Redefining comprehensiveness in the deficit era

As health care systems undergo funding cutbacks, we cannot expect to receive all needed and wanted health care services at public expense. Instead, choices must be made about which services will be provided from public funds (and to whom), which will be available to individuals who wish to purchase them, and which will not be available at all. These are ethical questions, if only because the proposed answers will reflect different concepts of social justice. This article identifies and describes some of the major ethical considerations in redefining the principle of "comprehensiveness" in the Canada Health Act. The authors argue that the criterion of "medical necessity" may no longer be, if indeed it ever was, adequate for determining which health services should be publicly funded. They do not believe that any single criterion can fulfill this role. Instead, they propose that policy makers focus on developing a better process for making choices among health care priorities. Clearly defined roles in this process must be established for payers, the public and providers.