Core Values in Health-Care
A Communitarian Approach
Christine Cassel, Charles Dougherty, Amitai Etzioni, C.
McCollister Evarts, John Griffith, James L. Nelson, Marian Osterweis,
and Daniel Wikler
Health-care reform is upon us. We urge that core values other than curbing costs and
ensuring universal access be given due consideration. We all favor saving money; indeed,
controlling health-care costs should allow the nation to provide more health services and higher
quality care. We also strongly favor the inclusion of all Americans in our health-care system.
However, we are deeply concerned that many of the reform efforts currently under review will
unwittingly undermine the culture of care in their pursuit of savings and access.
We rise to speak for the moral commitments, the social and institutional arrangements
that are essential to maintain both the trust between patients and health-care professionals, and
the professional commitments of health-care personnel. Let us not turn the health-care
community into a health industry; let us take the steps necessary to sustain and nourish the care
in health care. Specifically, we raise a communitarian voice for:
. sustaining the balance between individual rights and social responsibilities,
especially regarding that which we must do on our own, and for others, and that which we
can legitimately expect from others in the way of health care. As a matter of simple
justice, we believe that it is legitimate to ask one and all to make a contribution to the
commons and not simply seek more from the commons.
. the need to protect the moral integrity and unique character of the health-care
system. In particular, we warn against the intrusion of commercialism and the managerial
imperative. Unless health-care reforms are carefully crafted, they may undermine a
system which is far from flawless but treats millions every year--with a great deal of
. the imperative of providing coverage for and crafting a health system in which
preventing disease and promoting health are an integral part of the plan, not
. the imperative of reforming other aspects of American society to reduce the
burdens on our health-care system. We must not treat health care as the social garbage
can into which we deposit the ill consequences of our nations problems, and expect it
readily to absorb the costs.
. the moral justification for cutting administrative waste, defensive medicine, lavish
promotions and excessive profits before we begin rationing beneficial and humane health
. the priority of serving children, that vulnerable group of society which has no
vote, has no political muscle and represents the future of the nation.
. and, the social responsibilities of health-care professionals, who ought to raise
their moral voice to alert and counsel the society within which they work.
Only by attending to these signal areas, as we attempt to provide every American with
decent health care, will we ensure that our health-care system will sustain rather than lose the
culture of care and the moral values and institutional arrangements that sustain it.
I. On Keeping the Care in Health Care
1.1 Sustaining Factors
Health care suffers deeply, and may indeed ultimately be perverted, when attempts are
made to provide it as if it were just another service. Patients should never be treated as
consumers or clients; physicians and other health-care professionals should never see themselves
or be treated as though they are simply producers; and the relations among health-care
institutions and patients should never be one of the market. Health care requires a culture of
caring, moral commitments to be met by health-care professionals, and trust by the patients.
There is no denying that economic factors affect health care or that we must attend to
rising costs. However, the culture of care will be undermined and may ultimately be lost if health
care comes to be treated as just another industry or business. Highlighting economic
considerations at the expense of moral, humanitarian, and social considerations may end up
lowering costs but at the price of ultimately bankrupting the integrity of the system. We must not
take the care out of health care.
This is not an idle concern. Reforms in many areas have too often led to unanticipated
consequences. For instance, it is widely agreed that the campaign-financing reforms that
followed the Watergate scandals are a major cause of the problems that currently plague our
political system. We must be vigilant that as we move to curb unnecessary and unduly costly
procedures, we do not undermine the commitments and relations that are essential to a
Specifically, we submit that a system that maintains and reinforces personal relationships
between physicians, as well as other health-care professionals, and patients is preferable to one
that disallows or discourages such relations. Such relations nourish the moral commitments of
health-care professionals and sustain trust between the patient and doctor.
