Ethics, Institutional Complexity and Health Care Reform: The Struggle for Normative Balance

Michael J. Graetz, Yale Law School
Jerry L. Mashaw, Yale Law School


This essay has two messages: First, whatever the complexity of its articulation or its interest-group politics, reforming the financing and provision of American health care is ultimately a normative undertaking. Indeed, to some it takes on the quality of a moral crusade. This is not to say however, that the ethical foundations of health care reform are unitary, even coherent. Health care reform responds to a multitude of ethical demands. The ethical "goodness" of any plan will, therefore, be a question of its "balance" among those various ethical claims.

This trite observation leads to a more complex second message—one that seems often to be overlooked by those who decry the complexity of most proposals for reforming American health care finance and delivery. The more uncertain or compromised the choices among values, the more likely the scheme will exhibit high levels of institutional complexity. For complex institutional arrangements often are devices for managing conflict and uncertainty. In this sense, a health care plan can be viewed as a design for the conduct of further struggles over both the "right" and the "good." A system that has resolved more of these struggles in a relatively straightforward way can have a simpler institutional design. More importantly, we argue, no ethically acceptable system is likely to have wholly coherent ethical commitments. Hence, institutional complexity is a necessary price for ethical acceptability.