Deliberating Healthcare Policy Objectives
George Cautherley, Convenor, Healthcare Policy Forum
When deliberating healthcare policy objectives, it is probably sensible to both consult foreign experiences and our faculty of reasoning.
In December 2001, the European Commission, in response to the challenges of population aging, costliness of medical technologies, and rising expectations of citizens, proposed three common objectives for all healthcare systems in the European Union. The proposed objectives were equal access to healthcare regardless of wealth or income, high quality of healthcare, and financial viability of healthcare systems. Further, these three objectives were to be pursued in parallel. In other words, considerations of financial viability must not compromise accessibility to healthcare. The three objectives were subsequently endorsed by the Council of the European Union in 2002. For Europeans, access to healthcare is a fundamental right enshrined in the European Union's Charter of Fundamental Rights, which states that "everyone has the right of access to preventive health care and the right to benefit from medical treatment". The Commission's proposal was a reiteration of the Union's commitment to upholding its citizens' equal rights to healthcare.
In 2003, Ministers of Health from Chile, Germany, Greece, New Zealand, Slovenia, Sweden, and the United Kingdom established The International Forum on Common Access to Health Care Services. The Forum is based on a common belief that healthcare systems should aim to ensure universal and equitable access to good quality healthcare for citizens. What is more, the Ministers were united in defending this objective in face of the oft-cited challenges to all healthcare systems, namely, aging population, rising medical costs and rising citizen expectations.
Thus, foreign experiences appear to suggest that equal access to quality healthcare and distribution of healthcare based on healthcare needs is one central objective that many healthcare systems commit to. Most notably, the countries cited above have chosen to reiterate their commitment to this objective amidst dire financial challenges.
One might query why equal access should be of such central importance in healthcare provision and why such a right should be ascribed with society obliged to such a responsibility. One may reason that sheer pragmatism would caution against trying to meet all healthcare needs of all members lest the "rights" claim create a bottomless pit and force society to forego other social objectives. One may also opine that members of society do not have claims on one another and while it would be virtuous to offer help to those in need, no right would be violated and no injustice incurred if help is not rendered or rendered only up to an extent.
To answer these challenges, some theories of justice and the notions of equal opportunity and normal functioning can be invoked. It can be argued that even if inequalities in the distribution of social wealth are allowed, society has a responsibility to assure all its members of equality of opportunity (or of life chances). This means that disadvantages conferred by factors not solely of one's own making or which were beyond one's control (for example, loss of employment as a result of economic restructuring), and which leadto the curtailment of one's opportunities should be compensated for. In relation to healthcare provision, many diseases and disabilities cannot be solely attributed to those impaired. To the extent that disease and disability impair individuals' normal functioning and restrict the range of opportunities open to them while healthcare plays an important though limited role in restoring an individual's normal functioning, healthcare contributes to the protection of equality of opportunity. If one agrees that protecting equality of opportunity is a social responsibility, one must also accept that equal access to healthcare should be guaranteed.
As for the worry about creating a "bottomless pit" in healthcare expenditures, equality of opportunity would only oblige society to provide the healthcare necessary for restoring a person's normal functioning. To the extent that normal functioning is susceptible to medical and scientific determination, it should not be impossible to work out a relatively objective baseline for deciding what healthcare ought to be provided and how to provide it in the most cost-effective manner.
In the context of Hong Kong, a related question is likely to arise, namely, whether Hong Kong is not already keeping to the principle of equal access as the government has repeatedly pledged that no one would be deprived of healthcare for lack of means. Perhaps not necessarily. The notion of "equal access" entails positive duties of ensuring access, such as analyzing, removing, and avoiding creating barriers to access. In comparison, the Hong Kong government's pledge appears to indicate a more reactive and residual approach because opening the doors to those who seek help is not the same as facilitating or enabling access. Take for instance, if there is no investigation into whether fee-waiver application procedures are unduly complicated or even humiliating, some who otherwise need medical attention may have already been deterred from seeking help. Likewise, if steps are not taken to ensure easy and equal access to information about available services, information deficit may constitute another barrier in the system. If society is serious about "equal access", a lot more is probably required than just keeping the doors open.
The Chinese version of this article was published in Ming Pao on 29 April 2006 (below).