Health-care professionals are expected to put their patients ahead of their own
self-interest, to maintain high standards of competency, and to respect patients values. The most
ancient codes of the medical profession, for example, center around an ethic of paternalistic
beneficence. Although modern thinking and practice may reject some aspects of that paternalism,
it should not reject the beneficent concern for the welfare of the patient who is in a vulnerable
We note that a system that imposes specific economic-based performance (as distinct
from quality of care) measures on physicians and other health-care professionals in order to save
resources will tend to undermine the culture of care. Already, some health providers require
health professionals to see patients for ever-shorter periods of time, and, because of economic
pressures, deny procedures physicians believe are required. At the same time, other health-care
managers are "gaming" the system by putting undue pressures on health-care professionals to
order unnecessary tests or focus on bookkeeping rather than legitimate and compelling health
Although our concern here is with moral considerations, we note that excessive economic
pressures (and the micro-management these pressures often entail) may not reduce costs because
they tend to absorb large amounts of money in an administrative apparatus. In contrast, systems
that set overarching economic limits, such as budget caps, but leave the specific decisions to
health-care professionals and their communities, seem to be both more sensitive to the culture of
care and more economical than micro-managed, highly-regulated systems.
e note that discussions of managed competition (a concept that has numerous definitions)
often suggest that it will have the benefits that many market theorists associate with free markets.
This view stresses the "competition" element and downplays the "managed" part. In effect, a
health-care system in which providers compete without clear and effective regulations may tend
to avoid high-risk patients, screen out patients from lower socio-economic backgrounds and
minorities, reduce quality and focus on frills. In short, to the extent that the nation moves toward
managed competition, the emphasis will have to be on the "managed" (albeit not micro
managed) part rather than on uncurbed competition. Rules must be developed that ensure
attention to the values that we fear will be neglected: universal access, professionalism, and
humane commitments--the culture of care.
1.2. Community-based Institutions and Services
We note that health-care institutions, somewhat like schools, often serve as the core
institutions of residential or non-geographic communities (e.g., religious ones). We believe that
sustaining communities is a significant social goal and any changes that break the close
connection between a community and a hospital (or other health-care institutions) should be
made only where there are major benefits incurred from such a break.
II. Cost Reduction in a Communitarian World
The notion that "we spend too much on health care" has no moral standing. There is no
specific amount of money that is the correct amount. The idea that if we would spend less on
health care we would spend more, say, on education, is erroneous; it assumes a system in which
there are only two social needs that require resources and a political mechanism that ensures that
resources released from health care will be dedicated to education. Our society spends huge
amounts of resources on arms, useless and harmful consumer products, excessive administrative
waste, and other needless items. Spending less on health care could well mean spending more on
any of these items. If education or other deserving social needs require more resources, those
resources should be taken from these socially unredeeming expenditures, public or even private,
before one curtails beneficial health care.
A much more accurate and productive definition of our health-care "crisis" is that we are
achieving relatively few health-care benefits for the resources dedicated, compared to other
countries. Or, to put it differently, we are getting a low health-care bang for our bucks. These
observations point to the need to determine the structural sources of our low health yield per
dollar spent and address these factors. Otherwise, reforms may well lead us to a system in which
expenditures may rise less quickly but large portions of expenditures remain ill spent. This would
mean that health care would be curbed, but not excessive administrative waste, unnecessary care,
profiteering, litigation and other unhealthy proclivities within the system. The recent discussion
has focused unduly on patients who use "too many" services (allegedly because third parties pay
for them) and not enough on bureaucrats, the lifestyle of some health-care providers and
professionals, and the fees of trial lawyers.
For instance, taxing health-care benefits will lead many patients to use fewer resources,
even when they ought to use them by any medical judgement, but will leave intact several other
sources of high costs. Managed competition may lower some of these costs (e.g., administrative
waste) but do little to curb others (e.g., litigation and defensive medicine). These sources of
excessive administrative costs should be dealt with directly.
From a strictly ethical viewpoint, there seems to be no justification for cutting health-care
services that have proven to be beneficial to anyone, before the following structural corrections
. Reduce Administrative Costs. The United States is said to spend up to 24% of its
health-care resources on administration and paper work compared to around 11 % in the
Canadian system.1 Reducing these costs substantially, say to 14%, could be a major
source for health-care savings. More than money is squandered by our distorted
health-care system: health-care personnel who could be caring end up pushing paper
instead of attending to the ill.
. We must enact tort reform to dramatically reduce malpractice insurance fees and
defensive medicine. Limiting benefits for pain and suffering, and using arbitration and
mediation are among the mechanisms that should be considered.
. We must also stop performing procedures that are unnecessary or have shown no
proven health benefit. Some studies suggest that they amount to more than 20 % of all
. We could save billions a year by insisting that drug companies stop promoting
their wares by unsavory means such as granting individual physicians and members of
hospital pharmacies free entertainment, meals and travel expenses, other high-pressure
sales tactics, and undue lobbying.
