplier made and sold defective heart valves tutions and policies that structure incentives) to reduce its ajob 35
negative, and enhance its positive, impact on health care and tween policymaking and scientific advice is questionable (Fischer 2008). SHG maintains a middle view that recog-nizes the essential roles both of proceduralism for publicengagement and of epistemic values and standards for eval- MODELS OF GOVERNANCE
uating deliberative outcomes. While beyond this article’s The most widely employed approach to rein in self-interest scope to explore at greater length, SHG engages with el- maximization in any field, including health and health care, ements of “epistemic proceduralism” (Estlund 2008) in its is government regulation, although strong government is only one type of governance. This section contrasts SHG Decentralized, civic participation models of governance with different models of governance.
include quite a few variants. For example, another EU food There are at least two major types of governance mod- safety regulation model is “reflexive” governance, which els: top-down, hierarchical models, and decentralized/civic acknowledges that “facts are uncertain, values in dispute, participation models. Top-down, centralized, hierarchical stakes high and decisions urgent” (Fischer 2008, quoting governance is state-directed health system control, with Funtowicz and Ravetz 1993, 739). It seeks permanent, open the former Soviet Union (USSR) being a prominent and lines of communication among experts, politicians, and the extreme example. The USSR federal Health Ministry in public, and attempts to “democratize” science by “con- Moscow controlled medical education and training, health trol[ling] scientists in expert committees” and presenting care facilities, personnel, and finances throughout the USSR, the views of laypersons (Fischer 2008, 6). This is contrary to setting total health expenditures and allocating resources the central role SHG gives to science; it also reflects an overly through annual and five-year plans. Regional and local optimistic view of civil society, NGOs, and laypersons as health authorities operated under ministry budgets and key decision makers, ignoring the potential for laypersons rules, with little flexibility to address local needs (Row- to add inefficiency, irrationality, and incoherence to health land and Telyukov 1991). Another version of this top-down, policy decision making (Fischer 2008). The classic interest- government-mandated governance is the New Manageri- group representation model is a version of civic participa- alist/New Public Management model. “Process-oriented” tion, but one that underscores some undesirable features and “target-driven,” this model aims to reduce health ser- in a governance model: interest-group competition in rule- vice inefficiencies, close gaps, and reduce overlaps in ser- making; rulemaking based on log-rolling between agency vices, with the goal of moving individuals “to cheaper and stakeholders; the treatment of agency officials as in- parts” of the system (Rummery 2009, 1802). Both the cen- siders and other stakeholders as outsiders; adversarial re- tralized Soviet model and New Managerialism reflect the lationships among stakeholders; and government serving ideologies and goals of the center rather than local need. To primarily as a “neutral and reactive arbiter among stake- different degrees, the top-down hierarchical nature of both models is contrary to SHG. Where the center dictates poli- New localism and “local state entrepreneurialism” are cies and procedures, there is little mutual collective account- additional examples of models that place heavy empha- ability, little involvement of individuals and the commu- sis on civic participation. Citizens are asked to get involved nity, and little effort to achieve the consensus or agreement in “every government directive” (Blakeley 2006, 139). These sought by SHG and contractualist approaches. Resources approaches may not empower citizens as much as expected.
are shared, but often in arbitrary and unproductive ways.
Constant citizen consultation can result in fatigue and dis- Two other examples of hierarchical governance models engagement. Citizens are pressed to work with govern- have been examined within the context of evolving Euro- ment and the private sector, while entrenched inequalities in pean Union (EU) food safety regulation (Fischer 2008). One power and influence are not addressed; “professionalizing” is technocratic governance, where technical experts dom- citizen participation means that not all citizens are neces- inate and make decisions. Politicians (nonexperts) rubber- sarily equally empowered. Participation as a governmental stamp those policies since they lack the knowledge and abil- scheme may be a means of co-opting important citizens ity to understand complicated scientific and technological and “legitimizing domination,” instead of a strategy of em- issues. Public participation is unnecessary in the “produc- powerment (Blakeley 2006, 140). While new localism shares tion of scientific expertise” (Fischer 2008, 5). “Decisionist” SHG’s focus on individual agency, SHG relies significantly governance takes the opposite approach, giving priority to more on the give and take between the established social political decision makers over scientific experts in the in- order and individuals, and on an overarching framework terest of clear accountability. Both these hierarchical models of consensus on societal health goals. Moreover, in SHG, also run counter to SHG. While SHG respects scientific infor- participation and consensus seek to recognize inequalities mation and expertise, it differs from the technocratic model in understanding that political legitimacy involves norma- Additional variants of decentralized, civic participation tive reasoning and public deliberation. Political decisions governance models exist that still differ from SHG but share are not purely scientific (Gutmann and Thompson 2002).
