Democracy and Minorities

And what about minorities? Will 51% of the people decide about the access to health provisions of the other 49%? Is the parliamentary democracy the modern variation of dictatorship of the majority over the minority? Are elections a modern non-bloody form of revolution? In a modern society democracy has many faces. As I pointed out before, it is not only the parliamentary forum where the decisions, for instance about health care, are taken. In many countries democracy works on a federal level, on a state level, in the local community, by means of membership of trade unions, on the work floor, possibly in the church, in consumer organizations and through a critical approach to the role of insurance companies and other health-related industries (13). And the individual plays in this respect mostly more than one role, and perhaps may even take various standpoints and at different times show various faces, depending on the forum and regarding his personal interests. This leads to a result which is much more complex than the output of a one-dimensional "democratic" decision. The result will mould into concrete forms of solidarity. An acceptable form of the limitation of personal autonomy emerges. The result can be seen as the product of a much more complicated but at the same time more mature society and should therefore be respected carefully.

In practice, many of us will sometimes face the question of a very expensive medicine or treatment that exceeds by far the health budget. If there has been discussion and consensus in a practice, in a hospital or in a country how to act in such a case, then it is not immoral or unethical behaviour to follow such a protocol, even in the case that one has to abandon treatment for an individual. It is the result of the balance between the well-being of the individual and the well-being of society. It still has strongly autonomous elements in its outcome. It is not the result of a heteronomous process.

The responsibility of pharmacists and doctors is to develop protocols which respect the patients as individuals and discuss them with all (mentioned) parties involved. Only balanced and updated protocols will protect health practitioners from unbalanced moral dilemmas. Parallel to this process, clear protocols will show society where the ethical questions are (14,15). They will force society to take a position, not to hide from its responsibility and leave it to practitioners. A dynamic process of discussion, development and updating of the protocols will be necessary to adjust to changes in time and changes in generations, in other words changes in culture.

A practical case which demonstrates how difficult it is to apply these conclusions to the work place was published in a Dutch medical journal at the beginning of 1998 (16). The use of taxoids for a number of defined indications appeared to differ from one hospital to another, mainly due to

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