. Reduce profiteering by suppliers, insurers and health-care professionals which
drives up costs and undermines the publics trust in the system.
. Above all, we must call societys attention, in the strongest possible terms, to
other sectors that impose huge costs on the health-care system. It makes no sense to bind
the wounds of gun shots, and disregard the guns. We should not just take out the lead
from the bodies of children but also from the walls of the apartments they live in. We
should not just provide chemotherapy and radiation treatment but reduce the carcinogenic
elements in the world that surrounds us. These steps would do wonders for health-care
costs and for the American peoples well being. The same holds for enhancing car safety,
and pollution controls, and providing meaningful jobs to those often shut out of our
economic system. Together, these changes in non health-care sectors may do more to
reduce health-care costs than any changes within the health system.
Until such measures are taken and major progress is made, we fail to see the moral
justification for systematically and deliberately denying health-care services that have proven
benefits--so-called rationing. True, our system has already built into it various kinds of
rationing. But the fact that they are in place does not indicate that they are morally justified or
should be extended under the present conditions.
It might be important in this context to note that many religious and secular ethical
traditions distinguish between undesirable behavior and systems that are in place and acts of
active commission that add injury to existing injustices. The fact that there is some rationing in
America that is extremely difficult to remove does not suggest that adding to it is morally
We are not suggesting that additional rationing should never be considered. But we are
arguing that ethically it should come into play only after a serous attempt has been made to
improve the health yield by going after the red tape, unnecessary procedures, and other waste
before beneficial services are cut to anyone.
We find particularly troubling those arguments that favor systems that "ration" for the
poor but not for anyone else (for instance, for those on Medicaid but not on Medicare), or for
those who are members of a particular age group, disregarding their health status, and their
capacity to return to a productive and loving life.
If rationing occurs, age alone should not be the determining factor in rationing health
care. It is natural that the elderly should consume more health-care resources than other age
cohorts, just as the young consume more educational resources. Age should only enter decisions
about rationing when, along with other considerations, it is relevant in assessing the likely
outcomes of medical intervention. Otherwise it is a discriminatory consideration.
The communitarian values in providing health-care services are related to the value of
health to the extent that health-care services can restore individuals to a healthy state. Many
times health-care services cannot do this, but may provide comfort, palliation, improved
functional status or prolongation of life, even without restoration of health. A communitarian
value underlying the provision of that set of services would be better described as compassion.
One wants to live in a society in which ones own suffering would be tended to and
ameliorated whenever possible. Thus, we do this for others in order that the society we construct
is a caring one. This caring, however, does not logically include either futile attempts or curative
therapy of life extension beyond a point of meaningful participation in that life.
Communitarianism would reject simple vitalism as a value underlying the application of
health-care services and would seek rather a definition which both promotes the relatedness of
individuals to one another in the community and the positive and cohesive value of caring.
III. Children First
In a perfect world everyone would receive all the health care they require. Ethicists, though,
have long recognized that postulating such utopian states provides precious little guidance for those
who must act in the real world. We must hence take for granted that, even as a universal health care
system is introduced to these shores, at least initially, it will encompass some treatments and services
but not others.
Given the necessity of a gradualist approach to expanding the scope of care, in terms of what
is included in the package to be provided, the question arises: Once additional resources are freed
up (through cost controls, special taxes, or some other way) how may these resources best be
applied? A case could be made to provide some additional services to all (say, home health care).
We urge, as a first priority, that as new resources become available (after all the population is
provided with an elementary package of health care), they be dedicated to children, especially to
Children are the most vulnerable group of society. They do not swing elections or
demonstrate in Washington. Ensuring their health is a highly commendable way to use new
resources because children still have a whole lifetime ahead of them, and they will be called upon
to provide for the nation. As children grow older, we hope that an extended package of care will
grow with them until there is no one left without extended coverage.
IV. Responsibilities and Rights
4.1. Individual Responsibilities
Every person has a basic responsibility for his or her own health. This entails taking care of
oneself to the best of ones ability, minimizing dangers to the health of others, and reducing the
burdens one may impose on the community. No person is an island; we are all members of a
community, responsible for one another and the world which we share.