some important elements. Co-governance combines “a And even scientific experts can disagree (Fischer 2008). The strong state, extensive market economies, and a lively civil decisionist approach recognizes the political nature of pol- society” (Roiseland 2010, 140). Local governments share icy decisions, but the effectiveness of strict separation be- power and govern with actors like local businesses, civil 36 ajob
organizations, and neighboring cities, steering such efforts licanism emphasizes citizen deliberation and a pursuit of through “network management” or “metagovernance” (Roiseland 2010, 141). Like SHG, co-governance calls Finally, another decentralized model of governance is for collaboration among public, private, and civil actors the Boundary-Spanning Policy Regime (B-SPR), for unruly within the public sector or within levels of government.
cross-sector problems primarily at the domestic national However, co-governance lacks SHG’s emphasis on social level (Jochim and May 2010). B-SPRs bridge multiple pol- norms, which helps hold cooperation together. Under icy domains and encourage “integrative policies” by “pres- co-governance, cooperation would be hard to maintain sur[ing]” actors in relevant domains to work “more or less in difficult situations, as actors may cease cooperation if in accord toward similar ends” (Jochim and May 2010, 307).
further collaboration produces no common gains. Account- The goal is to achieve greater policy cohesion and to make ability mechanisms are also weakened by the removal of up for governance fragmentation. Examples of B-SPRs in decisions from elected institutions (Roiseland 2010).
the literature include community empowerment and pol- Community governance and collaborative governance lution abatement in the 1960s and 1970s; in the 1980s and models both devolve governance to lower tiers of gov- 1990s, drug criminalization, disability rights, and welfare ernment, frequently the local and even institutional level.
responsibility; and in the 2000s, homeland security.
Under community governance, community representatives Civic republicanism, community and collaborative gov- influence and specify policy, especially social welfare pol- ernance, and B-SPRs have features in common with SHG, icy, to best serve local needs and to build capacity through but SHG places greater emphasis on meta-rules within a youth and community consultation, local adaptation of ex- higher level structure assigning responsibility and stipu- ternally specified services, and greater awareness of re- lating authority for public and private actors in the joint source use (O’Toole et al. 2010). Collaborative governance collaboration in health, as discussed next.
emphasizes “problem-solving . . . information-sharing anddeliberation among knowledgeable parties,” the “partici-pation of interested and affected parties in all stages of SHARED HEALTH GOVERNANCE
the decision-making process,” and the “development of The academic and policy work in social cooperation and temporary rules subject to revisions” based on “continu- governance helps illuminate efforts to organize collectively ous monitoring and evaluation” (Zabawa 2003, 378). Ex- in health and health care. But despite progress in institu- amples of applications of collaborative governance include tional design, many efforts have begun with a problematic the public–private partnerships to expand health coverage orientation in health and health care: To found a theory of under the U.S. Health Insurance Flexibility and Account- cooperation and governance on the “singular subject” the- ability (HIFA) waiver, Seattle’s neighborhood planning pro- ory of rational individualistic thinkers and actors. Entities, gram, and the U.S. Environmental Protection Agency (EPA) individuals or groups, are seen as isolated agents, even if projects on watershed, Superfund, and environmental jus- they act collectively. On the other hand, a focus solely on the tice issues (Zabawa 2003; Neshkova 2010). Like SHG, col- common good, overriding individual interests, is equally laborative governance emphasizes actors’ interdependence unsatisfactory. What’s required is the preservation of the and accountability, with the government or a designated methodological and normative importance of individuals, agency at the center. SHG, however, sees government as adding to it that of collectives as a whole.
