Health Care OLD News
Extracts from EEIN 1991-1994. Latest news is at the bottom. Provided by Eubios Ethics Institute , at
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Abbreviations for journals
A special issue of JAMA looks at ways to transform the US health care system JAMA (May 15). There are many articles. For comments also see BMJ 302: 1163-4. On the US health care system and possible models from Germany see Nature 351: 433. Their has also been much comment on Oregon's health care initiative, to aid the spreading of the medicare budget by making a list of priority diseases. For some see JAMA 265: 2218-25, 2232-5, 2237-8, 2856-8; Lancet 337: 891-4, 1027-8; BMJ 302: 1020. See also D.M.Eddy, "The individual vs. Society. Resolving the conflict", JAMA 265: 2399-2406.

A report on the Oregon health cost plan is in a 16 page supplement in the Hastings Center Report (May/June 1991). Also see JAMA 266: 417-20, and BME (June 1991), 32-5. A book review of John F. Kilner, Who Lives? Who Dies? Ethical Criteria in Patient Selection (US$37.50, Yale University Press 1990), is in Lancet 337: 1400. It discusses rationing.
Comments on the USA health care system, or lack of it, are in Lancet 337: 1401-2, 338: 174-5; JAMA 265: 2998-3002, 3296-9, 3300, 266: 104-9, 399-401. See also J.E. Verby et al., "Changing the medical school curriculum to improve patient access to primary care", JAMA 266: 110-3. They suggest choosing trainees who will reach the poorer portions of the population, in primary care work. On the UK health care system see Lancet 337: 1588-90, and on the role of citizen's in the NHS see BMJ 303: 203-4. The question of whether doctors should set priorities is addressed in Lancet 337: 1464. The second paper on the German health care system is in NEJM 324: 1750-7. A comment on the problems of Canada's health care system is in BMJ 303: 8.
A review is S.R. Benatar, "Medicine and health care in South Africa - five years later", NEJM 325: 30-6. A discussion on what are the best hospital's for different specialities, at least those perceived by physicians, in the USA is in U.S. News & World Report (5 Aug 1991), 36+.
There continues to be a difference in the mortality of workers in different groups, as seen in M.G. Marmot et al., "Health inequalities among British civil servants: the Whitehall II study", Lancet 337: 1387-93.

Comments on President Bush's lack of doing anything about funding changes for health care because it is politically safe is in Lancet 338: 561-2. On free clinics to treat the uninsured see JAMA 266: 838-40. On the Oregon health care budget; Lancet 338: 808-9; Archives of Diseases in Childhood 66: 990-3. On Maryland's plans to ration health care; BMJ 303: 670. Also see Lancet 338: 440; JAMA 266: 1123-4, 1215-6, 1510-1, 1562-5, 1566, 1570-2, 1901; NEJM 325: 198-200, 738-9; BMJ 303: 259-60; Archives of Diseases in Childhood 66: 997-9. A review of a book entitled Free to be Foolish: Politics and Health Promotion in the United States and Great Britain, by Howard M. Leichter (Princeton 1991, 281pp., US$35) is JAMA 266: 1575.
On the costs of medical education in the USA see NEJM 325: 404-7. On how to pay for expensive drugs in Britain under the NHS see BMJ 303: 593-4. On aging and rationing see BMJ 303: 869-70. On measuring inequalities in health care see Social Science & Medicine 33: 545-58; and R.J. Boys et al., "Mortality from causes amenable and non-amenable to medical care: the experience of eastern Europe", BMJ 303: 879-83. Non-amenable causes are the principle cause of death, but many include harm due to environmental causes.
On the NHS in Britain see Nature 353: 587-8; BMJ 303: 867-8. Changes to the health care schemes in many countries are underway; in Australia and the U.K., BMJ 303: 485; in New Zealand, Lancet 338: 374-5, BMJ 303: 327; and in Sweden, BMJ 303: 267. In these countries with public health schemes, the system is to switch to more private medicine. Although it may be complicated by trying to reduce government spending, these governments don't seem to notice the problems experienced in the USA with the coverage of private health insurance! They also seem to have forgotten about the ethical ideals behind public health, and that all people have a right to equal access to equal health care.