醫療政策目標的思辯
高德禮(George Cautherley)，醫療政策論壇召集人
香港的醫療政策應該以什麼為目標呢﹖就這個問題，我們或可參考外國的經驗，並對其作出批判性的論證。
在歐盟，「醫療的享有」（access to healthcare）是《歐盟基本人權憲章》（Charter of Fundamental Rights of the European Union）所保障 的其中一項基本權利。面對人口老化、醫療技術日益昂貴及公眾需求不斷增加的挑戰，歐盟委員會（European Commission）在01年12月訂出各成員國醫療系統的3個長遠共同目標，並重申憲章對醫療權利所作出的保障。這3個共同目標為﹕
1. 不論收入或貧富，皆可平等享有醫療的照顧﹔
2. 高質素的醫療水平﹔及
3. 財政上的可持續性。
委員會並指出這3個目標必須同時併行。換言之，平等享有醫療這一目標不能因財政上的考慮而有所妥協。委員會這一目標建議於02年獲歐洲理事會（Council of the European Union）通過。
另一方面，智利、德國、希臘、新西蘭、斯洛文尼亞、瑞典和英國等7國的衛生部長於03年成立「共享醫療國際論壇」（The International Forum on Common Access to Health Care Services）。論壇的成立建基於7國對醫療系統目標的一個共同信念，即醫療系統必須保證人民能平等及普及地享有高水平的醫療照顧。值得注意的是，縱使醫療系統面對人口老化、醫療成本及公眾需求不斷增加等的眾多挑戰，7國仍一致地捍衛這一共同目標。
從以上的論述，似乎可見「平等享有醫療」和「醫療按醫療需要分配」是不少醫療系統所追求的目標。更重要的是，以上所提及的國家，在面對嚴重財政挑戰的同時，依然重申對這目標的堅持。
我們或許會問，「平等享有」為何這麼重要﹖為什麼要賦予每個人平等享有醫療的權利，並要求社會作出承擔﹖從現實考慮，社會能滿足每個人的醫療需求嗎﹖賦予每個人平等醫療權利，難道不會為社會的財政負擔構成一個「無底深淵」嗎﹖不會令社會無法追求其他共同目標嗎﹖有論者可能更會指出，社會對每個人的醫療需求根本沒有任何責任。社會可能基於「同情」或「慈善」的考慮，對有需要的人施以援手﹔但即使不伸出援手，也談不上是對人權的侵犯或造成社會的不公義。
就這些問題，我們可嘗試引用公義理論和「平等機會」（equal opportunity）及「正常活動功能」（normal functioning）兩個概念作答。我們可指出，即使社會接受財富不均、貧富懸殊，社會仍有責任為每個人提供平等的機會。由種種個人能力未能控制的因素而引致的不幸（例如由經濟轉型而導致的失業），並因此而引致的機會不平等，社會就有責任給與適當的補償或援助。由此引申到醫療的範疇內，我們可以作出以下的推論﹕
1. 患病與否很多時不是個人能控制﹔
2. 患病會損害個人的「正常活動功能」而引致機會不平等﹔
3. 由於醫療能恢復個人的「正常活動功能」，故此醫療對保障社會上機會的平等起一定作用。
假如我們認同保障機會平等是社會的責任，我們就必須同時接受「平等享有醫療」也應得到社會的保證。
上述的推論，同時可為回應「無底深淵」的憂慮，訂出醫療開支的一個底線。「平等機會」的考慮只要求社會承擔恢復個人「正常活動功能」的醫療支出。由於「正常活動功能」較能從醫學及科學的角度定義，要理出一張社會必須提供的基本醫療清單，應該不是沒有可能的。
至此，讀者可能會問，香港不是已保證市民能平等享有醫療嗎﹖有關官員不是諾「市民不會因沒錢而不能看病」嗎﹖要指出的是，「平等享有」這概念包含（entails）「主動責任」（positive duties）的意思﹔「主動責任」包括分析和清除對「平等享有」可能構成的種種障礙。相反，香港政府的諾，則看來多一點「被動」（reactive）的意味。政府的諾看來只限於「門是打開的」，病人摸上門來，不會因無錢而失救。但政府可有顧及醫療政策和系統內，有沒有令病人卻步的措施或其他障礙，從而令病人不願或不敢「摸上門來」﹖當政府考慮提高醫療收費並提出醫療收費減免機制時，可有同時研究申請程序本身可能構成的障礙﹖申請程序會否太繁複而令部分病者減少就醫次數或甚至卻步而延誤就醫﹖不同處境或階層的病人，是否平等地接收到醫療資訊﹖看來「門是打開的」和「保證平等享有醫療」之間，還有頗長的一段距離。
文章刋登於2006年4月29日明報
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