Overview - abgeschlossen

Summary

´Health standards are the criteria used to determine whether an individual is healthy. But since the terms 'healthy' and 'ill', as used colloquially, are a matter of individual experience to some degree at least – in other words, there is no objective yardstick for comparing different subjects – we must consider ways of determining health standards in terms which are equally applicable to all subjects. It is essential to identify criteria in view of the fact that

- services for the restoration of individual health and for the prevention of illness have to be collectivized under a system of institutionalized health care;

- health services for individuals need to be apportioned due to shortages or on grounds of cost;

- health services for individuals must be allocated 'correctly', having regard for considerations of justice.

Collectivization, apportionment and allocation of preventive, diagnostic, therapeutic and other services are what makes it essential to determine health standards using standard criteria applicable to all subjects. Only when this has been done can we proceed to discuss the legal regulation and economic organization of health care. The formulation of health standards is also a concern of major importance when it comes to identifying the dividing line between the responsibilities to be shouldered by the health services and those by health and social policy. It is no simple matter to solve these problems given the considerable difficulties in defining standards. On the surface they are problems of semantic distinction, but ultimately they derive from conflicting interests. Where health services are collectivized, the settlement of these conflicts cannot be left to individual or party interests or else to public groups which lay claim to expertise.

The brief for a health standards research group ranges from elementary explanations of terms to recommendations for solutions in the light of health policy controversies. The following issues are of special importance:

1. It needs to be established whether it is preferable to formulate health or illness standards. Since health in the colloquial sense is taken to signify more than the absence of illness, the formulation of health standards makes considerable demands on the health care system over and above the diagnosis and treatment of illness. We can illustrate this with reference to the debate on preventive health care which has been going on for decades. To determine the type and extent of preventive health care services we first have to develop health standards. Similarly, the services to be provided by the health care system need to be distinguished from those which fall within he domain of the social system.

2. Many of the problems which arise when we seek to distinguish between health and illness revolve around whether standards should be defined with reference to objectifiable biological circumstances (naturalistic definition) or should rest on whether the individual feels healthy or ill (normative definition). But there are plenty of arguments in favour or avoiding such a stringent dichotomy and moving on to a complementary notion of health/illness.

It is incontestable that the diagnosis of illness must rest on 'facts' which can be verified scientifically. But illness as such is a normative concept. Hence the need to formulate a 'mixed' model. It follows that medical subjects must be construed not as natural sciences pure and simple, but first and foremost as 'practical sciences'.

3. The notion of health and illness is obviously subject to historical and cultural change. This is closely related to the normative nature of health/illness. Even the attitude of considering illness an acceptable occurrence or, alternatively, a defect to be remedied may undergo considerable change. The history of medicine reveals that certain states of the body and of the mind have been labelled 'pathological' at some times and 'non-pathological' at others. At present, however, it is the medical disciplines themselves which are the motor behind the changing notion of health/illness. Scientific advance has demonstrated that illnesses initially classified as psychosomatic are in fact infectious diseases (e.g. gastritis, type B), and behavioural disturbances have been shown to stem from genetic defects (e.g. Morbus Wilson).

4. The notion of health/illness in the medical sciences and in the various clinical disciplines is by no means uniform. Illnesses are defined by reference to the respective focus of interest, e.g. the anatomical structures affected, the physiological systems, the mode of transmission or the dispersion area. Neither does research in these disciplines pursue any single purpose except for the general concern to improve diagnosis and therapy. It should be verified whether the molecular medicine paradigm – i.e. the search for the molecular mechanisms at the root of illness – provide a basis for a single transdisciplinary definition which has an impact, among other things, on the development of health standards.

5. Health standards and the issues associated with them have traditionally been the preserve of expert committees. For some considerable time these committees have been employed as a vehicle to address questions inside and outside the health service (e.g. the Council of Experts 'Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen' reporting to the German ministry of health). More recently, however, interest has focused increasingly on calls for participation. The idea is that decisions of major importance to the common good should be taken with the involvement of the largest possible part of the population. The consensus conferences in Oregon, United States, are examples of this approach. But participatory opinion-forming methods do not guarantee inward or outward consistency, sufficient stability to ensure long-term practicability or scientific validity. We must therefore ask whether the opinions voiced by the public concerned do not require normative control as to their ethical foundations, elementary anthropological insights and scientific validity. This shows that we need to find a combination of expert culture and participation which does justice to the issues at hand.

6. Ever since the Occident began addressing 'health' and 'illness', it has been left to medical ethos to decide what falls into which category. We should recognize that this medical ethos has a legitimate part to play. Moves towards an universalistic ethics, e.g. the so-called Bioethic Convention, play a growing role given the rise of economic considerations in health services, the harmonization of European health care systems and the global dimensions of numerous issues. The traditional medical ethos must therefore be scrutinized to ensure it is a match for a health service under conditions.

In rather schematic terms, we may say the doctor-patient relationship is characterised by the doctor’s expertise and the patient’s complaints and desires. But the formulation of health standards extends beyond the sphere in which doctor and patient interact. When a health care system is of such complexity as those at the present day, it requires the expertise of many different disciplines to formulate health standards. Above all, they must accommodate economic, legal, historical and ethical considerations.