There are social inequalities in health in many countries. The case in Britain is reviewed in BMJ 303: 1046-50; Lancet 338: 1059-63. Health care reform is a major issue in most countries, especially in the USA, and many want health care for all; BMJ 303: 1011-3, 1221. The public and private expenditures on health care in industrialised countries are listed in Lancet 338: 1259-60. The primary care comparisons between ten of these countries are compared in JAMA 266: 2268-71.
Health rationing is one approach to saving costs, and some of the actualities in Britain are discussed in BMJ 303: 1039-42; Lancet 338: 1133-4. Age-based rationing is discussed in JAMA 266: 3012-5. Some hope that there may be better health care in a united Europe; BMJ 303: 1081-2, 1284. Health care reform in Sweden will be examine by a new commission; BMJ 303: 1288. The Netherlands is also thinking of reexamining its health care; JAMA 266: 2215-7. See also BMJ 303: 1350. 77% of French people believe that they visit the doctor too often, and other questions were examined in a recent poll of the French; SCRIP Notes (11 Dec 1991), 3. In Britain, the government is encouraging the public to ask their pharmacists more medical information instead of going to physicians, yet a recent consumer survey found that poor advice was received from pharmacists; Times (12 Dec 1991). Is this a veiled scheme to reduce the costs on the national health care scheme by bringing in pharmacists to avoid some doctor's visits?
On US health care reform see JAMA 266: 2078-80, 2135-8, 2185, 2238-43, 2274, 2439-5, 3023-9; BMJ 303: 1216-7; NEJM 325: 1099-1100. On social science contributions in general to government decision making see Science 254: 226-31.

The results of a recent survey in Britain on the popularity of the NHS is in Lancet 338 (1991), 1511-2. Like all statistics, they will be used in different ways by politicians. In New Zealand the accident compensation scheme is changing, which is being criticised by many; Lancet 338 (1991), 1583. It is a very efficient system internationally, partly because only 6% is spent on administration, and it is a no fault system, but political change is the mood of the government. Russia is intending to change its health care system to, and make it decentralised like many other moves there; Lancet 339: 236. The province of Quebec in Canada is also changing its medical system; BMJ 304: 72.
The costs of an aging population, and who should care for the elderly are discussed in Lancet 339: 96-7, 294-5; 310. On rationing see BMJ 303 (1991), 1561-2; 304: 182. In the USA comment on health care resource allocation is in JAMA 266 (1991), 3328-31.
On reform of the USA health care see E.R. Brown, "Health USA. A National Health Program for the USA", JAMA 267: 552-8. A question of whether physicians should be given incentives is addressed in JAMA 267: 403-5, and on fraud by US physicians against medicare; JAMA 266 (1991), 3318-22. For evidence of inequities in US health care; P.A. Braveman et al., "Differences in hospital resource allocation among sick newborns according to insurance coverage", JAMA 266: 3300-8. Related to the broader issues of inequality; V.R. Fuchs & D.M. Reklis, "America's children: economic perspectives and policy options", Science 255: 41-6.
On general economic questions, including issues in the developing countries, and health see BMJ 303 (1991), 1572-7. See also; R.G. Wilkinson, "Income distribution and life expectancy", BMJ 304: 165-8. It looks at income within Britain, in addition to internationally.
On the financial crisis in Russian science see; Nature 355: 391. The USA has stepped in and said that they will pay for some of the scientists. It is a waste to have all the resources unused, both material and human resources.

