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Society's Choices: Social and Ethical Decision Making in Biomedicine
The experience of the passage of the ADA suggests that the legislature can most effectively act in situations where it is implementing the will of society, where pressure groups act in unity, and the opposition is muted. This is true majoritarian politics. When it works, it can provide powerful and lasting benefits to society. The problem, however, is that legislative processes rarely work in an atmosphere of consensus, especially in the highly controversial health policy arena.
In health policy, the issues are often bitterly contested and divisive. One disease may be pitted against another. For example, legislators may be lobbied to divide scarce resources between competing diseases such as AIDS, tuberculosis, cancer, heart disease, and mental illness 67 or between competing segments of the health care industry such as prevention, acute care, long-term care, and research. The interests of patients may be pitted against those of health care professionals. A pertinent case is the ongoing struggle between doctors and patients for the "right to know" the HIV status of the other. Struggles between generations are even apparent as debates ensue about who should bear the financial burden of paying for health care and who should receive the benefits-the young versus the old, the poor versus the rich, the healthy versus the sick.
A classic example of legislative failure to produce a badly needed public benefit is in health care reform.68 Health care reform, on its face, ought not to be inordinately difficult for legislatures. A substantial majority of Americans express dissatisfaction with the health care system.69 Indeed, both candidates in the 1992 presidential campaign supported health care reform.70,71
The current system has failed to provide universal access to health care with an equitable sharing of benefits and burdens. An estimated 37 million people do not have health care coverage, with many more people inadequately covered.72 Disparities in access to health care and poor health outcomes have been shown on grounds of socioeconomic status,73,74 race and ethnicity,75 and gender.76
The current system has also failed to control escalating health care costs relative to health care expenditures in other countries. The United States spent more than $666 billion on health care in 1990, approximately 12 percent of the nation's gross national product.77 Health care expenditures are projected to reach $1.6 trillion, between 16 and 18 percent of the gross domestic product by the end of the decade if effective controls are not instituted.78
Given the fact that the current system appears not to serve the interests of large numbers of individuals, as well as the fiscal interests of American society, one would have expected Congress to act. Prominent members of Congress have worked on commissions and other initiatives to accomplish that objective,79 and congressional committees have conducted many hear-