more than simply a “facilitator of multi-stakeholder nego- A narrow lens cannot accommodate continual interac- tiations” (Zabawa 2003, 378). It allocates more authority tions of individuals and groups in a cascade of iterative to government in the framework for mutual collective ac- and cumulative processes. Even the most basic health care countability, to enhance the legitimacy of both government example—the doctor–patient relationship—demonstrates and nongovernment actors. SHG also calls for a reorien- the extensive “jointness” and “interaction” involved in tation of underlying norms and motivations for authentic health and health care. Producing an effective and efficient health system, and ultimately individual and population The civic republican ideal envisions citizens connected health, requires shared resources, shared sovereignty, and in pursuit of the greater common good. One view of civic shared responsibility based on the specific functions and republicanism directs lawyers, for example, to identify the roles individuals and groups take on in this enterprise. Thus, common good and to align their clients’ endeavors with so- rather than relying solely on individualistic rationality, SHG cial justice; thus, oddly, within this tradition lawyers don’t concentrates additionally on social rationality in an alterna- pursue only their clients’ interests. Preferences develop “di- tive view of health governance, which seeks to help us better alogically, through a process of engagement and discussion understand how to effectuate principles of health and social among citizens” (Wendel 2001, 2000). Other versions of civic republicanism permit lawyers, as representatives of their The first basic premise of the SHG framework is a clients, to pursue client interests, but stipulate that lawyers social scientific one: Multiple societal actors, public and work toward the greater good of the system on their own private, engage in a joint enterprise that either by omission time (Gordon 1988). Deliberation does not merely present fails or by collective action succeeds in co-producing extant preferences; participants must be ready to amend the conditions (including institutions and policies that their preferences according to the public good. Civic repub- structure incentives) for all to be healthy. SHG offers an ajob 37
alternative set of fundamental assumptions for collective mechanisms and places both individual health agency and social norms (particularly public moral norms) as central The second basic premise is both normative and social to its framework. SHG recognizes that not only is it im- scientific: Approximating justice in health requires individ- possible to micromanage all actors’ health and health care ual and group commitments to produce this social goal. A behavior at all times, but such micromanagement may be specific type of social norm—public moral norm—is put less effective than social norm internalization. Internalized forth as an effective motivation and authoritative standard norms provide a shared authoritative standard by which for individual and group action on health justice. Internal- individuals and groups can use their health agency to make ized public moral norms convey the shared values and goals more effective decisions for optimal individual and societal of society and are key for SHG’s successful realization. The framework needs to work out issues related to this premise: A sixth premise involves shared sovereignty and con- Who frames the norms, situations of disagreement with the norms, requirements for adhering to them, and better un- The extensive theorizing and empiricism about derstanding of how norms are internalized and followed governance and the oscillation between ends of the and what proportion of people need follow them. Lessons central–local, expert–layperson, scientific–political, and from public health (e.g., vaccination) and environmental procedural–substantive spectra demonstrate how frustrat- policy (e.g., recycling) are instructive here.
ingly difficult it is to fine-tune institutional designs to get at A third basic premise stresses that generating a shared improved health governance. And regardless of the inten- commitment to an ideal or set of ideals can serve as the stim- tion to rein it in, self-interest maximization can take hold ulus for attention and role fulfillment across governance and produce suboptimal results in virtually every gover- subsystems (e.g., financing, organization, delivery of health nance model. These models fall short of instilling a holistic care). The ideas constitutive of the shared commitment bind sense of what is to be shared and mutual: (i) actions and the subsystems together to achieve a common purpose. Il- goals, (ii) responsibility, (iii) resources, (iv) norms, and (v) lustrations of such ideas are found in the principles and sovereignty. An internalized and joint ethical commitment their application as put forth in Health and Social Justice.
to ensure the conditions for all to be healthy undergirds This shared commitment can in turn lead to political obli- SHG and serves as motivation to hold ourselves account- gations and commitments. The actors then give legitimacy able for our respective roles and conduct. SHG does not and power to that regime, forming the bases of support for deny or seek to eliminate altogether self-interest or individ- SHG. No single decision accomplishes this, but simultane- ual “rationality”; rather, it aims to align it with shared goals ous decisions together bring the SHG framework to fruition.
through joint commitments. By jointly committing to this A fourth basic SHG premise is shared resources. Part enterprise we accept our shared responsibility for health.
of the social commitment to ensuring the conditions forall individuals to be healthy involves sharing individual GENERAL AND SPECIFIC DUTIES AT THE NATIONAL
and social resources. There are three components to thispremise. The first is the commitment to contribute one’s LEVEL: A RECAP OF HEALTH AND SOCIAL JUSTICE
fair share to the collective pot to fund the joint enterprise.
AND OTHER WORKS
The implementation of this principle involves progressive Health and Social Justice argued for a universal duty to re- financing such that, on a sliding scale, wealthier individuals duce shortfall inequalities in central health capabilities as and groups pay a greater percentage based on the overall efficiently as possible and conceived of SHG as a gover- level of wealth. The second is on the receiving end and nance model for achieving this general obligation. All in- is the conviction that each individual is entitled to receive dividuals have obligations to each other, obligations dis- that person’s fair share of resources. The implementation charged through our own actions and through public and of this principle allocates resources based, for example, on private actors and institutions. Obligations of health jus- the criteria of health functioning and health agency needs.
tice are grounded in individuals as members of a cooper- The third is the responsibility to use these shared resources ative joint venture to produce a health society. These du- wisely and parsimoniously and not to demand more than ties involve creating and upholding conditions for all to be one’s fair share, based on bona fide needs as opposed to healthy. SHG rests on a robust sense of shared responsibil- desires or preferences. We all share in the benefits that ac- ity. Thus, we need public moral norm internalization and crue to society from achieving justice in health, including a voluntary commitments to recognize and take ownership more healthy, stable, well-cared-for, productive population, in this cooperative enterprise, ownership that applies both as well as cost containment and reduction in disease risk.
to our own actions and in holding institutions accountable.
Thus, we all share in mobilizing and using the resources Political obligations follow from these duties.