On public opinion and the NHS in the UK see BMJ 304: 680-2, 892-4. The problems of medical insurers in the UK are discussed in BMJ 304: 458-9. Health policy had been one issue of the British election, we will wait to see if any changes are made. A book review of media and health care is in Science 255: 1750.
In New Zealand the waiting lists for surgery and medical services have been growing rapidly following the present government's policy, ironically aimed at reducing waiting lists; Christchurch Press (4 March 1991), 33. The health care expenditures of different OECD countries are described in BMJ 304: 770-1, and New Zealand follows Greece as the second lowest, while age expectancy and perinatal mortality are reasonable good. However such type of analysis is too simplistic. Rationing of health care is discussed in BMJ 304: 496-9, 716-7.
The socioeconomic health differences in the Netherlands are reviewed in Social Science & Medicine 34: 213-26. On income and health worldwide see BMJ 304: 715-5. An opinion survey in Finland asked people about different areas of government spending which could be cut; Lancet 339: 813. Health care was valued the most among 12 options. US health costs are discussed in papers in JAMA 267: 687-91, 945-8, 113-7, 1399, 1511-5, 1624-30, 1665-7, 1669-75, 1780; NEJM 326: 340-4, 565-9, 962-7; K.B. Weiss et al., "An economic evaluation of asthma in the United States", NEJM 326: 862-6.

The large number of deaths due to tropical diseases and infectious diseases in developing countries is the greatest discrepancy in health care funding, and some statistics are shown in Science 256: 1135. The incidence of chronic disease is reported in Nature 356: 557-6. Public health expenditures in Sub-Saharan Africa (Botswana, Burkina Faso, Cameroon, Ethiopia and Senegal) are analysed in Social Science & Medicine 34: 615-24.
In the USA, the NIH is spending US$45 million on a minority health acre initiative; Science 256: 24. Ironically it is the minority thinking that is the cause of the worldwdie injustice, because the minorities in the USA may be majorities worldwide. This word "minority" should be removed from our thinking, as the world tries to become global in outlook.
In New Zealand their is concern over the apparent increase in cot death rate amoung Maoris, while the rate in those of European descent is falling; BMJ 304: 1074. The Maori rates in 1991 were about 20-40 times higher. Another comment on New Zealand health statistics is in BMJ 304: 1330-1. A paper suggesting that health care resources as a whole do not make a significant contribution to accounting for the variance of infant mortality rates is K. Kim & P.M. Moody, "More resources better health? A cross-national perspective", Social Science & Medicine 34: 837-42. Health care in Canada is reviewed in NEJM 326: 1469-72; and in Czechoslovakia in JAMA 267: 2461-6.
A special issue on rationing of health care in the USA is the AJLM XVIII. It includes papers by D. Callahan, R.M. Veatch & C. Mason Spicer, D.C. Hadorn, and S. Rosenbaum. Also on rationing see BMJ 304: 1440; and on Oregon's sytem for priority setting, JAMA 267: 1925-31, 1967. On inequalities in health care in the USA; JAMA 267: 2503-8; 2719; 2760-4; and on deciding which is the best health care payment system (in the USA) a review is JAMA 267: 2509-20. medical liability is discussed in JAMA 267: 2355-8; 2487-92.

A review essay of P.T. Menzel, Strong Medicine, is in Bioethics 6: 130-57, with author's response p. 158-65 and the so-called prior-consent theory, based on distributive justice in medical care, is supported. The February issue of Journal of Philosophy of Medicine focuses on "Ethics and alternative health care systems".
Consideration of the prospects for rationing of health care in a Canadian context are in Trends in Bioethics (July 1992), 1-5. The way costs are calculated for the future is discussed in Lancet 340: 148-9. Cost effectiveness analysis is questioned in JAMA 267: 3342-8; and its ethics are questioned in JME 18: 7-11. A call for evaluation of all heath technology is made in BMJ 305: 67-8.
The US health care system is discussed in NEJM 326: 1715-20, 327: 274-7; JAMA 268: 344-5, 774-9. "Minority" group health in the USA, which is linked to health care access is discussed in AJPH 82: 1079-81, 1082-4, 1168-70; Lancet 340: 346-50. The health care plans in Washington state in the USA to set maximum premiums for health insurance, and to set up universal health care; HCR (May-June 1992), 3. The whole issue will be voted in 1993, in addition to political changes in the US elections.
Changes to the New Zealand Accident Compensation Act are reported in the Newsletter of the Otago Bioethics Research Centre (Winter term 1992), 3-4. To save costs, there will be generally more limits on the coverage of this no-fault accident compensation scheme, and reduced awards. No claims against medical malpractice are allowed. In a US court decision, a woman who lost two legs and an eye has been awarded US$5 million for compensation; Washington Post (29 Aug 1992), C1. Health cost expenditure problems in Australia are taking an increasing proportion of the government budget, from 13.6% in 1989-90 to 15.4% in 1993-4; MJA 156: 592-4. Changes to UK general practice are in BMJ 304: 1548-50; and on reforms in Germany; BMJ 304: 1650; and Czechoslovakia; BMJ 304: 1650-1.

