How should medical services be distributed within society? Who should pay for them? Is it right that large amounts should be spent on sophisticated technology and expensive operations, or would the resources be better employed in, for instance, less costly preventive measures? These and others are the questions addreses in this book. Norman Daniels examines some of the dilemmas thrown up by conflicting demands for medical attention, and goes on to advance a theory of justice in the distribution of (...) class='Hi'>health care. The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services. Access to care, preventive measures, treatment of the elderly, and the obligations of doctors and medical administrations are fully discussed, and the theory is shown to underwrite various practical policies in the area. (shrink)

Few in our society believe that access to health care should be determined primarily by ability to pay. We believe instead that society has an obligation to assure access to adequate health care for all. This is the view explicitly endorsed in the President's Commission Report Securing Access to Health Care. But there is an important moral ambiguity here, for this obligation may be construed as being either beneficence-based or justice -based. A beneficience-based construal (...) would yield a much weaker obligation with respect to the distribution of health care. In the first section of this paper I argue that the President's Commission is committed only to this weaker construal of this obligation. In the second section I argue that such a beneficence-based obligation is really rooted in a libertarian conception of justice, similar to that recently articulated by Engelhardt, and that this conception is seriously flawed when it comes to effecting a just distribution of health care. (shrink)

Book reviewed in this article: The Needs of Strangers. By Michael Ignatieff. The Health Economy. By Victor Fuchs. Just Health Care. By Norman Daniels.

This book addresses an intruiging question: What do we mean by justice in health care? It concentrates on the social level of decision-making rather than the individual decisions which are more commonly the subject of medical ethics.

This article investigates what notions of “just health care” are found at three Swedish hospitals among health care personnel and whether these notions are relevant to what priorities are actually made. Fieldwork at all three hospitals and 114 in-depth interviews were conducted. Data have been subject to conceptual and ethical analysis and categorisation. According to our findings, justice is an important idea to health care personnel at the studied hospitals. Two main notions of (...) just health care were found. The main idea was the notion of “equal treatment according to need”, the basic idea being that differences in treatment should be justified by differences in needs. The competing idea that merit should affect the treatment received is occasionally encountered, the idea here being that patients, by acting irresponsibly, may no longer deserve to be treated strictly according to needs. In practice, priorities are made on grounds that only partly comply with the basic idea of justice in health care, as it is understood by staff at the studied hospitals. Exceptions are made due to regional differences, considerations of cost-effectiveness, economic incentives, tradition, the daily patient flow, research, private alternatives, patient influence and favouritism of health care personnel. (shrink)

The pluralism that democratic regimes foster creates the following serious problem in societies: When people disagree so fundamentally about the good life, where are the grounds of social unity to be found? This is a quite general problem for liberal political theory, but in this chapter I want to focus on a related but narrower set of issues having to do with what justice requires with respect to the provision of health care in modern democratic societies.

It is important to bring Catholic social teaching to bear on the decisions we make as responsible citizens. We will not have a just health care policy or meaningful health care reform until the people in this country demand it. For us as Catholics, we come to decisions about what is a just health care policy based largely on the Church's social teaching.

Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health (...) care justice, and outlines a new approach that can justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)

The Human Genome Project is expected to increase dramatically our ability to predict the likelihood of genetic disease in an individual. It is important to reject the myth of genetic determinism—i.e., the simple-minded belief that such complex outcomes as heart disease, cancer, or autoimmune diseases are caused exclusively by particular genes. But it is equally important to acknowledge that genes may play a role in making a person more or less susceptible to such diseases. The ever-increasing prospect of genetic prediction, (...) spurred by the Human Genome Project, has implications for social practices such as insurance, in which predicting the risk of disease or death plays a crucial role. Concerned that improved genetic prediction might have unfortunate social consequences unless the impact of such predictions were anticipated, the U.S. Human Genome Project's Working Group on Ethical, Legal, and Social Issues established a Task Force on Genetic Information and Insurance in May 1991. -/- The Task Force met seven times over its two-year life. By the end of the first year, it had reached several tentative conclusions. Most importantly, we became convinced that the problem posed by increased genetic prediction in insurance was a genuine and important one. When we began, the danger seemed plausible but far from certain. The information we gathered in the first year persuaded us that genetic prediction of disease was in one sense already with us and, in another sense, likely to grow massively in the foreseeable future. (shrink)