In the past, when most diseases were of an acute, infectious character caused by poor
sanitation or some other social condition, there was relatively little individuals could contribute to
the improvement of their personal health and to public health. In recent decades, however, as the
disease mix has changed and our knowledge of the role of behavior has grown, it has become evident
that changes in ones individual lifestyle have significant affects on personal and public health, and
on the social and economic burdens imposed on the community.
It follows that even under adverse circumstances, out of concern for others and ones own
dignity, all persons are expected to do their share to enhance their health and to reduce their burdens
on others. To take an extreme example: a quadriplegic permanently committed to a bed, able only
to turn the pages of a book by the use of a small device controlled by his or her mouth, should be
expected to do that much rather than to call for an aide each time a page is to be turned. The same
holds for all Americans. The fact that social forces may account to a significant extent for ones
condition and limit ones choices does not exempt one from the duty of helping oneself and not
unnecessarily burdening others.
In particular, all members of the community should be expected to change their lifestyles in
ways that ensure that they do not harm others, unnecessarily impose health-care burdens on the
community, or abuse their own health, in and of itself a treasure of the community. Smoking,
drinking alcohol to excess, and irresponsible sex are clear and significant examples of irresponsible
behavior that meet all three criteria. Such behaviors also satisfies an important fourth criterion to
qualify as a legitimate communitarian claim: there is a clear and significant correlation between
behavioral changes on the one hand and health outcomes on the other.
Health is determined by many factors. Often, the connection between behavior and changes
in health is not firmly established, the efforts needed to improve unhealthy behavior are gigantic and
the results are limited. Dieting to reduce cholesterol, for instance. The moral claim we seek to
establish arises most clearly when the change in behavior is either relatively easy to make, and/or
the health outcome is well-established, and/or the consequences of ones effort is substantial.
Wearing seatbelts and motorcycle helmets meet all these criteria. Refraining from smoking, drinking
alcohol only in moderation, and engaging only in safer sex are a close second. Dieting, exercising,
and sleeping eight hours a night, while commendable, do not seem to qualify at the present state of
To argue that there is a moral claim for people to act responsibly suggests that those who do
not live up to these claims ought to be subject to social censure, while those who do discharge their
responsibilities are to be awarded social approbation. Before any stronger enforcement measures for
poor-health behavior are considered, and while they are undertaken, intensive efforts should be made
to inform and educate the public about the health consequences of their behavior, and the need to
act in socially responsible ways, as well as to call upon their nobler selves to live up to their personal
responsibilities. Informing and educating should encompass the provision of those services, from
counseling to rehabilitation, that people require to help them change their habits.
Those who have been informed and educated but disregard the message may be prodded by
the imposition of some extra charges. These will not prevent them from obtaining care but will serve
as symbolic reminders of communal displeasure that these people continue to neglect their health.
These charges will also shift some of the extra costs they generate back to those who contribute an
excessive burden. Thus, we see merit in assessing additional health insurance charges to those who
smoke or accumulate speeding tickets, and, conversely, granting discounts to those who do not, as
long as such premiums are moderate. At the same time, because such poor behavior is, in part, driven
by social and genetic factors over which individuals have little control, these charges should not be
so severe as to absorb fully the extra costs entailed (for instance, a $12.50 a month surcharge which
some insurance companies exact on smokers, rather than, say, a $125 surcharge).
For the same reasons, it is justified to tax "sins" because raising the costs of cigarettes and
alcohol are a particularly effective way of discouraging both young people from becoming addicted
and also encouraging those addicted to rehabilitate themselves3. The regressive character of sin taxes
can be corrected for, as the Clinton Administration already plans to do, by introducing a graduated
earned income-tax credit to all those below a certain level of income.
Society has been reluctant to use its regulatory power to encourage changes in lifestyle that
promote health. We believe that regulations that require seatbelts, motorcycle helmets, and sobriety
checkpoints--as long as they encompass only those changes in lifestyle singled out above--are fully
justified. Given that we live in an age of exploding health-care cost that are forcing us to consider
draconian measures to reduce health-care costs--even to the point of cutting off services that are
clearly beneficial in order to save money--some regulation of ill behavior seems appropriate. At the
same time, it is unduly harsh and flies in the face of human nature to refuse treatment to those who
did not abide by these claims. The community has a responsibility to care for one and all, even if
individuals have failed to fulfill their responsibilities in one way or another.
