Tom Beauchamp

L'actuel débat sur l'« égalité face aux soins » et le « droit aux soins » est la conséquence directe des progrès techniques réalisés dans le domaine de la santé, mais il reste encore à fonder rationnellement les politiques suivies en la matière et à formuler une théorie adéquate de la justice distributive. Le présent article analyse le rôle et le statut du droit aux soins, ainsi que les considérations tenant à la justice qui vont à rencontre de la rentabilité et de l'utilité sociales. Les choix de répartition budgétaire sont décisifs pour la formulation de revendications au nom de l'existence d'un droit positif aux soins, et il convient de se demander si un tel droit existe et quelles en sont les limites. Discussions today of « equal access » and « the right to health care » are the direct descendants of advances in the technology of health care, and we are still in search of a rationale for our policies and a theory of distributive justice adequate to the task. The role and status of rights to health care, together with considerations of justice in conflict with social efficiency and utility are discussed in this paper. It is argued that allocation decisions are central to claims on behalf of a positive right to health care, which forces questions both of whether there is such a right and of the limits to the right.

Western ethics and law have been slow to come to conclusions about the right to choose the time and manner of one's death. However, policies, practices, and legal precedents have evolved quickly in the last quarter of the twentieth century, from the forgoing of respirators to the use of Do Not Resuscitate (DNR) orders, to the forgoing of all medical technologies (including hydration and nutrition), and now, in one U.S. state, to legalized physician-assisted suicide. The sweep of history—from the Quinlan case in New Jersey to legislation in Oregon that allows physician-assisted suicide—has been as rapid as it has been revolutionary.

The last twenty-five years of published literature and curriculum development in bioethics suggest that the field enjoys a successful and stable marriage to philosophical ethical theory. However, the next twenty-five years could be very different. I believe the marriage is troubled. Divorce is conceivable and perhaps likely. The most philosophical parts of bioethics may retreat to philosophy departments, while bioethics continues on its current course toward a more interdisciplinary and practical field.I make no presumption that bioethics is integrally linked to philosophical ethical theory. Indeed, I assume that the connection is contingent and fragile. Many individuals in law, theological ethics, political theory, the social and behavioral sciences, and the health professions carefully address mainstream issues of bioethics without finding ethical theory essential or breathtakingly attractive. This is not surprising. Moral philosophers have traditionally formulated theories of the right, the good, and the virtuous in the most general terms.