The philosophical question of age-based differences and inequality is addressed in D. McKerlie, "Equality between age-groups", Phil. & Public Affairs 21: 275-95. Discrimination is also addressed in D.C. Hadorn, "The problem of discrimination in health- care priority setting", JAMA 268: 1454-9. It also discusses the Oregon health care plan (see below). Legal approaches to cost-containment are discussed in L.I. Sederer, "Judicial and legislative responses to cost containment", Amer. J. Psychiatry 149: 1157-61. The public versus private health care are debated; Lancet 340: 772-5.
Comments on the European Community proposals for health care are in R.H. Nicholson, "divide and rule", HCR (July-Aug 1992), 22: 5. The NHS in the UK and the issue of continuing care is discussed in Lancet 340: 539-40. International health care approaches are commented on in Biotechnology 10: 1176; and global health independence is stressed in JAMA 268: 1462-3. On the cost containment problems of Canadian Medicare; BMJ 305: 705-6.
A review of the Minnesota Health Right program is in HCR (Sept.-October), 22: 4-5. It aims at making health insurance affordable for more people, and offers insurance at subsidised prices for those unable to pay. Also on the US health care system see JAMA 268: 900-3, 916-8, 1265-6, 1332-6, 1588-94; Nature 359: 257-8; Lancet 340: 594-5, 717-8; NEJM 327: 742-7, 821-5; BMJ 305: 817-9. The Oregon test case and other state proposals for reform of health care are discussed in Science 257: 1202-3; NEJM 327: 642-4, 821; JAMA 268: 1267-8. President Bush vetoed the Oregon proposals, BMJ 305: 437-8; Lancet 340: 418. Drug prices in the USA have been said to be increasing too much by various politicians; Lancet 340: 597-8. The presidential health care plans are compared in NEJM 327: 800-11.
A brief trial of user fees at a clinic in Kenya had a negative impact on health, S. Moses et al., "Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya", Lancet 340: 463-6. Maternity services from Nigeria in Lancet 340: 732.
A review of no-fault compensation systems is J. Havard, "'No fault' compensation for medical accidents", Medicine, Science & Law 32: 187-8.

