Introduction

This chapter has five sections: First, we describe the structure of the German health care system. This is done in terms of the system's ethical foundations and in terms of the social, political, and economic traditions that have institutionalized these foundations in a health care system. Some fundamental points of comparison and contrast between the German and U.S. health care systems are also established. Second, we explore some of the ethical principles that ought to guide our review and reform of health care. This is done by reference to some of the organizational, discursive, and representational structures within the German system that, by extension, can help keep ethical concerns at the forefront of a reform effort. Third, we explore the ways in which concerns about ethics and cost-containment have interacted within the German reform effort. We draw some analogies—ethical, organizational, and political—between German procedures of reform and possibilities for reform in the United States. Fourth, we discuss some of the primary reasons for the initial failure of the wholesale effort of the Clinton administration to reform the U.S. system at the federal level. We attempt, in this context, to identify structural and procedural flaws in the reform effort, especially as these became exacerbated by economic and political interests and ideologies, and especially as these interests and ideologies short-circuited the need to sustain an ongoing public discourse on reform within the public sphere. Fifth, we outline some suggestions for furthering the reform process in ways that would help secure a more sustainable public sphere of discussion and, thereby, help foster the kind of public discourse that is ultimately necessary if any structural reform effort is to have a chance of success, and if this effort is to keep ethical considerations at the forefront of the public discussion. Our suggestions take not only a restrictively ethical but also a communicative, procedural, and expansively political cast. Ethical considerations would be meaningful but useless without an attempt to insinuate them within public (and in this sense, political) processes.