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Book and Media Reviews
August 26, 2009

Just Caring: Health Care Rationing and Democratic Deliberation

JAMA. 2009;302(8):903-904. doi:10.1001/jama.2009.1255

Most would consider it morally objectionable for someone driving down a country road not to take a severely injured hiker to a hospital merely out of concern that bleeding would cause $200 in damage to the car's upholstery. Many would not find it objectionable, however, if that person chose not to donate $200 to a reputable charitable organization for hunger relief overseas.

Differences in reactions to cases like these have been the subject of an intense interdisciplinary debate in recent years. It has been speculated that evolution explains these differences. Rescuing persons in imminent peril might promote the survival of small groups in primitive environments and thus may have been valued throughout human existence. Donations to assist strangers on the other side of the world presuppose international communication and so may have been literally unimaginable in the remote past. Consequently, it is argued, individuals are naturally more disposed toward helping someone in distress nearby than a large number of individuals they never have, and probably never will, meet. These questions are not merely of academic interest. A dichotomy like that between the cases of the injured hiker and the donation for hunger relief lies at the heart of many contemporary problems of resource allocation, especially in health care. In 1993, for example, in a case attracting considerable media attention, a hospital performed surgery to save one of two conjoined twins with a single 6-chambered heart, at a cost of more than $1 million and despite an estimated 1% success rate. Both then and today, however, millions of children in the United States lack basic health insurance.

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