Core Values in Health-Care Reform
A Communitarian Approach

Prepared By
Christine Cassel, Charles Dougherty, Amitai Etzioni, C. McCollister Evarts, John Griffith, James L. Nelson, Marian Osterweis, and Daniel Wikler

Preamble

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 care.

. 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 afterthoughts.

. 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 services.

. 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 health-care system.

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 position.

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 care considerations.

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 are advanced:

. 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 procedures.2

. 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 justified.

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 prenatal care.

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 our knowledge.

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 our communities.

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 community."7

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 profession.9

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.

© 1993

Acknowledgments

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 Responsibility.

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.

Endorsements

ADDENDUM

Organizational Endorsements:

. 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 Institutional Values

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

Individual Endorsements:

(organizational affiliation provided for identification only)

. John Alksne, M.D., Dean of the School of Medicine for University of California at San Diego

. 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 of Pediatrics

. 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 Kentucky

. 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 Miami

. 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 University

. 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 Southern Florida

. 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 University

. 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 University

. 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 Center Campus

. James A. Zimble, M.D., President of Uniformed Services University of the Health Sciences

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