The basic ethic involved in health care systems is that of beneficence, and justice. If a country with sufficient resources fails to provide health care to its citizens it is failing in these principles. A paper on these issues is C.J. Dougherty, "Ethical values at stake in health care reform", JAMA 268: 2409-12, 2352. The importance of health for children to learn is discussed in JAMA 268: 1643; health care is a basic and fundamental human need.
For explanation and opposing views of ethicity of the changes in the New Zealand medical system see the Newsletter of the University of Otago Bioethics Centre (Spring Term 1992) (P.O. Box 913, Dunedin, New Zealand). Major structural changes are being made in the New Zealand health care system, basically continuing the shift to privately-funded medicine. In the same newsletter there are also descriptions of a new Mental Health Act, and changes to the no-fault Accident Compensation Scheme. See also BMJ 305: 854.
A report on the system in Japan is N. Ikegami, "The economics of health care in Japan", Science 258: 614-8. The Ministry of Health and Welfare intends to try to introduce more general practice ideas, as a screening for specialists in large hospitals; Yomiuri Shinbun (4 Nov 1992), 3. However, teaching hospitals say this will take away patients for student training. In Ibaraki prefecture, japan, up until October 1992 a total of 12 million Yen in unpaid debts was owed by uninsured foreigners to hospitals; Yomiuri Shinbun (18 Dec 1992), 22. The Prefecture government has said it will pay the debts, most of which are owed by illegally working foreigners - who lack health insurance.
A report on the switch to private health care in former Eastern Germany is in BME (Oct 1992), 33-5. On health care reform see: Germany, Lancet 340: 1216-7; BMJ 305: 909; Italy , Lancet 340: 1217; BMJ 305: 849 California , BMJ 305: 1047; London , Lancet 340: 1070-1; UK , BMJ 305: 1248. A general comparison of the funding of several industrialised countries on health care is in JAMA 268: 2032-3. The question of whether real change in health care and apartheid are occuring in South Africa is reported in Lancet 340: 1324.
A comparison of the Canadian and US health care funding systems, and the need for change is W.W. Benjamin, "Combining the best of two medical worlds: Canadian Universality and United States' Freedom", Humane Medicine 8(4), 271-85; F.H. Lowy, "Restructuring health care: rationing and compromise", Humane Medicine 8(4), 263-7. Criticism of the Canadian government decision to dissolve the Law Reform Commission is BME (Oct 1992), 2, 4-5.
As reported in the last issue of the newsletter, the Oregon State Health plan received a presidential veto, with the reason given that it may contradict with anti - discrimination measures of the American's with Disabilities Act (EEIN 2: 84). This veto is criticised in a legal commentary, A.M. Capron, "Oregon's disability. principles or politics?", HCR 22 (6), 18-20. Some type of rationing is required, and quality of life decisions should be a part of that. Another comment is P.T. Menzel, "Oregon's Denial. Disabilities and Quality of Life", HCR 22 (6), 21-5. Reform of the US system is discussed in SA (Nov 1992), 22-9; NEJM 327: 1090-5, 1245-6, 1310-15, 1463, 1467-72, 1525-8; JAMA 268: 2029-31, 2383-7, 2388-94, 2426-7, 2545-52; Lancet 340: 1086-7; BMJ 305: 878-80, 941-4, 1313. Rationing and cost-effectiveness are discussed in JAMA 268: 2050-4, 2139-41, 2142-3, 2575-82; BMJ 305: 1049, 1240-1; Science 258: 489-90; Lancet 340: 1343-4.
A paper arguing for the use of Quality Adjusted Life Years (QALYs) in rationing health care is K. Kappel & P. Sandoe, "QALYs, age and fairness", Bioethics 6: 296-316. QALYs are argued to be fair, and not to be against aged people. Additional comments on the quality of life are in Bioethics 6: 356-64; BMJ 305: 875-7, 1074-7, 1145-8, 1205-9; and in the Euthanasia section.