In other works, this line of reasoning is taken a step A fifth premise comprises enforcement and social sanc- further, providing a theory for assigning responsibilities tions created to hold actors responsible, apportioned sym- among the multitudes of institutions and actors (Ruger metrically according to the responsibilities attached to SHG 2009b). A theory of health justice necessitates additional functions and roles. While SHG includes a role for incen- principles for distributing responsibility to ground the tives and external motivation, it does not rely solely on such obligations of specific actors and institutions. Principles 38 ajob
identified for allocating specific duties involve (i) functional barked on in Health and Social Justice to set out for society and role-based requirements and (ii) voluntary commit- as a public which moral ideas serve as guides and which ments. Under the functional and role-based requirements ought to be favored or disfavored. I agree, in part, with principle, SHG dispenses functions and roles to those in- Elizabeth Anderson in arguing that public moral norms au- dividuals and groups best situated by their positions and tonomously motivate our behavior and do not necessarily require appeal to self-interest or even to the threat of social The voluntary commitments principle asserts that indi- sanctions (Anderson 2000). In many individual decisions viduals and groups voluntarily embrace their role, share re- about health and health care, it will not be possible or even sources, and relinquish some autonomy through collective desirable to apply social or even emotional sanctions for action to address health problems. This links with a consen- enforcement—on individuals failing to comply with AIDS sus on a shared authoritative standard (discussed later) for medication instructions, for example, or on doctors recom- specific duties so that specific actors and institutions will mending treatments to patients. Rather, we require a more fulfill their obligations. In other words, specific actors and profound commitment to both the individual (building on institutions intend to be bound by these obligations, with self-regard as a human motivation) and the common good, a clear understanding of what they are to do. The process an understanding that we work together as a body to create of reaching consensus on specific duties in turn relates to the conditions for all (including ourselves) to be healthy.
actors internalizing public moral norms, for example, pub- The autonomy of the normative motivation under an lic moral norms of health equity, motivating them to act SHG framework is important. Willingly living out the pub- to reduce inequalities in health capabilities as efficiently as lic moral norm is important for achieving conditions for possible. Efforts to establish consensus, through for exam- individual and population health. It is significant if we are ple incompletely theorized agreements, amidst pluralism, to reach a steady state of enabling conditions. Millions of individual decisions to get vaccinated for H1N1 or to ad- Ethical commitments to this goal are key to motivating here to tuberculosis treatment regimens or to cover one’s actors, both in sacrificing resources and autonomy and in mouth when one sneezes or wash one’s hands or to provide discharging their duties. Voluntary commitments enhance recommendations for high-quality, cost-effective care are individual liberty by appealing to individually agreed-upon illustrations. Internalized public moral norms also entail, and embraced principles. The next section discusses public like the Golden Rule, the recognition that we’re all hanging moral norms as a shared authoritative standard for individ- together in this enterprise: That we’re as likely to benefit from a society where all can be healthy as to contribute toit. Thus, the public moral norm incorporates interest foroneself (self-interest) in the context of society as well as in- PUBLIC MORAL NORMS AS A SHARED AUTHORITA-
terests for others. It links and aligns individual and society.
TIVE STANDARD
While sanctions, incentives, and punishments can be helpful The content of SHG’s social norms is an important focal (e.g., in binding doctors to comply with standards for what point. To unpack this idea, we differentiate between pub- they recommend to patients or regulating what providers lic and private norms. Public, here, means applicable to the can discuss with patients), without the autonomous effect public sphere. So a public norm is a form of social norm since of internalized norms on individuals embracing their re- it applies to the social sphere, as opposed to applying only sponsibility for themselves and society, there will likely be to our private spheres, but a public norm, in this view, has insufficient motivation to act, and the wisdom and skills un- more political heft, concerning what we do as a society, with derpinning action will not develop over time. The claim is public resources in publicly created conditions. While it de- not that this type of norm is “all effective” but that it can as- rives its content from the public and social, its internaliza- sist in improving effectiveness. To achieve socially rational tion and application involve both public and private actors.
objectives we need socially informed individual judgments It is important to stress the morality of the norm. Norms of behavior can, in fact, be immoral, such as infanticide,rape, pillage, and corruption. A moral norm, by contrast,involves a deep shared conviction of its “rightness” or at the COMMITMENTS,
very least its lack of “wrongness.” An example is the fairness RESPECTIVE ROLES
norm known as the Golden Rule, which some have argued The third premise of SHG calls for a joint commitment is engrained in human culture, having evolved with the hu- among individuals and society to work together to secure man species (Binmore 2005). SHG therefore employs public the conditions for all to be healthy. Under this premise, moral norms in creating a standard for joint commitments individuals and groups will be committed to doing their and joint decision making. Health and Social Justice, argued, fair share, including playing allocated roles, in creating however, that not all moral norms are equally desirable for these conditions. This joint or societal commitment is a key health and health care. There are even some moral norms premise of the SHG framework. This feature shares the ele- whose fairness is debatable, such as absolutist libertarian ments of self-understanding and identity with frameworks or individualist theoretical approaches as applied to health of collective agency and group membership put forward in and health care. The SHG project continues the journey em- social theory (e.g., Tuomela 1984; Gilbert 1989; Searle 1990).
