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Dr. Nussbaum makes points out that it is useful to refer to the Constitution of the United States as a background to considering how to devise an appropriate healthcare system.

In this regard, it can be useful to review and consider the Preamble to the Constitution, which reads:

"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."

And by way of comment:

To "secure the Blessings of Liberty" is certainly a central and noble goal mentioned in the Preamble to the Constitution, but it is important to note that it is not the only goal mentioned, and given that the other general goals in the Preamble are stated first, this could imply that these other goals may in some ways be prerequisites or foundations for the goal of securing the Blessings of Liberty, and therefore would be important priorities to take into consideration in formulating any policy.

What is a "more perfect Union"? Is it only agreements among states, or does it imply the entire social compact, including all of the social and economic interrelationships between all of the people. What form of health care system supports a "more perfect Union"?

What form of health care system allows us to "establish Justice"? What are the criteria we use for defining justice? Justice for whom? For what purpose? Inasmuch as there are conflicting interests among various groups relating to various issues, what are the just resolutions of these conflicts?

What insures "domestic Tranquility"? Is it merely a police force, legal system and correctional system? Or does tranquility and social cooperation involve a much broader set of processes? Does health have anything to do with tranquility and social cooperation?

Does "providing for the common defense" only involve defense against threats of physical attack? Is defense against disease at least suggested by the concept "common defense"? And doesn't the word "common" imply everyone in society, not just those who can pay for it privately?

What does it mean to "promote the general Welfare"? Welfare of whom? What are the criteria for what constitutes "welfare"?

The preamble uses the word "common" in "common defense" and "general" in "general Welfare". These have two sets of implications -- who benefits, and who provides. Common defense and general welfare suggest that everyone in society benefits. They also imply that there are appropriate circumstances for society (through government) to provide services for the common and general good, both by allocating funds raised through public taxation and by enacting laws and regulations. We have public transportation, public education, public roads, public libraries. And we have public health measures as well. None of these are specified in the articles of the Constitution. But are they not implied in the Preamble? Sure, one could say that there is no "right" to public schools or public libraries specified in the Constitution. But legislatures are constitutionally empowered to enact laws which create laws, rules and services to which every citizen has a "right" by virtue of the laws enacted. And one could argue that any one of these laws are "unconstitutional", but one could also argue that a) they are implied by the Preamble, and thus not inherently "unconstitutional", and furthermore that they are constitutional insofar as the Constitution devolves to the legislature the right to make laws.

Living in a society in which justice, domestic tranquility and general welfare are pursued requires all of us to do things that we may not prefer, and that we may consider to be contrary to our personal liberty and pursuit of happiness. Children may not like to go the dentist, airplane pilots may not like having to go through a preflight checklist, drivers may not like wearing seatbelts or observing speed limits. Similarly, doctors may not like certain precertification procedures. Without arguing for or against any specific healthcare administrative procedures, the general point is that the basis for evaluating those procedures is their outcomes, not their inconvenience. If preflight checklists and auto seat belts save lives, aren't they justified? Similarly, if things like precertification for certain costly and risky medical procedures does demonstrably help to prevent unnecessary cost and suffering, couldn't they also be justified under certain circumstances?

Finally, consider President Abraham Lincoln (who, we recall, presided over the great challenge of preserving the union of American states and established a most basic element of justice by emancipating the slaves). In his Gettysburg Address, Lincoln referred to "government of the people, by the people and for the people". Doesn't that include all of the people?

Matt (an MD)