It should be noted, however, that whenever regulatory power is used, special measures must
be taken to avoid undesirable side effects. For instance, should HIV testing be introduced, special
pains must be taken to provide counseling and to protect privacy.
Some argue that the body is our own property and hence we should be free to treat it as we
wish, that a person has an inalienable right to, say, abuse drugs. They further argue that since adults
have to live with the consequences of their acts, they should be free to make their own choices, and
that all other approaches to human behavior are "paternalistic." We note, first of all, that individuals
who act irresponsibly do impose "their" costs on the rest of us; smokers, drunken drivers, and those
who engage in irresponsible sex endanger others and not merely themselves. There is no way the
irresponsible can limit dire consequences to themselves.
Second, we care about the persons involved. Some became addicted to unhealthy behavior
before they reached adulthood; many others clearly indicate that they wish to break out of their
addictive behavior but are unable to act without community help. Thus, while we would deem it
paternalistic to impose our preferences on a person (say, make a person who is an avowed atheist
attend a prayer, or vice versa), to help a person who already has been to several clinics, bought
nicotine patches and otherwise tried to break the habit of smoking, is like providing a drowning
person a life preserver.
There are others who argue that people conduct themselves irresponsibly simply because of
social conditions not of their own making. Indeed, increases in unemployment, for example, help
drive thousands to drink and smoke. Society should work to mitigate these stress-producing and
other unhealthy conditions. However, it does not follow that, however pressing the social factors,
individuals are left without any room for personal choices nor that the community must assume all
responsibility for their care just because the social conditions are unfavorable.
While the preceding observations hold true at all times, they are especially compelling under
the crisis conditions in which we seem now to find ourselves. Indeed, it might be argued that a major
way of enabling us to provide health care to all Americans would be for Americans to act more
responsibly in such matters than they did in the past. Just as it is always inappropriate to waste water,
but especially in a drought, so we hold, all Americans must help bring health-care costs down by
acting more responsibly.4
4.2 Responsibilities to and by Others.
All Americans should be expected to take the best care they can of those closest to them.
Elderly men and women should not be dumped into nursing homes and left there with rare family
visits. Children should not be left unattended in public libraries or placed in child-care centers that
parents have barely examined. Of course, it is true that our society should do much more to enable
families to earn an income that is sufficient, in turn, to enable them to discharge their responsibilities
to their parents and children. But we must also avoid creating ever more government-financed
institutions that seek to replace the care that families, as a rule, best grant to their members. Dying
in a hospice, for instance, might be more humane than dying in a hospital, but we should not rush
to institutionalize the dying; rather, whenever possible, we should enable people to die at home with
their families. Visiting nurses and counseling services should be made available to families and
individuals as an important first step.
4.3 The Role of the Government and Its Responsibilities Versus a Right to Health Care
To the extent that people cannot take care of themselves and their own, directly or indirectly
(by pooling resources), the government should step in to ensure that health care is available to all.
It should be the governments responsibility to provide health care when all else fails. This
responsibility is rooted in our elementary sense of compassion for the more vulnerable members of
There has been a long and intensive debate regarding whether or not individuals have a right
to health care or whether it is merely a communitys responsibility to provide it.5 Those of us who
are concerned about the incessant minting of new rights, the spiraling social and economic costs of
new entitlements, the tendency to interpret rights as absolute "trumps" and to litigate over rights, are
troubled by this development.6 At the same time, we recognize that calls for a right to health care
are rooted in a deeply-held conviction--one that we fully share--that no one should be left without
needed health care.
As we see it, the debate is now reaching a socially beneficial and fair conclusion: once health
care is available to all Americans, under government prodding, supervision and partial funding, the
question of whether or not Americans are entitled to health care as a matter of right or as a matter
of social responsibility, becomes largely a theoretical one.
Now, the discussion by necessity focuses on the scope of responsibility--what is to be
encompassed in the elementary package of health benefits. Nobody can seriously argue that everyone
has a constitutional right to a particular list of treatments (a check up every year, an x-ray but not
necessarily an MRI, and so on). Accordingly, the range of available treatments clearly must be sorted
out by a set of principled criteria and through the democratic process.
V. The Social Responsibilities of Health-Care Professionals
Because of their special knowledge in matters of health, their unique moral commitments,
and their privileged and powerful positions in society, health-care professionals have a special social
responsibility to minister not merely to their patients as individuals but also to the societal conditions
that deeply affect their patients.
