A civic republican view of hospital closures and community health planning.

• Author: Lee, Jin Hee

1. INTRODUCTION

   Listening to today's news, it is impossible not to hear someone call for immediate health care reform. The uninsured, rising health care costs, the diabetes epidemic, the financial instability of health care facilities--these are just some of the issues that have contributed to what has become a health crisis of epic proportions. Presidential candidates,(1) former New York Governor Eliot Spitzer,(2) and even New York City Council Speaker Christine Quinn(3) have presented various reform proposals to cover the uninsured and underinsured, expand primary care, and curb inflated health care costs in an effort to manage this crisis. What is missing from these proposals, however, is a crucial element that health care policymakers have overlooked for far too long: meaningful community participation in a deliberative process whereby community residents can influence decisions about their local health care resources.

   The concept of community residents participating fully in a deliberative decision-making process is hardly new. Legal scholars have discussed what has been called a "republican(4) revival" for over two decades. (5) The modern form of republicanism--what this Article refers to as "civic republicanism"--stresses the transformative nature of deliberation as people with diverse interests collectively seek the common good. Thus civic republicanism, with its emphasis on deliberation and community, is a counterpoint to liberal pluralism, which conceives of society as individuals with competing interests bargaining within the political process.

   This Article utilizes the civic republicanism framework to call for a form of community health planning that incorporates the active participation of community members in the deliberative process of allocating health care resources. Like liberal pluralism, the current health policy model rests upon the competing interests of special interest groups, such as hospitals and labor unions, as they battle for leverage within the political process. Yet recent hospital closures in New York City communities have demonstrated the fallibility of excluding community input within this pluralist model. By failing to consult the people most affected by health policy decisions, the State, as well as health care administrators, makes uninformed choices that have proven to be costly for both the community's health and the financial stability of the health care system. Thus, no health care reform proposal can succeed without engaging the public in a meaningful dialogue that learns from community members' localized knowledge while at the same time empowers them to take control of their health care needs.

   Part II of this Article provides some background on civic republicanism, drawing heavily from the work of Professor Cass Sunstein, whose conception of civic republicanism has four key principles: deliberation in the public sphere, equality within the deliberative process, group consensus towards a common good, and the development of the civic virtues of active citizenship. (6) These principles of civic republicanism are further discussed in the context of health care policymaking, particularly regarding the need for civic participation in community health planning. Part III of this Article moves the discussion of civic republicanism beyond just theory by telling the story of four communities in New York City--Central Brooklyn, Southeast Queens, the Northeast Bronx, and Southwest Brooklyn--that have endeavored to insert themselves in the public discourse regarding the possible closure of their respective neighborhood hospitals. By making their voices heard, these communities have demonstrated that localized knowledge and concerns are essential features of good government, especially in an area like health care that so greatly impacts the welfare of the community. Equally as important, these stories demonstrate the need for comprehensive, community-based health planning that incorporates genuine community participation as part of any successful health care reform.

2. CIVIC REPUBLICANISM AS A FRAMEWORK FOR HEALTH PLANNING

   It is important to clarify what exactly "civic republicanism" means as the term is used in this Article. Like many forms of political theory, it is subject to various distinctions and possible disagreements among legal scholars. (7) But there are general themes of community, deliberation and the common good which serve as the foundations of modern republicanism and inform our understanding of political processes as an analytical framework to critique the failures of the present health care system. Civic republicanism conceives of citizens as part of a larger political community and stresses the potential of reaching consensus for the common good through deliberation, rather than competition among independent and isolated actors within the political process. (8) The contrast between the "community" and the "individual" is particularly helpful when discussing health care, which currently suffers from a more market-based emphasis on competition among individual self-interests. Indeed, it would be difficult to think of a more "common good" than a community's health and health care, rendering civic republicanism especially apropos to this area of public decision-making.

   1. Background on Civic Republicanism

      What has been coined the "republican revival" is a response by some legal scholars to the over-emphasis of liberal and pluralist ideals in U.S. constitutional jurisprudence. Liberal theory considers the individual to be the "ultimate concern of moral and political justice," and thus focuses on the individual's desires as the engine of political activity. (9) Drawing upon liberal theory, pluralism likewise emphasizes the primacy of the individual in the political sphere as conflicting interests compete with each other. (10) As a consequence, pluralism has little faith in the capacity of people with diverse interests to deliberate collectively towards a common goal. Instead, pluralism conceives of individuals utilizing "deception, coercion, or other manipulation" in their interactions with each other within the political process. (11) As a consequence, pluralists consider politics to be nothing more than a "market-like medium" navigated by competing individuals who seek to satisfy their own private interests. (12)

      Dissatisfied with the shortcomings of liberal pluralism's individualistic and market-based approach towards political participation, (13) republican theorists have challenged the "hegemony" of liberal assumptions and pluralist ideals in American political culture. (14) The efficacy of connecting civic republicanism to the foundational principles of the U.S. Constitution or pronouncing republicanism's superiority over the rights-based discourse of liberal pluralism is beyond the scope of this Article. Rather, this Article utilizes civic republicanism as a theoretical framework to critique the exclusion of community participation in decisions concerning the allocation of health care resources. Of particular insight is Professor Sunstein's theory of republicanism and its four main principles: deliberation in politics, equality of political actors, universalism or a common good, and citizenship. (15) Each of these principles supports the argument that community participation in political decision-making, in this case health care policy, is necessary for an effective democracy and the judicious allocation of health care resources.

      Civic republicanism's emphasis on open dialogue and deliberation presupposes that policymakers cannot know what is best for the community. (16) Thus, according to Professor Sunstein, the requirement for deliberation should not be "purely formal" nor should politically powerful groups be allowed to impose outcomes onto the deliberative process. (17) Rather, in believing in the transformative potential of deliberation, civic republicanism requires exposure to as many diverse interests as possible, which are then subject to scrutiny and revision based on the multiple perspectives that contribute to and are borne from the interactive discussions. (18) The ideal of civic republicanism, therefore, "is not initial agreement on substantive issues, but belief in the consensual possibilities of deliberative dialogue." (19) Moreover, the potential for consensus is less dependent on "identical conceptions of the good," but instead depends on the faith that interaction that is truly open and free among individuals will eventually lead to a common understanding. (20) Consensus in this manner benefits from the process of vetting decisions through multiple perspectives, which is a "measure of the legitimacy of government action." (21)

      A prerequisite for true deliberation--representing the wide array of interests demanded of civic republicanism--is equal participation in the deliberative process. Indeed, the integrity of the deliberative process, as well as the value of subsequent results, would be wholly undermined by the failure to ensure equal access to the political process due to disparities in wealth and power. (22) Because civic republicanism values the opinions of everyone, regardless of status or power, unequal influences within the political sphere do not further its goals. (23) Thus, for Professor Sunstein, efforts to equalize political power, such as proportional representation, are more justified on republican bases because the deliberative process thrives on the inclusion of multiple voices, especially the voices of disadvantaged groups that may have less access to the process. (24) Furthermore, in contrast to a pluralist model where diverse interests are viewed as in competition with each other, republicanism seeks to ensure that certain groups have access to the deliberative process. Rather than giving these groups a "piece of the action," the goal is to examine as many views as possible in search of the best outcome for...