The right to health care is the subject of a recent SCOPE note (#20), published in Kennedy Institute of Ethics Journal 2 (1992), 389-405. A legal essay by G.J. Annas addresses a New York court case that decided that people had to pay for unwanted medical treatment; NEJM 327 (1992), 1885-7. Risk-related health insurance is discussed in JAMA 269: 213-4.
The question of economies and bioethics is discussed in a French paper in IJB 3 (1992), 157-62. The treatment, alglucerase, for Gaucher's disease is very expensive, and makes us ask again the question, "is no price to high?", NEJM 327 (1992), 1676-7. It can cost hundreds of thousands of dollars annually during the first few years, is such a price justified? Not if we consider global justice, and read about the tragedies of Africa; BMJ 305: 1479-80. The question of what technologies are suitable for developing countries is asked in World Health Forum 13 (1992), 356-62. The August 1992 issue of J. Med. & Phil. 17 (1992), 367-480, looks at solidarity in health care. The effects of poverty on health are reviewed in SSM 36: 157-66. A comparison of the access to health care is C.M. Grogan, "Deciding on access and levels of care: A comparison of Canada, Britain, Germany, and the United States", J. Health Politics, Policy and Law 17 (1992), 213-32. It draws out the US concept of minimum health care, whereas in socialist countries all are entitled to the same health care.
In the next few month a new health care funding scheme in the USA is suggested. It appears likely that it will be the so-called "managed competition", which includes the concept of minimum health care. Just how ethical it is depends on what medical treatment is included in the US concept of minimum health care. Managed competition may not work in rural districts, NEJM 328: 148-52, 133-5. Papers on national health schemes include: Lancet 340 (1992), 1458-9; NEJM 327 (1992), 1682-5; Science 259: 16-7, 105; NY State J. Med. (Dec 1992), 513-5; JAMA 268 (1992), 3115-8, 3468-72,79; 269: 374-8, 498-501; J. Health Politics, Policy and Law 17 (1992), 233-53, 403-23; Int. J. Health Services 22 (1992), 381-96; Hospital Ethics (Nov/Dec 1992), 1-4. A discussion of Minnesota's HealthRight law is in Kennedy Institute of Ethics Journal 2 (1992), 201-16; JAMA 269: 511-5. The situation and plans in other state include:, Massachusetts, JAMA 269: 87-91; New Jersey, Lancet 341: 41; New York, BMJ 305 (1992), 1384; Oregon, JAMA 268 (1992), 3292. Rationing is discussed in Hospital Ethics (Jul/Aug 1992), 13-6; (Sept/Oct 1992), 9-11; and poverty in Pediatric Nursing 18 (1992), 553-7.
The health funding and delivery systems in other countries are discussed in: U.K., BMJ 305 (1992), 1415-8, 306: 155-6, 166, 227-8, 381-2; Germany, BMJ 305 (1992), 1384-5; Hungary, J. Med. & Phil. 17 (1992), 455-62; Lancet 341: 43-4; the Netherlands, J. Med. & Phil. 17 (1992), 463-77. Financing of rural China in 1988 is discussed in SSM 36: 385-91. It was found that 5% of family income was spent on health, but access was reportedly wide.

On the prior consent model of health care rationing see Bioethics Research Notes 4(1), 1-2.
A review on the rise of market led health financing, and the competition ideas, is in Lancet 341: 805-12; see also Nature 362: 1, AJPH 83: 418-26, which defend the welfare ideal. A report on ethics and health care in the Czech Republic is in BME (Feb 1993), 13-6; on the crisis in funding shortages in Bulgaria , in BME (Feb 1993), 17-9. The political problems in trying to change the New Zealand health care system are discussed in Lancet 341: 748-9, 885-6. The NZ Medical Association is opposed to the changes, involving contracting in health. Political discussions on changes in Australia are discussed in BMJ 306: 783-7, 877-8; Lancet 341: 484-5. On the Brazilian system; BMJ 306: 503-6; the Russian system see BMJ 306: 909-11, 914-6; Lancet 341: 409; and Lithuania , p. 911-4. The changing situation in Albania is reported in BMJ 306: 446-7. Starvation is a problem more basic than medical health in many countries, especially in Somalia; NEJM 328: 1055-61.
A comparison of primary care in the UK and USA is in NEJM 328: 940-5; and a book review on the situation in the Arab World is in BMJ 306: 662. The UK system is moving to fewer hospitals with bigger medical schools; Lancet 341: 620-1; other comments on the UK include BMJ 306: 474, 647, 667-70, 673, 863. Canada is decentralising health care; Lancet 341: 483-4. Some US patients may come to the UK for discount treatment; BMJ 306: 539.
In public opinion polls in the USA , 78% believed that their health care system had failed, and 71% believed that it was ready for a complete overhaul; BMJ 306: 739. Clinton has approved the Oregon rationing plan that Bush vetoed; BMJ 306: 811; Lancet 341: 817. Comments on the US health care system are in NEJM 328: 621-7, 651-4, 772-8, 805-7, 896-90, 892-3, 928-33, 961-3, 1129-30; Newsweek (5 April 1993), 40-3; Lancet 341: 548, 682-3, 791-2, 816-7; Biotechnology 11: 434-5, 444-5. On the end-stage renal program see NEJM 328: 366-71; and on Minnesota health care reform, NEJM 328: 970-1. Hispanic and Latin health issues are discussed in JAMA 269: 1603. Plastic surgery is being performed as a tourist economy in Costa Rica, CMAJ 148: 74-6.
In Japan , the local prefecture governments are having to pay for the medical treatment of some foreigners without medical insurance. However, as noted before, if they have HIV, they may be refused from some hospitals.