We join here those who have argued that just as it is morally inappropriate to argue that the
only business of business is business, so it is similarly inappropriate to argue that health-care
professionals fully discharge their duties only as practitioners. We agree with the American Medical
Association (AMA) statement: "The responsibilities of the physician extend not only to the
individual, but also to the society and demand his cooperation or participation in activities which
have as their objective the improvement of the health and welfare of the individual and the
Some social responsibilities are already built into physicians roles, and we fully endorse
those; for instance, the requirement to report to public health authorities the presence of certain
contagious diseases, and the requirement on psychiatrists to report to law enforcement officials any
credible threats their patients may pose to others and the public. We see a need for a much greater
social role for health-care professionals. We applaud the physicians who demonstrated before car
exhibitions to call attention to the reluctance of auto manufacturers to make safer cars; we see much
merit in the work of physicians who warned society about the dangers of pollution and nuclear war.8
It is important that when health-care professionals act in the public interest they make it clear
when they are drawing on their special training, expert knowledge and professional experience, and
when they are acting merely as concerned citizens, speaking to matters about which they have no
more knowledge than other citizens. Otherwise, their fellow community members may be misled
as to the basis of their actions.
The specific mode of discharging ones social responsibility is less important. Some may
wish to testify before legislatures, others to join demonstrators. Some may wish to bear witness,
others to write letters to the editors or join call-in shows. In any instance, health professionals
engaged in fulfilling their social responsibilities should not be censured for "embarrassing" the
dignity of the medical profession. On the contrary, they should be recognized as a credit to their
Not only do individual health-care providers have a special responsibility to work to improve
conditions that affect health, but the health-care professions also have a social responsibility to work
to improve the health of all citizens. This responsibility means that all professional groups should
speak out about health and health care, and act in ways that promote and ensure the provision of all
levels of health care including special attention to primary care and preventative services.
Discharging this responsibility fully and effectively requires a level of interaction among the
professions that has been traditionally lacking. Especially in light of todays complex array of health
and social problems, the health professions must work together to ensure health care for all and to
overcome the social conditions that contribute to poor health.
This position paper was drafted by Amitai Etzioni drawing extensively on written statements
provided by Christine Cassel, Charles Dougherty, C. McCollister Evarts, John Griffith, James L.
Nelson, Marian Osterweis and Daniel Wikler. The paper grew out of a group discussion conducted
under the auspices of the Association of Academic Health Centers which included the above and
Alexander Capron of the University of Southern California, Thomas Detre of the University of
Pittsburgh, J. Michael McGinnis of the Department of Health and Human Services, and Elaine Rubin
of the AAHC.
The draft document was further discussed during a combined session of two task forces of
the AAHC, the task force on Health Care Delivery, chaired by M. David Low of The University of
Texas Health Science Center at Houston, and the task force on Leadership & Institutional Values,
chaired by John Griffith of Georgetown University Medical Center. This session led to the final
revision of the paper.
At the Communitarian Network, W. Bradford Wilcox directed the process. Also, David S.
Brown contributed editorial comments.
About the Authors
CHRISTINE K. CASSEL is Chief of the Section of General Internal Medicine and Director of the
Center on Aging, Health and Society at the University of Chicago. The author of more than 100
articles in medical, policy and scientific journals, Cassel is a past president of Physicians for Social
CHARLES J. DOUGHERTY is Director of the Center for Health Policy and Ethics at Creighton
University. The author of American Health Care: Realities, Rights, and Reforms, Dougherty served
on the Clinton Health Care Transition Team.
AMITAI ETZIONI is Editor of The Responsive Community and University Professor at The George
Washington University. He is the author of The Spirit of Community.
C. MCCOLLISTER EVARTS is the Senior Vice President for Health Affairs and Dean of the
College of Medicine at The Pennsylvania State University. The author of over 175 scientific articles,
Evarts is also a member of a Health Care Advisory Committee for the United States Congress.
JOHN F. GRIFFITH is the Executive Vice President for Health Sciences and Executive Dean of the
School of Medicine at Georgetown University. He is immediate past chairman of the American
Board of Pediatrics.
JAMES LINDEMANN NELSON is Associate for Ethical Studies at The Hastings Center and has
authored publications in such leading journals as The New England Journal of Medicine, The
Hastings Center Report and Bioethics.
