Sliced down to the moral backbone? Ethical issues of structural reforms in healthcare organizations

Throughout the 1990s we have experienced a wave of healthcare reforms. This article assesses central issues in policy and systems as well as structural changes in the provision of services against the ethical principles of non-maleficence, beneficence, autonomy and justice. The lack of universal coverage is a serious threat to a just and equitable healthcare system. Doubts have recently been expressed concerning the benefits of competition, even within a regulated internal market. Service reorganization raises fewer ethical concerns. Cost-cutting has followed in the aftermath of the financial crises of the early 1990s, and when carried out by restricting access, it may be in conflict with principles of justice and autonomy. Mere cost-cutting does not, however, establish a viable political agenda. It is argued that changes in healthcare need to be implemented in a way that does not lead to conflict with professional values.