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  The Problem of Scarce Resources-稀缺資源的問題

  The problem of how health-care resources should be allocated or apportioned, so that they are distributed in both the most just and most efficient way, is not a new one. Every health system in an economically developed society is faced with the need to decide (either formally or informally) what proportion of the community’s total resources should be spent on health-care; how resources are to be apportioned; what diseases and disabilities and which forms of treatment are to be given priority; which members of the community are to be given special consideration in respect of their health needs; and which forms of treatment are the most cost-effective.

  衛(wèi)生保健資源應(yīng)該如何分配或指定以保證它們能以最公平、最有效的方式分布，這個(gè)問題已經(jīng)不算新了。在經(jīng)濟(jì)發(fā)達(dá)的社會(huì)，每一個(gè)衛(wèi)生系統(tǒng)都需要做出決定(正式或非正式)：在衛(wèi)生保健方面投入資源應(yīng)占社會(huì)全部資源的多大比例?這些資源應(yīng)該如何分配?什么樣的疾病和殘疾以及什么形式的治療應(yīng)該享有優(yōu)先權(quán)?社會(huì)中的哪部分成員應(yīng)該在衛(wèi)生需求方面給予特別關(guān)照?什么形式的治療是最節(jié)省成本的?

  What is new is that, from the 1950s onwards, there have been certain general changes in outlook about the finitude of resources as a whole and of health-care resources in particular, as well as more specific changes regarding the clientele of health-care resources and the cost to the community of those resources. Thus, in the 1950s and 1960s, there emerged an awareness in Western societies that resources for the provision of fossil fuel energy were finite and exhaustible and that the capacity of nature or the environment to sustain economic development and population was also finite. In other words, we became aware of the obvious fact that there were ‘limits to growth’. The new consciousness that there were also severe limits to health-care resources was part of this general revelation of the obvious. Looking back, it now seems quite incredible that in the national health systems that emerged in many countries in the years immediately after the 1939-45 World War, it was assumed without question that all the basic health needs of any community could be satisfied, at least in principle; the ‘invisible hand’ of economic progress would provide.

  新近的發(fā)展是，自20世紀(jì)50年代以來(lái)，人們看待資源有限性及衛(wèi)生資源有限性的態(tài)度都有了總體的改變，另外關(guān)于使用衛(wèi)生資源的用戶和社區(qū)所需做出的開支方面也有了具體的變化。在20世紀(jì)50年代和60年代，西方社會(huì)意識(shí)到：化石燃料能源的供應(yīng)資源是有限的，并能被耗盡，自然界或環(huán)境維持經(jīng)濟(jì)發(fā)展和人口增長(zhǎng)的能力也是有限的。換句話說(shuō)，我們開始意識(shí)到一個(gè)顯而易見的事實(shí)，就是增長(zhǎng)是有限制的。衛(wèi)生保健資源同樣也會(huì)有一些限制的新觀念就是這個(gè)顯而易見的亊實(shí)的一部分。回溯起來(lái)，有一個(gè)觀點(diǎn)現(xiàn)在看來(lái)不可思議：在1939年到1945年的世界大戰(zhàn)結(jié)束后的幾年內(nèi)，很多國(guó)家建立了國(guó)民衛(wèi)生體系，人們認(rèn)為這樣的國(guó)民衛(wèi)生體系至少在理論上能夠滿足任何人群的所有基礎(chǔ)衛(wèi)生需求，經(jīng)濟(jì)增長(zhǎng)中“看不見的手”將提供一切所需。

  However, at exactly the same time as this new realisation of the finite character of health-care resources was sinking in, an awareness of a contrary kind was developing in Western societies: that people have a basic right to health-care as a necessary condition of a proper human life. Like education, political and legal processes and institutions, public order, communication, transport and money supply, health-care came to be seen as one of the fundamental social facilities necessary for people to exercise their other rights as autonomous human beings. People are not in a position to exercise personal liberty and to be self-determining if they are poverty-stricken, or deprived of basic education, or do not live within a context of law and order. In the same way, basic health-care is a condition of the exercise of autonomy.

  然而，就在這種認(rèn)為衛(wèi)生資源是有限的新思想銷聲匿跡的同時(shí)，一種相反的思想在西方社會(huì)發(fā)展起來(lái)了。這種思想認(rèn)為享受衛(wèi)生保健是人們的一項(xiàng)基本權(quán)利，而這種權(quán)利是人們正常生活的必要條件。像教育、政治程序、法律程序、機(jī)構(gòu)、公共秩序、溝通、交通和金錢供給一樣，衛(wèi)生保健被看作是人們行使作為自治人類的權(quán)利的必需的一項(xiàng)基本社會(huì)的設(shè)施。如果為貧窮而苦惱，或者被剝奪了基礎(chǔ)教育，或者沒有生活在法律法規(guī)的框架下，那么人們就不能擁有個(gè)人自由，自主行事。同樣，基礎(chǔ)衛(wèi)生保健也是人實(shí)現(xiàn)自由的一個(gè)條件。

