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We have reached a phase of diminishing returns in medicine. Increasing costs produce smaller and smaller incremental benefits in health status. Medical scientists continue to work within the ideology of the Enlightenment, whereby advances in knowledge will eventually lead to control of health and welfare. The enormous costs of this ideology have led to two new ideologies: those of economic rationalism and managerialism. At the public level, the Western liberal emphasis on the value of individual life is generally held to justify the amount of public money spent on health. Those who frame health policy are influenced to some extent by this ideal, but we cannot continue to develop costly interventions without constraint. To overcome this impasse, we might accept that economic rationalism provided a proper base for health care; or we might redefine disease so that more people were excluded from treatment programmes; or we might agree to limit medical research in costly areas; we might change our ethical thinking to emphasize classical utilitarianism; or we might undertake systematic studies of community values and opinions to find out what people really want from their health and welfare services. There are serious ethical problems with each of these solutions, except for the last: the idea of modifying services to take note of community values. Testing community values is difficult, but there are ways of doing it, and there have been some exercises in which the process has been undertaken with some success. The recent Constitutional convention suggests that it may even be possible in Australia.

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