This article appears in the November 2001edition of the Catholic Medical Quarterly

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Kenneth Calman

Health Care Allocation : an ethical frame work for public policy. Edited by Anthony Fisher and Luke Gormally.

+Published on behalf of the Catholic Bishops� Joint Bioethics Committee by the Linacre Centre for Health Care Ethics, 2001, �14.95

This book makes it clear from the outset what its purpose is to be. It is to provide an ethical framework for policy making, but not to set out a blue print for resource allocation. In a sense this is the potential problem for the book itself. While an ethical framework is critical it is the second step, what this means for the use of resources, which is the problem faced by the doctor, nurse or health care manger. While this could be considered a major drawback.of the book, in fact the clarity of the framework developed may make it easier to tackle the consequences. It is to be hoped that this will follow.

There is a useful section in the beginning on the definition of the terms used and on the background to resource allocation and the problem of rationing. There is a fascinating analysis of the ways forward; spend more, be more efficient, distribute better. The key is the question of justice which is discussed in detail. The allocation of resources in an ad hoc way (the current practice) is discussed, as is the rise of market mechanisms. It is the "Golden Rule" which will set the agenda, "Do unto others as you would have them do to you". Where this model becomes difficult is in its implementation. In the Chapter on implications for public policy it states " is clear that healthcare spending should be sufficient to ensure access for all to a level of health care adequate to satisfy their general needs within a reasonable time and without unreasonable disincentives."

Herein lies the nub of the issue. If resources are not adequate to meet reasonable needs how should they be allocated to satisfy the "golden rule"? The authors rule out the use of an algorithm for this purpose and make the point that there is no right answer, only a number of inadequate answers. Allocation should be by recognising certain moral norms, virtues and values which guide and structure human choice. The list of such values and norms is well developed, and this critical section ends with the comment, "We argued in favour of an egalitarian distribution according to health care need, with a preference for those in greatest health care need, those other wise disadvantaged, and those upon whom others are dependent".

It is not difficult to agree with this statement. However it is the practical implications of it which remains difficult. The authors further argue that where difficulties in allocation occur that "a strong case can be made for shifting much of the responsibility for allocative decision making away from health care workers, while taking proper cognizance of their views." Once again this is a statement with which it is difficult to disagree.

How then can this book be summarised? First it present a coherent analysis of the ethical issues surrounding resource allocation and rationing. Second, it provides a framework around which decision making can take place. There are two remaining issues, recognised by the authors but specifically not dealt with, which need more attention. The first relates to what constitutes a "reasonable" level of health care allocation and how is this decision arrived at? The second is what to do if this allocation is not sufficient, and how then can the "golden rule " be implemented? These two issues deserve further attention and this book provides a platform for further work.

Finally it is always a pleasure to open a book and read a preface by someone you respected and admired. I was privileged to meet Cardinal Winning on a number of occasions and to share both his sense of humour and his humanity. It is fitting that it was he who chaired the Catholic Bishops' Joint Ethics Committee to begin this work. In his memory it deserves to be developed further .

Professor Sir Kenneth C Calman CBm FRSE, former Chief Medical Officer, Dept of Health is now Vice-Chancellor and Warden of the University of Durham


Peter Doherty

Theological Musings by Louis Marteau, The Dympna Centre, 4 Christ Church Oval, Harrogate, HG1 5AJ  Price �5.00.

Canon Marteau was formerly a very experienced sailor in his youth and his recounting his adventures when crossing the Channel are most exciting. Navigation is still his main hobby and with the aid of his computer he now pilots aircraft on his software into all the main air terminals.

In this small volume we join the navigator from his early days in a parish in the East End to being the representative of three Jewish Boroughs on the old GLC Youth Committee, Chaplain to a Mental Hospital, soap box speaker at Tower Hill to finally finding his main interest as a psychotherapist and founding the Dyrnpna Centre in 1971 which he directed for the next 25 years. It cares for the priests, religious and ministers of religion of all the Judeo-Christian denominations who were in some sort of emotional turmoil. Canon Marteau is not a doctor or psychologist, nor even a qualified theologian. He describes himself as a pastoral priest who has been fortunate to have been exposed to such a wealth of knowledge and to have sat at the feet of so many learned doctors, psychologists, anthropologists, sociologists and psychotherapists that he feels a responsibility to share some theological musings which may be of value to others. Humility is for Louis the greatest virtue; he describes himself as a dreamer, he plays with the dreams that may have some reality in the lives of those individuals whom he sees. He even points out that the reality of his work as a psychotherapist has taught him he is unable to know anyone, to understand anyone.

His training and experience has moved him to a study of the new philosophy of existentialism. Perhaps this should not be described as a dogma or system but more a philosophical trend or attitude. It became influential in continental Europe in the second quarter of the 20th century through the writings of Heidigger, Jaspers, Marcel and more popularly through Jean Paul Sartre.

It is generally opposed to rationalist and empiricist doctrines that assume the universe is a determined, ordered system intelligible to the contemplative observer who can discover the natural laws govern all beings and the role of reason as the power guiding human activity. Its view is that being takes precedence over that of knowledge in philosophical investigations. Existence is basic: it is the fact of the individual's presence and participation in a changing and potentially dangerous world. Each self -aware individual understands his own existence in terms of his experience of himself and his situation. The self is a thinking being which has beliefs, hopes, fears, desires and a will that can determine his action. On the other hand there were prominent Christian existentialists, notably Gabriel Marcel, who held that natural law was primary and who presumably influenced Louis. His musings led him wonder how this world view might affect our present expression of the mysteries of our Faith. Although they remain eternally true how can they be more readily accepted by the modern mind. ?

He discusses television. To what are we reacting ? Not the box of electronics but the performers. He feels they are with him in his room and have more effect on his life than fellow travellers in the underground or those passing him by in the street. In his view there is a peculiar reality about these people on the box who influence him sometimes in a most dramatic way. Their presence is a new reality .

He has a new view in the mystery of the Eucharist. The Real Presence is not as vivid to him in terms of �substance' and 'accidents' but in the reality of 'being' He is' with' Christ and He is with him. It is no longer the host - it is Himself. The words of the consecration have' turned on the box '. For Louis " the existential reality is that He is with me and that I am with Him "

But television is not the only, or even the most important of our present day world experiences. The satellite have an even greater impact. By being above the world's surface we are able to see the whole world as it is happening. It is now possible to be with one's relatives in Australia, talk to them and see them on our computers with the aid of a little camera. We can truly 'be' with one another in a real way. Our souls mingle, and support, accept and understand at the same time.

He then muses on the whole concept of prayer. For him God is the Divine Satellite. With Him and through Him we can 'be with' anyone any where. �Being with' is one of the most important thing in life. This is true prayer; to be with God.

For Louis the Real Presence is not so much an intellectual theological illustration of the substance and accidents of the Eucharist. The existential question must be asked - what or Who is present in the here and now? Only one and He is real.

There are many other fascinating theological musings interspersed with amusing anecdotes from a long and fruitful pastoral life.

The Westminster branch has been fortunate in having Louis' guidance over so many years and now that he has finally retired from that post we wish him even greater success in his future navigational forays.

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