  Although the language of ‘rights’ sometimes leads to confusion, by the late 1970s it was recognised in most societies that people have a right to health-care (though there has been considerable resistance in the United States to the idea that there is a formal right to health-care). It is also accepted that this right generates an obligation or duty for the state to ensure that adequate health-care resources are provided out of the public purse. The state has no obligation to provide a health-care system itself, but to ensure that such a system is provided. Put another way, basic health-care is now recognised as a ‘public good’, rather than a ‘private good’ that one is expected to buy for oneself. As the 1976 declaration of the World Health Organisation put it: ‘The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.’ As has just been remarked, in a liberal society basic health is seen as one of the indispensable conditions for the exercise of personal autonomy.

  雖然權(quán)利這個(gè)詞有時(shí)在語(yǔ)言上會(huì)混淆，但是到20世紀(jì)70年代晚期，大多數(shù)社會(huì)都承認(rèn)人們有享受衛(wèi)生保健的權(quán)利(雖然在美國(guó)，人們享有衛(wèi)生保健的正式權(quán)利這一觀點(diǎn)受到了相當(dāng)大的抵觸)。還有一個(gè)觀點(diǎn)也是被普遍接受的：這種權(quán)利使得國(guó)家有義務(wù)有責(zé)任確保從公共預(yù)算中劃撥足夠的資金提供衛(wèi)生服務(wù)。國(guó)家本身沒有義務(wù)去建立衛(wèi)生健康體系，但是有義務(wù)去保證這樣一個(gè)體系的存在。換句話說(shuō)，基礎(chǔ)衛(wèi)生保健是一種公共產(chǎn)品，而不是需要花錢去購(gòu)買的私人產(chǎn)品。世界衛(wèi)生組織在1976年的宣言中寫道;“享受可能達(dá)到的最髙標(biāo)準(zhǔn)的健康是每一個(gè)人的基本權(quán)利，不因種族、宗教、政治信仰、經(jīng)濟(jì)或社會(huì)情境而異。”正如剛才所提到的，在一個(gè)自由的社會(huì)，基礎(chǔ)衛(wèi)生是行使個(gè)人自治的一個(gè)必不可少的條件。

  Just at the time when it became obvious that health-care resources could not possibly meet the demands being made upon them, people were demanding that their fundamental right to health-care be satisfied by the state. The second set of more specific changes that have led to the present concern about the distribution of health-care resources stems from the dramatic rise in health costs in most OECD1 countries, accompanied by large-scale demographic and social changes which have meant, to take one example, that elderly people are now major (and relatively very expensive) consumers of health-care resources. Thus in OECD countries as a whole, health costs increased from 3.8% of GDP2 in 1960 to 7% of GDP in 1980, and it has been predicted that the proportion of health costs to GDP will continue to increase. (In the US the current figure is about 12% of GDP, and in Australia about 7.8% of GDP.)

  當(dāng)衛(wèi)生保健資源不能滿足需求的這一現(xiàn)象比較明顯的時(shí)候，人們要求國(guó)家滿足他們享有衛(wèi)生保健的這一基本權(quán)利。大規(guī)模的人口數(shù)量及社會(huì)的變化導(dǎo)致大多數(shù)經(jīng)濟(jì)合作發(fā)展組織的國(guó)家的衛(wèi)生費(fèi)用急劇增加，這再一次引發(fā)了一系列改變，使人們開始關(guān)注醫(yī)療衛(wèi)生資源的分配問題。例如，老年人現(xiàn)在是最主要的(相對(duì)來(lái)說(shuō)也是最昂貴的)衛(wèi)生健康資源消費(fèi)者。在歐共體總體中，健康資源的消費(fèi)從I960年占GDP的3.8%到1980年的7%,而且這一增長(zhǎng)趨勢(shì)將會(huì)持續(xù)。(在美國(guó)，目前的數(shù)字是占GDP的12%，澳大利亞是7.8%)。

  As a consequence, during the 1980s a kind of doomsday scenario (analogous to similar doomsday extrapolations about energy needs and fossil fuels or about population increases) was projected by health administrators, economists and politicians. In this scenario, ever-rising health costs were matched against static or declining resources.

  結(jié)果，在20世紀(jì)80年代在各國(guó)衛(wèi)生部長(zhǎng)、經(jīng)濟(jì)學(xué)家和政治家身中都出現(xiàn)了一股極度的悲觀情緒(和以往人們的悲觀推測(cè)類似，比如關(guān)于能源需求和燃料問題，或是人口增長(zhǎng)問題)在這樣的論調(diào)中，他們認(rèn)為資源是穩(wěn)定的或是減少的，而醫(yī)療費(fèi)用卻是不斷上漲的。

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