THE IMPORTANCE OF CARE

This paper is in three parts. In Part One we briefly explain that an u nsophisticated form of utilitarianism-economic rationalism (ER)-has be come dominant in many health systems. Its proponents argue that one of ER's most important effects is to increase consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, th e logic of ER requires the construction of systems which tend to restr ict individual participation. In Part Two we argue that although some have advocated an 'ethic of care' in an attempt to counteract ER's uti litarianism, two decades of campaigning have had little influence on h ealth policy. ER's pro-care adversaries have failed to make an impact because they have not developed a taxonomy of fare-they have not estab lished a language compatible with, or as powerful as, ER's. In Part Th ree, in an attempt to raise the conceptual and practical status of car ing in contemporary health systems, we distinguish four different form s of care. In opposition to those who believe the 'ethic of care' can adequately direct health care practice, we demonstrate that care is a secondary notion. We show that in order for a carer to decide which fo rm of care to adopt in different situations she requires a more powerf ul idea. We contend further that health care ought to be governed by a theory of health, and suggest that 'the foundations theory of health' should be adopted by planners searching for a more humane alternative to ER. We conclude that ER's dominance can and must be challenged. Ho wever, only those arguments which offer detailed theoretical analyses of health care, as well as meticulously derived practical policies, ha ve any chance of success. (C) 1997 John Wiley & Sons, Ltd.