This study addresses the question of justice in health care. Increasing numbers of Americans are uninsured, the cost of health care is escalating, and is projected to continue doing so. In response to these and other concerns, Americans have looked to their neighbor to the north, Canada, for possible help in treating the ills of America's health care system. In addition to offering a comparative analysis of the Canadian and American health care (...) systems, we have sought to identify the facts that motivate concerns on both sides of the border. It is within this larger context, we argued, that the question of justice in health care must be answered. ;We consider two alternative answers that have been advanced in response to the question of justice in health care, Norman Daniels' fair equality of opportunity argument and Allen Buchanan's enforced beneficence arguments for a right to a decent minimum of health care. After subjecting these arguments to critical scrutiny, we found that they could not bear the moral weight that the authors thought they could. ;We then considered an alternative account that might be used to address the question of justice in health care, David Gauthier's theory of justice. We concluded, among other things, that under his theory people would have a right to a just minimum of health care. In addition, we argued that a just minimum of health care would resolve the theory-dependent version of the bottomless pit problem. (shrink)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government (...) regulations tend to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

The interface of health care and insurance requires not just the medical, legal and financial perspectives, but a clear ethical analysis. A varied team of contributors ranging from experts in philosophy, law, medicine and ethics to actuarial science, underwriting and insurance have contributed a series of essays. The ….

In this book by the award-winning author of Just Healthcare, Norman Daniels develops a comprehensive theory of justice for health that answers three key questions: what is the special moral importance of health? When are health inequalities unjust? How can we meet health needs fairly when we cannot meet them all? Daniels' theory has implications for national and global health policy: can we meet health needs fairly in ageing societies? Or protect health (...) in the workplace while respecting individual liberty? Or meet professional obligations and obligations of justice without conflict? When is an effort to reduce health disparities, or to set priorities in realising a human right to health, fair? What do richer, healthier societies owe poorer, sicker societies? Just Health: Meeting Health Needs Fairly explores the many ways that social justice is good for the health of populations in developed and developing countries. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just (...) another commodity to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

Dr Hillel Steiner in this reply to Elizabeth Telfer takes each of her arguments for different arrangements of a health service and examines them--'four positions which can be located on a linear ideological spectrum'--and adds a fifth which could have the effect of 'turning the alleged linear spectrum into a circle'. Underlying both Elizabeth Telfer's article and Dr Steiner's reply, the base is inescapably a 'political' one, but cannot be abandoned in favour of purely philosophical concepts. Whatever the attitude (...) of mind of the reader of these two papers to the provision of a health service, the stimulus to more careful assessments of our own National Health Service and its problems can only be good. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but (...) with the more modest and limited topic of medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in (...) jeopardy of falling beneath the threshold has a legitimate claim to justice. People's entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold). (shrink)

This work offers a philosophical appraisal of accounts of social justice in health care. By analyzing and comparing seven different accounts, it shows what is involved in advancing such an account and discloses what is involved in providing a moral justification, identifying a tripartite interplay among moral accounts, theories, and perspectives regarding the proper allocation of health care. Based on a distinction between substantive and procedural accounts of justice in health care allocation, it concludes (...) that the prospect of agreement regarding substantive accounts of health care justice is unlikely. This study illustrates that it is moral perspectives, rather than moral theories, that are foundational to accounts of justice in health care. A moral perspective includes the complete content of a morality lived by a group of people, while a moral theory identifies general statements formulatable within a moral perspective, a moral account restructures in a systematic way a moral perspective regarding a domain of issues, such as that of justice in health care. Although a moral theory contributes to an account a general framework that arranges moral commitments into a discursive system, only a full-bodied moral perspective can provide a moral account the substance that it needs. Through closely looking at various moral perspectives embodied by different accounts of just health care, it becomes clear that disagreements in morality are extensive and deep. It is impossible to justify a particular substantive account of just health care without begging the question. Finally, a theoretical reconstruction of Singapore's Confucian moral perspective regarding health care justice is provided so as to offer a picture of a quite different theoretical foundation as well as a substantively different moral perspective from those that are often taken for granted in the West. It shows that moral perspectives are different from people to people, from community to community. A successful account of just health care will thus require more than what can be drawn from theories of justice. (shrink)

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, (...) but it is mostly hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

I agree with Professor ter Meulen that there is no need to make a forced choice between “justice” and “solidarity” when it comes to determining what should count as fair access to needed health care. But he also asserts that solidarity is more fundamental than justice. That claim needs critical assessment. Ter Meulen recognizes that the concept of solidarity has been criticized for being excessively vague. He addresses this criticism by introducing the more precise notion of “humanitarian solidarity.” (...) However, I argue that these notions are still not precise enough and are in need of behavioral translation, especially in relation to the problem of fair health care rationing. More specifically, I argue that translation ought to take the form of a well-ordered process of rational democratic deliberation, which I describe and defend in this essay. Such a process is what is required to construct a working model of just solidarity as opposed to a merely abstract idealization of just solidarity. (shrink)