ajob 39
The “We” in Health and Health Systems, A Nod to
stitute a fair share, nor what constitutes a reasonable defini- Plural Subject Theory
tion of health justice, it can buttress the idea that individuals This third premise of SHG is conducive to theorization un- in a society have a political obligation to one another. This der “plural subject” theory (PST) (Gilbert 1989). PST ex- political obligation could involve supporting laws or norms plores the self-understanding of individuals in a group who that strive to foster, for example, health capabilities.
view themselves and one another as a body of people jointly Another question is whether SHG could, at least tem- porarily, rely on a political obligation to inculcate certain In the PST account, joint commitments create an ex- norms and align behaviors with them. But even if individu- ternal force that binds one to act or believe a certain way, als have a political obligation to do X, as theorized by PST, counter to expected actions or beliefs absent the commit- one must wonder how relevant this obligation is if individu- ment. The joint commitment thus creates a binding rule, so als do not believe it to be legitimate, and if it is not enforced.
to speak, that individuals follow even when the rule might The SHG framework of internalizing norms and behaviors, conflict with short-term rational self-interest. Individuals while more time-intensive, seems a sustainable approach.
are answerable, to others and to themselves, for violations.
One key is the norm or set of norms emerging to be viewed The plural subjects in SHG are all of us. As plural sub- jects acting and in many cases working together, we create DIVISION
RESPONSIBILITY
(or by omission or action fail to create) the conditions forall individuals (including ourselves) to be healthy. The PST RESPONSIBILITY
understanding that “social groups” are “plural subjects” SHG entails individuals taking actions to improve their own and that “plural subject phenomena” include “social rules health, building on self-regard as a human motivation, as and conventions, group languages, everyday agreements, well as that of others, and encompasses duties to avoid collective beliefs and values, and genuinely collective emo- harming others and the system as a whole. SHG parts com- tions” (Gilbert 2003, 55) is highly relevant to SHG. Among pany with the pure notion of collective belief in the soci- the features stipulated by PST for joint commitments and ological sense (that a belief can inhere in the social group plural subject-hood are: (i) open expression of willingness without individuals in that group taking it on individually).
or “quasi-readiness” to do X together, where X connotes Individual-level believing and thinking are a necessary part a belief or action (Gilbert 1989; Gilbert 2003); (ii) common of the SHG framework, fundamental to the principle of re- knowledge among the plural subjects that others have ex- sponsibility allocation and responsibility division. SHG in- pressed willingness to do X together (this constitutes an volves spontaneous convergence, since explicit agreements element of trust in the reciprocity of others’ behavior and is at every stage and every decision point are not possible.
akin to the sociological notion of “consciousness of unity” Specific responsibilities in the collective arrangement fall to (Schmitt 2003); and (iii) obligations binding plural members those who, by their roles or resources, are best positioned of the group together, such that “each party is answerable to all parties for any violation of the joint commitment” Based on these principles, the primary responsibility for efficiently reducing shortfall inequalities in central health Under SHG, individuals need to express “readiness” capabilities should be allocated to the state (federal gov- to endow an individual or a group of individuals with ernment), because national governments have the political decision-making power—forming a basic joint commitment authority, resources, and regulatory and redistributive abili- to embrace public moral norms, for example, of health eq- ties to create health system infrastructures, including health uity. Then individuals are politically obligated to uphold care, public health, and other systems affecting health, like these decisions; political obligations flow from such com- food, drug, consumer, and work safety. They are also in the mitments. SHG diverges a bit from PST, however, in the best position to create and disseminate public goods neces- content of the moral imperative. PST does not distinguish sary for sustaining central health capabilities. National du- between types of political obligations. Political obligations ties include developing and maintaining a national health related to health under PST, for example, might not entail care and public health system that guarantees a universal a significantly binding commitment as related to political comprehensive benefits package of medically necessary and obligations in other domains. However, under SHG, if po- medically appropriate goods and services, and that creates litical obligations related to health can be persuasively bol- an environment that supports central health capabilities.
stered by moral considerations, they could entail a robust National duties also involve delegating specific duties to commitment as related to other types of commitments, for specific actors based on these principles. Actors can be pri- example, taking health functioning and health agency as vate or public, but SHG relies on empirical evidence as to central to human flourishing. An extensive discussion of the most cost-effective route to achieving desired ends. Ac- these points are beyond this article’s scope; an examina- tors also have a duty to inculcate norms—for example, of tion of health capabilities vis-`a-vis other capabilities (Ruger health equity—in their own spheres of influence.