In Japan in 1991 people paid 21,800 billion yen for health.
On economics and life and death; SA (May 1993), 18-25. On ethical issues and health costs; JAMA 269: 2116-21, 2558-62; NEJM 328: 1358-62; AJLM (1992), 301-46. Attitudes of medical students in a Southwest US medical school to providing care for the poor was found to decrease in fourth year students compared to first years; JAMA 269: 2519-23.
Papers on health care rationing : in the UK, Lancet 341: 1525; on health care reform in the USA; NEJM 328: 1208-12, 1489-93;JAMA 269: 2437-42, 2548-9, 2524-32, 2533-7, 2553-5, 2573-8; on states, Newsweek (17 May 1993), 42-3, Oregon , Harvard Law Review 106: 1296-1313; Hawaii , JAMA 269: 2538-43. Health care in Austria is discussed in JAMA 269: 2789-94; in Germnay ; BMJ 306: 1017-8.

The widely reported separation of Siamese twins at the Children's Hospital in Philadelphia, reportedly costing about $1 million, could be considered a waste of money by many, as well as a crude example of experimental excess. Two girls were separated, who shared a 6 chamber heart, with the automatic death of one. The longest survival of 5 cases is 3 and a half months, and the outlook is dim.
Statistics show that Canadians spend less on health (US$1837 in 1990) compared to people in the US (US$2566), but they have lower infant mortality and greater life expectancy. However, Sweden, Germany, Finland and Denmark are better still. The development of guidelines to control expense is discussed in CMAJ 148: 913-7. Also on Canadian health care, Int. J. Health Sciences 23: 239-56; CMAJ 148: 2191-3; Trends in Bioethics (July-Aug 1993), 1-3; Lancet 342: 102.
A series of papers on US health care reforms are in JAMA 269: 3136-9, 270: 198-200, 254-5, 377-8, 380-1; SA (July 1993), 91; J. Health Politics and Policy 18: 1-174; Int. J. Health Sciences 23: 193-238, 257-78; NEJM 328: 1778, 329: 130-3, 372-6; Lancet 341: 1652; AJPH 83: 945-6; on Oregon health care, AJOG 168: 1870-4; AJLM XIX: 1-144; BMJ 307: 373-7. One quarter of US hospital funds are spent on administration; NEJM 329: 400-3, 428-9;BMJ 307: 401. More papers on the US health care system and possibilities for reform are in Health Care Analysis 1: 5-42.
Papers on the reforms in the UK NHS health system include: BMJ 306: 1703-4, 307: 73, 78-9, 81-2216-7, 280; Lancet 341: 1651 and on psychiatric care there, Nature 364: 657-8; BMJ 307: 248-50; also on psychiatry, JAMA 270: 252-3. Market reforms in Sweden are discussed in Int. J. Health Sciences 23: 185-8. The free health care in Germany is drawing refugees, CMAJ 148: 2184-6. Poland may have too many specialists and not enough general practitioners, CMAJ 148: 624-6. On the UK health reforms, in psychiatry, Nature 364: 90. A comparison of the French system with the US system for caring for uninsured persons is JAMA 270: 748-56. On European health care, BMJ 306: 1629-30.
On other countries see: Netherlands , Health Care Analysis 1: 43-56; SSM 37: 572-3, 833-9; Israel , BMJ 307: 219; New Zealand , BMJ 307: 219; South Africa , BMJ 307: 82. In New Zealand a survey of patient satisfaction with health care and hospitals reported in the Consumer (July 1993) found that in terms of the health care people are very satisfied with public health care, as much as private health care, contrary to the views expressed by the Government which wanted to change the system.
International health articles include: JAMA 270: 629-31; AJPH 83: 941-3; Lancet 341: 1563-4, 342: 245; SSM 37(6): 697+; on war, JAMA 270: 600-5, 616-20, 632-3, 637-8; Lancet 342: 360. A list of overseas service organizations is in JAMA 270: 567-71.
A review is N.E. Adler, "Socioeconomic inequalities in health. No easy solution", JAMA 269: 3140-5. There is increasing differences between the health of the rich and the poor in the USA, in a study looking at 1960 and 1986; NEJM 329: 103-9. Lacking health insurance is shown to increase risk of mortality in JAMA 270: 326-31, 737-41. General comments on health costs are in Lancet 341: 1566-7, 342: 105-6; NEJM 329: 126-7, 321-5; BMJ 307: 140-1.
Research and health costs are discussed in Science 261: 155, 416-8; Nature 364: 91; Amer. J. Med. Sciences 306: 5-9; JAMA 270: 43-5, 800-1; Lancet 342: 63-5, 99-100. Feminist views on enriching health care are in Humane Medicine 9: 201-6. The environmental issues are discussed in EST 27: 1242.
The refusal of several UK hospitals to treat nonurgent cardiac surgery in smokers was discussed in the Disease Risks section; see also Newsweek (30 Aug 1993), 44. Papers on racial differences in the US health care system are in AJPH 83: 948-59.

