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  • Print publication year: 2007
  • Online publication date: August 2009

5 - Beware of the libertarian wolf in the clothing of the egalitarian sheep: an essay on the need to clarify ends and means



Ideologies permeate policy debates in health care. However, they do so in an implicit manner and the combatants rarely reveal their underlying objectives. Typically, in both public and private health care systems, policy makers focus on expenditure control and efficiency, paying lip-service to equity issues. A focus on efficiency is clearly merited, as many health care interventions have no evidence base; there are large variations in clinical practice, which have been well evidenced and ignored for decades. Furthermore there is an absence of outcome measurement and evidence that consumers' health is improved by expensive health care systems.

Political frustration about the inefficiency of health care enables policy advocates holding competing libertarian and egalitarian perspectives to debate reform as if it were ideologically neutral. Libertarians seek economic and social structures that maximize individual freedom, minimize the role of government and ensure that health care is delivered by market-orientated insurers and providers. Egalitarians seek to maximize equality of opportunity. They regard government as a means by which the inequalities of market provision and finance can be reduced to provide real opportunities for all, and in particular the disadvantaged.

Reform debates in socialized health care systems are characterized by libertarians advocating reforms to increase individual freedom and undermine equality. In more libertarian systems, the egalitarians seek reforms to increase equality and circumscribe the freedom of the advantaged to experience better care. Rarely do the combatants reveal their ideological preferences. Egalitarians should beware libertarian wolves posing in sheep's clothing.

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