MARIAN OSTERWEIS is the Vice President of the Association of Academic Health Centers. She
has served on staff of the Institute of Medicine and the Presidents Commission for the Study of
Ethical Problems in Medicine and Biomedical and Behavioral Research.
DANIEL WIKLER is Professor in the University of Wisconsin Medical Schools Program in
Medical Ethics, and in the Universitys Department of Philosophy. Wikler was Staff Philosopher for
the Presidents Commission for the Study of Ethical Problems in Medicine.
. The Association of Academic Health Centers Task Force on Health Care Delivery
Chairman: M. David Low, M.D., Ph.D., President of The University of Texas Health
Health Science Center at Houston
. The Association of Academic Health Centers Task Force on Leadership and
Chairman: John F. Griffith, M.D., Executive Vice President for Health Sciences of
the Georgetown University Medical Center
Individual Endorsements by Association Leaders:
(organizational affiliation provided for identification only)
. Roger J. Bulger, M.D., President of the Association of Academic Health Centers
. Richard J. Davidson, President of the American Hospital Association
. Larry S. Gage, President of the National Association of Public Hospitals
. Lawrence A. McAndrews, President of the National Association of Childrens
Hospitals and Related Institutions, Inc.
. John Rother, Director of Legislation and Public Policy for the American Association
of Retired Persons
(organizational affiliation provided for identification only)
. John Alksne, M.D., Dean of the School of Medicine for University of California at
. Sherry Arnstein, M.D., Executive Director of the American Association of Colleges
of Osteopathic Medicine
. Reed Bell, M.D., Chairman of the Section on Bio-Ethics for the American Academy
. T. Michael Bolger, J.D., President of the Medical College of Wisconsin
. Peter P. Bosomworth, M.D., Chancellor for the Medical Center at the University of
. Arthur L. Caplan, Ph.D., Director of The Center for Biomedical Ethics
. Gregory L. Eastwood, M.D., President of the State University of New York Health
Science Center at Syracuse
. John W. Eckstein, M.D., Professor of Internal Medicine at the University of Iowa
. Clyde Evans, Ph.D., Associate Dean for Clinical Affairs at Harvard Medical School
. Bernard J. Fogel, M.D., Vice President for Medical Affairs of the University of
. Joel L. Fleishman, First Senior Vice President of Duke University
. J. Richard Gaintner, M.D., President of New England Deaconess Hospital
. Donald C. Harrison, M.D., Senior Vice President and Provost for Health Affairs at
the University of Cincinnati Medical Center
. Charles R. Hatcher, Jr., M.D., Vice President for Health Affairs at Emory University
. Leo M. Henikoff, M.D., President of Rush-Presbyterian-St. Lukes Medical Center
. Richard Janeway, M.D., Vice President for Health Affairs at Wake Forest University
. Michael E. Johns, M.D., Vice President for Medicine at The Johns Hopkins
. Robert J. Joynt, M.D., Ph.D., Vice President for Health Affairs at the University of
Rochester Medical Center
. Ronald P. Kaufman, M.D., Vice President for Health Sciences at the University of
. Peter Kohler, M.D., President of Oregon Health Sciences University
. Ben W. Latimer, President of SunHealth Corporation
. M. David Low, M.D., Ph.D., President of The University of Texas Health Science
Center at Houston
. Richard A. Matre, Ph.D., Vice President for the Medical Center at St. Louis
. Russell L. Miller, Jr., M.D., Senior Vice President and Vice President for Health
Affairs at Howard University
. Richard L. OBrien, M.D., Vice President for Health Sciences at Creighton
. Lawrence J. OConnell, Ph.D., S.T.D., President and CEO of The Park Ridge Center
. Herbert Pardes, M.D., Vice President for Health Sciences at Columbia University
. Iqbal F. Paroo, President of Hahnemann University
. Perry G. Rigby, M.D., Chancellor of Louisiana State University Medical Center
. Richard D. Ruppert, M.D., President of the Medical College of Ohio
. W. Douglas Skelton, M.D., Provost for Medical Affairs at the School of Medicine
of Mercer University
. Tessa Martinez Tagle, President of the Miami-Dade Community College-Medical
. James A. Zimble, M.D., President of Uniformed Services University of the Health