A number of papers discus the reform of the US Health Care system; Nature 365: 281-2; BMJ 307: 813-4, 819-20;BME (Aug 1993), 13-8; Newsweek (27 Sept 1993), 42-5; Lancet 342: 732-3, 797, 815-6, 851-3; NEJM 329: 804-5, 880-6; JAMA 270: 927, 1357-62, 1449-53, 1513-6; Science 261: 1667. The plan to extend health care to all people in the US is an ethical improvement on the current situation, but will cost much. The ethical case may be summed up in the title of the paper, W.A. Glaser, "The United States needs a health system like other countries", JAMA 270: 980-4. The Oregon priority listing approach has been experiencing delays in Oregon state; HCR 23(4), 6-7. See also a book review on the plan in Bioethics 7(4): 351-8.
Comparisons between Canadian health and the US situation are in NEJM 329: 964-6. On reform to the UK NHS see BME (Aug 1993), 3-4; BMJ 307: 516-7, 750-1. A UK paper published lists of waiting times for treatment by individual consultants, which is good for patient choice but upset the consultants, BMJ 307: 699. The health care financing in different countries includes: New Zealand, BMJ 307: 635-6; Austria , Lancet 342: 736; Swiss people have voted for a uniform hospital charge, that could result in a uniform health cost system, Lancet 342: 857; Chile , BMJ 307: 729-30; Nicaragua , JAMA 270: 989-93. In Cuba the continued American embargo is threatening heath progress and an end has been called for, BMJ 307: 521. In Japan the costs of medicines increased 7.7% last year, and 30% of hospitals are in the red. Many are small hospitals, but the ones in the red are in big cities where costs are higher, and mental hospitals where there is less income from drug prescriptions; Yomiuri Shimbun (30 Sept 1993), 3.
General papers on cost-benefit analysis in medicine are in BMJ 307: 670-3, 726-8, 793-5, 859-62, 924-6. On the ethics of public health medicine see JRSM 86: 611.

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