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Imaginary trees.

"Alternatives, and particularly desirable alternatives, grow only on imaginary trees . . ." The Dutch government committee document Choices in Health Care takes its epigraph from Saul Bellow's Dangling Man and tries to imagine an alternative to the prevailing Dutch view that everyone has the right to all possible medical treatments, regardless of price. It tries to imagine a health care system in which, with a view to the good of the whole, choices are made that limit the access of some individuals to some kinds of treatment.

In the face of rising costs, increasing technological options, and an aging population, the committee thinks that there are three logically possible ways to reduce the pressures on its health care system. The first way is to make more money available to health care by increasing revenues; the second to save money by increasing efficiency; and the third to make explicit choices about and set limits on care. The committee finds, however, that because increased revenues for health care will not be forthcoming and increased efficiency, while good, is not sufficient significantly to reduce pressures on the system, attention must be turned to painful choices.

How, then, does the committee propose to make such choices? Though its invocation of Saul Bellow and its appeal to solidarity as its fundamental value sound alien to an ear attuned to American government documents, the Choices in Health Care committee's recommendations for dealing with health care questions sound strikingly familiar. Indeed, the report advocates a plan much like Oregon's.

The committee urges that in articulating the basic package to which all citizens are entitled, the Oregon procedures be followed. The first step is to identify categories of diagnosis-treatment combinations and order them according to the priorities of the given community. The second step is to consider the cost-effectiveness of each combination. The third is to decide which combinations to include in the basic package on the basis of the following criteria:

* is it necessary care, from the community point of view?

* is it demonstrated to be efficient?

* is it efficient?

* can it be left to individual responsibility?

Using these criteria, the committee suggests, for example, that whereas in vitro fertilization, homeopathic medicines, and dental care for adults all are inappropriate for the basic package, treatment of sports injuries and admission to homes for the elderly should be included.

The committee does not believe, however, that each of its suggestions will be accepted by every Dutch community. What it calls its "community-oriented approach" does not assume consensus on the particular elements in the basic package across all communities but does assume consensus on the general principle that the needs of the community must be put before those of individuals. Though we may doubt that at any time soon American communities will emphasize to the same extent the good of the community over the interests of the individuals who constitute it, we should know that there are places in the world where, upon imaginary trees, such alternatives are growing.

[Erik Parens, research associate, The Hastings Center]
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Title Annotation:health care in the Netherlands
Author:Parens, Erik
Publication:The Hastings Center Report
Date:Jan 1, 1993
Previous Article:Better than physicians.
Next Article:Who's to choose? Surrogate decisionmaking in New York state.

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