2009a) and routes to consensus amidst pluralism (Ruger Medical providers (the medical profession and hos- pitals, clinics, and other players) have duties to provide PST thus offers some intellectual resources that support high-quality goods and services to patients as efficiently as an SHG view. Although PST cannot define what would con- possible. Private and public insurers have a duty to insure 40 ajob
all citizens with a universal comprehensive benefits package of health equity, serve as a focal point for responsibility; re- of medically necessary and medically appropriate goods sponsibility on the part of all parties for this joint endeavor and services at the lowest possible costs. If these entities is a basic premise for achieving the shared goal. This en- cannot fulfill this duty more efficiently than the state, then tails not just “group morality” but individual morality as the state is to assume this duty. Empirical evidence from well, preserving the methodological and normative impor- comparative health systems suggests that the national gov- tance of individuals and adding to it that of collectives as a ernment is likely in the best position to insure the population whole. Because SHG is designed positively to establish con- with efficiency, equity, and control over costs (e.g., Hussey ditions in which all have the ability to be healthy, it differs and Anderson 2003; Reinhardt et al. 2004). Individuals and from the traditional “motivation for responsibility” schol- families have duties to promote their own health, fostered arship, which takes causation, blameworthiness, and guilt by self-interest, and we all (patients and other actors) owe for harm as a point of departure. SHG is both an individual each other a commitment to use our shared resources as and group-based construct; both individuals and groups wisely as possible. We also all share the duty to refrain from can have health agency, intentions, and goals.
harming others and the system as a whole (e.g., throughfraudulent claims or making imprudent health choices).
Finally, the state shall allocate the duties of research SOVEREIGNTY
CONSTITUTIONAL
and education in a multistep process, first to governmental COMMITMENTS
and nongovernmental institutions best positioned to make A sixth basic feature of SHG is shared sovereignty. SHG scientific decisions about such activity (e.g., the National depends on individuals and groups coming together to de- Institutes of Health [NIH], Institute of Medicine [IOM], Na- velop structures and procedures to make decisions, govern tional Science Foundation [NSF]), and then to entities such collectively, and set standards for self-regulation and soci- as universities and research institutes that fulfill this duty etal regulation. While SHG brings in the overarching po- by creating and disseminating knowledge.
litical economic philosophy put forth in Health and SocialJustice, SHG employs a constitution of sorts to delineate theends and means of health governance at the societal level.
SHARED RESPONSIBILITY, COLLECTIVE
An SHG framework based on its own constitution will pro- RESPONSIBILITY: A CAVEAT
vide a structure for different institutions as they relate to Collective responsibility and shared responsibility have each other (e.g., federal and state governments, civil soci- multiple meanings, and a point of clarification on their ap- ety, and individuals). As a superstructure, a “health consti- plication in SHG is warranted. In SHG, individuals’ under- tution” would delineate the respective actors (institutions, standing of their roles leads them to take on the responsibil- organizations, groups, individuals) in health governance ity of doing their part successfully, pursuing specific goals and specify their respective duties and powers, thus allo- to achieve together the overarching social aim. My use of cating specific responsibilities for creating a health society.
“shared responsibility” thus has quite specific functional The health constitution would set the framework and proce- and role-based foundations and entails particular commit- dures informed by authoritative standards and principles.
ments, unlike broader, more existential notions of shared re- Constitutional interpretation would then assess whether or sponsibility. In essence, my use of “shared responsibility” is not such duties have been fulfilled and whether actors are a thin conception, linking explicit behavior and actions with meeting their obligations to ensure conditions for all to be values and attitudes to create conditions for all to be healthy.
healthy. To date the different actors in the health system Existentialist responsibility has a more diffuse and general (e.g., providers and physicians, federal and state govern- structure; as one scholar notes, “Even when there is seem- ment, insurers, clinics and hospitals, and individuals them- ingly nothing that one can do to prevent an evil in the world, selves) have not known what their respective duties and one has a responsibility to distance oneself from that evil at powers are. It would be difficult and unfair to attempt to the very least by not condoning it” (May 1992, 3). Under a hold them accountable for unspecified responsibilities. The SHG framework, actors can and must do something—they intent is to define effective institutional arrangements and pursue their role-specific activities effectively.
divisions to bring about the conditions for a health society.
