Need--is a consensus possible?

Medical care is commonly cited as a service to be distributed according to "need".1 There are those, (such as Barry and Flew,2 who interpret "need" instrumentally, that is, that the thing or state asserted to be needed is necessary to achieve some more ultimate purpose. This view is opposed by others, such as Miller and Thomson,3 on the ground that statements using the word "need" are intrinsic or elliptical, implying an objective that would be trivial to make explicit (the statement "I need open heart surgery" is not much elucidated by adding "if I am to live"). In medicine (and elsewhere too, no doubt) the intrinsic concept is hardly tenable: the great value of the instrumental view is that it confronts practice with the necessity to be explicit about whether it is effective, how effective it is and for whom. Since much practice has in the past been demonstrably ineffective (if not plain harmful) emphasising the role of medi cine as a means rather than an end in itself is a non-trivial matter and, on the face of it, the instrumental approach seems to be a useful point of departure. It may be an illusion to suppose that there might ever be a consensus about the meaning of "need", even if the context of its use were specific (thus per mitting other concepts in other contexts) and even if it were merely provisional (contingent on a mani fest improvement for the context in question or a generalisation that embraced this and other con texts). The attempt seems, however, worthwhile. The context I propose is a planning context in which broad decisions have to be taken about the allocation of resources, for example (British) to the National Health Service (NHS) out of the health vote, or to regions in the NHS, to health authorities in regions, or to trusts and general practitioners by health authorities through com missioning, to decisions about priority groups of beneficiaries, or as between preventive and other types of health care. Common features in all these decisions are that they relate to aggregates of peo ple rather than specific individuals with their own preferences, fears and personal circumstances, all of which normally require attention in individual decisions (preferably joint, for example, by doctor and patient). I suggest that the concept of "need" in these situations ought to have two elements. The first is empirical: given a goal defined in terms of outcome, there should be empirical evidence (preferably valid and reliable) that the thing or state said to be needed can (with acceptable prob ability) actually achieve the goal set. The second is ethical: the goal set and the means adopted to realise it ought to be ethically compelling. It is this latter requirement that gives "need" its ethically compelling quality, while the former requirement is essentially a cost-effectiveness condition em bodying technological knowledge about the ef fects on outcomes that procedures may be expected to have and opportunity costs, so that the means chosen to realise the goal maximise the residual availability of resources to meet similar needs of other groups and individuals for similar morally compelling goals. Thus, one might assert that "health" is needed if people are to "flourish", that there is indeed evi dence to support the proposition that "health" will actually enable the group in question to "flourish" better, and "flourishing" is indeed the ultimate ethical good which transmits its moral persuasive ness to "health", making that too a good thing (an instrumental good thing). In such a case, ill health indicates a need (for health). This may come close to what some have taken as the intrinsic view. Or, one might argue that health care is needed if peo ple are to have better "health", that the specific health care proposed is likely to produce the appropriate "health" gain sought, and that the ultimate good of "flourishing" now transmits its moral persuasiveness to health care, which is therefore an instrumental good thing for the achievement of better "health". In this case, ill health does not necessarily indicate a need for health care, evidence of its cost-effectiveness being required to reach this conclusion. This contrasts with Daniels4 for whom the need for care depends not on the ability of care to return a person's impairment to the "normal opportunity range" but on the magnitude of the existing shortfall from