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Am J Public Health. 2008 Oct;98(10):1756-63. doi: 10.2105/AJPH.2007.121350. Epub 2008 Aug 13.

Ethics in American health 2: an ethical framework for health system reform.

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Yale University School of Medicine, Graduate School of Arts and Sciences, and Law School, 60 College St, PO Box 208034, New Haven, CT 06520-8034, USA.


I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination.

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