Shared responsibility under SHG is thus more narrow This enterprise requires empirical research and evidence.
and delimited. What SHG shares with the social existential- The health constitution is not a legal constitution, nor ists, however, are two ideas: That both community mem- does it overreach in governing every aspect of society. It bership and shared attitudes create responsibilities for all sets out meta-level rules for health, but it neither replaces members (May 1992; Jaspers 2001; Smiley 2010), and that nor competes with the legal “Constitution.” Rather, the two individuals and groups are responsible for “joint actions types of constitutionalism are complementary. The health to which one contributes” (May 1992, 8). A change in atti- constitution is constitutional in the sense of prescribing tude is necessary so individuals and groups see themselves institutional arrangements and procedures and in assign- as sharing responsibility for creating the conditions for all ing responsibilities and authorities to public and private to be healthy, whether they do so by their own individual actors. The principles set out in Health and Social Justice actions or those actions they share with groups and insti- imply a correlative obligation that falls on society as a tutions. Ethical commitments to a shared goal, for example whole. As the institution that represents society at large, the ajob 41
government will need to spearhead the effort to map a plan supply or demand side, in an individualized ad hoc capac- for all entities. Through the health constitution it will have ity. What is needed is the understanding that together, we the ultimate responsibility for making sure this societal obli- gation is met. The federal or national government has the Still, “free rider” problems and failures to comply are regulatory, legislative, taxation, and distributive authority omnipresent in health and health care. SHG, drawing on to oversee a just allocation of responsibility. The federal PST, can help address and minimize these concerns. One government has the authority and legitimacy to ensure the approach is to demonstrate dependence or co-dependence realization of important social goals. The health constitu- among individuals as parties to a social group. This ap- tion specifies the obligations of different actors. It is to be proach appeals to the individualistic, rational side of per- consistent with and undergirded by the public moral norms sons and to social rationality, simultaneously, but it requires monitoring, sanctioning, and a sense of co-dependence tomaintain stability (Hechter 1987).
EXTERNAL AND INTERNAL MOTIVATION: FAILURE TO
COMMIT, POSITIVE MOTIVATION, SOCIAL

REACTIONS AND OBJECTIONS
SANCTIONS, AND ENFORCEMENT
Reactions to the SHG model may come in a variety of forms, The challenge is for people to commit, share resources, and but I’d like to return just briefly to—and conclude with—a agree to be held collectively responsible. Thus, individu- discussion of what SHG is not in relation to existing social als and groups can’t internalize just any social norm; it is a set of public moral norms. Normative principles are dis- First, SHG is not social solidarity. SHG is not nearly as cussed and set forth, for example, in the health capability communitarian and allows a more central role for individu- paradigm, which spells out the reasons for equity in health alism and self-regarding behavior. While examples of social and explains why individuals and actors should see such solidarity in health systems exist—for example, in universal norms as socially rational. It may very well be, for example, coverage in countries throughout the world—SHG is not that many individuals, indeed most people in many soci- just universal coverage, does not require a “common con- eties, see health as an individual responsibility rather than science” across life, and recognizes realistically that actors a social obligation. In this case the heavy lifting is in peo- conflict considerably (rather than cohere) in the division ple committing, in persuading and convincing them of the of labor (Durkheim 1933). While social solidarity meets the necessity of the joint enterprise. This task in many cases is SHG idea of shared resources, it is less focused on people possible through positive motivation (see later description).
governing themselves to use resources parsimoniously.
There will also be a segment of the population that resists, Social solidarity also doesn’t emphasize individual action and, once institutions and procedures are put in place (as al- and individual responsibility and doesn’t embrace, to the ready described), in these cases an effective system of sanc- extent in SHG, the opportunity to build a social system tions, formal rules, and even laws and regulation may be out of individual self- and other-regarding behavior. The necessary to ensure that actors are fulfilling prescribed du- Swiss and German systems, for instance, exhibit solidarity ties. Thus, this fifth basic premise of SHG involves primarily in the form of universal coverage (in Switzerland there is positive, but in some cases negative, motivation to commit universal coverage and one-third of individuals receive to the joint enterprise. Even though numerous incentives government subsidies to purchase health insurance) and mechanisms of external motivation have been tried in (Herzlinger and Parsa-Parsi 2004), yet the Swiss system is virtually every health system worldwide, these efforts alone second only to the United States in the proportion of gross will not suffice to create the conditions approximating jus- domestic product (GDP) spent on health care (OECD 2004), and both Germany and Switzerland have had as much if Drawing on what Gilbert calls “common knowledge,” not more health care overutilization than the United States the task of positive motivation is to generate common (Weil 1994; Reinhardt 2004). Social solidarity is thus not knowledge, self-understanding, and societal understand- quite enough to contain costs and use shared resources ing so that individuals are clear about both the empirical wisely, nor are occupational or interest group affiliations evidence and the values: Individual and population health sufficient for solidarity in the health system; indeed, they are inextricably linked, and improving our own health and (e.g., medical profession and health insurance industry) that of others requires the shared commitment of us all.
require greater governmental oversight. It further neglects Health is a unique individual and social good, different to address many of the other elements of SHG, particularly from other types of private goods and requires a different those focused on responsibility, constitutionalism in health, magnitude of joint effort. Allowing self-interest maximiza- and individual-level costs and benefits.
tion to run rampant throughout the health sector produces Second, SHG is not socialism. Socialist health systems suboptimal outcomes for everyone. Redefining individu- are government funded and government run; the pub- als’ self-understanding and institutionalizing this common lic sector controls both funding and service delivery. The knowledge underlie the SHG framework. As it stands, in United Kingdom and Cuba are examples. By contrast, one many health systems, even those fully nationalized, actors of SHG’s distinguishing features is an emphasis on individ- see themselves as interacting with the system, either on the uals, private entities, and their actions, which are driven by 42 ajob
internalized norms promoting societal interests in addition Arce M., D. G., and T. Sandler. 2003. Health-promoting alliances.
to their own. A public system may not necessarily be in- European Journal of Political Economy 19: 355–375.
imical to SHG, though public funding and public service Armstrong, D. 2005. Medical center is investigated for scan deals.
delivery cannot preclude active individual involvement in Wall Street Journal July 28: B1.
Ashford, E., and T. Mulgan. 2009. Contractualism. The Stanford en- Third, SHG is not just stewardship. In a way, social cyclopedia of philosophy (winter 2009 edition), ed. E. N. Zalta. Avail- solidarity and socialism can both be considered as mani- http://plato.stanford.edu/archives/win2009/entries/ festations of government stewardship: Government (with various degrees of democratic backing) decides to imple-ment solidarity-based or socialist policies. As highly cen- Aumann, R. J. 2008. Game theory. In The new Palgrave dictionary of tralized and hierarchical health care systems show us, gov- economics (2nd ed.), ed. S.N. Durlauf and L.E. Blume. Available ernment directives and designs are not enough to ensure at: http://www.dictionaryofeconomics.com/article?id=pde2008 good health outcomes, and laws are not always sufficient to achieve health goals if popular norms oppose them. SHG Baird, P., J. Downie, and J. Thompson. 2002. Clinical trials and would seek to address pressure points where self-interest maximization and/or social norms override government Benda, D. 2003. Surgery charges high at RMC. Hospital ranked laws and projects. In Japan, for example, despite legislation fifth in U.S. for operating room markups. [Redding, CA] Record to promote organ donation, rates of donation are low and have been falling since the mid-1990s. One barrier is the re-luctance of family members to grant permission for organ Bentham, J. 1961. An introduction to the principles of morals and removal from the deceased (Ishida and Toma 2004). Govern- legislation. Garden City, NY: Doubleday. [Originally published ment action has not been able to overcome this normative Binmore, K. 2005. Natural justice. New York: Oxford University Fourth, SHG is not just enhanced autonomy, shared clin- ical decision making, or enlightened self-interest. SHG is Blakeley, G. 2010. Governing ourselves: Citizen participation and more than consumer-directed medicine or the patient tak- governance in Barcelona and Manchester. International Journal of ing an active role in her own care with her physician or team Urban and Regional Research 34(1): 130–145.
of providers. Decisions should account for both individual Bombardier, C., L. Laine, A. Reicin, et al. 2000. Comparison of upper and societal interests at every stage. Finally, following prin- gastrointestinal toxicity of rofecobix and naproxen in patients with ciples of “enlightened” self-interest or self-interest “rightly rheumatoid arthritis. The VIGOR study group. New England Journal understood” (de Tocqueville 1863), while interesting in the of Medicine 343: 1520–1528.
abstract, has failed to curtail the emergence of the currentdysfunctional American health care system. Relying on en- Bowles, S., and H. Gintis. 2008. Cooperation. In The new Palgrave lightened self-interest as a guiding principle leaves us with- dictionary of economics (2nd ed.), ed. S.N. Durlauf, and L.E. Blume.
out an overarching social objective toward which all have Available at: http://www.dictionaryofeconomics.com/article?id= respective roles and responsibilities in the joint enterprise Broome, J. 1991. Weighing goods. Oxford: Blackwell.
Buchanan, A. 2009. Justice and health care. New York: Oxford Uni-versity Press.
CONCLUSION
Cudd, A. 2008. Contractarianism. The Stanford encyclopedia of phi- Achieving justice in health has eluded most nations. Eco- losophy (fall 2008 edition), ed. E. N. Zalta. Available at: http://plato.
nomic rational choice theory based on Homo economicus, the stanford.edu/archives/fall2008/entries/contractarianism dominant social theory of cooperation, has failed to ground De Tocqueville, A. 1863. Democracy in America (3rd ed.) Cambridge, an effective approach to health. Even when societies coop- erate on a grand scale through national health policy andnational health systems, they do so in vastly different and Durkheim, E. 1933. The division of labor in society. New York: Macmil- often inadequate ways. It is a daunting challenge to allocate responsibility, resources, and sovereignty to create condi- Estlund, D. 2008. Democratic authority: A philosophical framework.
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ject to SHG on the account that its conditions are too onerous Finz, S. 2003. Guilty plea in medical fraud—12 patients die/Bay and arguably implausible. Despite objections, shared health area branch of Guidant fined $92 million over malfunctions. San governance offers a promising new way forward.
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