This paper firstly distinguishes between principles of “global justice” that apply the same anywhere and everywhere – Tännsjö’s utilitarianism, egalitarianism, prioritarianism and such like – and principles of “local justice” that apply within the specific sphere of health-care. Sometimes the latter might just be a special case of the former – but not always. Secondly, it discusses reasons, many psychological in nature, why physicians might devote excessive resources to prolonging life pointlessly, showing once again that those reasons (...) might themselves be morally significant. (shrink)

Health care is provided in many contexts—not just hospitals, clinics, and community health settings. Different institutional settings may significantly influence the design and delivery of health care and the ethical obligations and practices of health care practitioners working within them. This is particularly true in institutions that are established to constrain freedom, ensure security and authority, and restrict movement and choice. We describe the results of a qualitative study of the experiences of (...) doctors and nurses working within two women’s prisons in the state of New South Wales (NSW), Australia. Their accounts make clear how the provision and ethics of health care may be compromised by the physical design of the prison, the institutional policies and practices restricting movement of prisoners and practitioners, the focus on maintaining control and security, and the very purpose of the prison and prison system itself. The results of this study make clear the impact that context has on professional practice and illustrate the importance of sociology and anthropology to bioethics and to the development of a more nuanced account of professional ethics. (shrink)

The factions debating health care reform in the United States have gravitated toward one of two positions: that just health care is an individual responsibility or that it must be regarded as a national concern. Both arguments overlook a third possibility: that justice in health care is multilayered and requires the participation of multiple and diverse communities. _Communities of Health Care Justice_ makes a powerful ethical argument for treating communities as critical (...) moral actors that play key roles in defining and upholding just health policy. Drawing together the key community dimensions of health care, and demonstrating their neglect in most prominent theories of health care justice, Charlene Galarneau postulates the ethical norms of community justice. In the process, she proposes that while the subnational communities of health care justice are defined by shared place, including those bound by culture, religion, gender, and race that together they define justice. As she constructs her innovative theorization of health care justice, Galarneau also reveals its firm grounding in the work of real-world health policy and community advocates. _Communities of Health Care Justice_ not only strives to imagine a new framework of just health care, but also to show how elements of this framework exist in current health policy, and to outline the systemic, conceptual, and structural changes required to put these justice norms into fuller practice. (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or (...) demands in and by the ‘exterior environment’. Social systems must be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

Toronto physician Brian Goldman had thought about “joining the camp that favours private health care for Canada.” Writing in the Canadian Medical Association Journal, he tells us that he changed his mind after one of his cats experienced a series of illnesses and misadventures that resulted in a Can$3,101 medical bill. “I’m just glad,” he says, “that the cost of health care never entered my deliberations.”’Canadian citizens and permanent residents are similarly free from most worries (...) about the direct costs of their own medical care, and have been for more than a generation. This reflects a fundamental difference between the Canadian and United States contexts for health policy. Since the failure of President Clinton's first-term efforts to provide something approximating universal health insurance, reforms to the existing regime of providing and financing health care in the United States have been incremental, and primarily responsive to the changing nature of the health care marketplace. In Canada, universal publicly funded first-dollar coverage for most physicians’ and hospitals’ services has been a reality since the early 1970s. (shrink)

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to (...) be met in order to ensure that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)

Political philosophers often formulate the problem of distributive justice as the problem of how the government ought to distribute different types of goods—for example, income or health care—to its citizens. They therefore presuppose that the government is a unitary agent that governs its citizens directly. However, although a number of governments are unitary in this way, many are federations, exhibiting a division of sovereignty between two or more levels of government having independent grounds of authority. In contrast to (...) unitary states, therefore, within a federation, two or more levels of government directly govern their citizens and are directly accountable to them. Because of the way in which different levels of government in a federation can separately affect the distribution of goods in society, federations face resource allocation problems that are far more complex than those of unitary states. In addition to determining what a just distribution of goods is, federations must also determine (1) whether distributive justice is a shared responsibility amongst different levels of government, and, if so, (2) how this shared responsibility should be allocated between them. (shrink)

In this commentary on Torbjörn Tännsjö’s Setting Health-Care Priorities, I argue that sufficientarianism provides a valuable perspective in considering how to set health care priorities. I claim that pace Tännsjö, sufficientarianism does offer a distinct alternative to prioritarianism. To demonstrate this, I introduce sufficientarianism and distinguish two forms: Tännsjö’s “weak sufficientarianism” and an alternative strong form of sufficientarianism that I call “revised lexical sufficientarianism.” I raise a problem for Tännsjö’s sufficientarianism, and advocate for the revised view (...) on this basis. I then demonstrate that in the area of population ethics, the revised view outperforms the other views Tännsjö considers. As such, I aim to demonstrate that sufficientarianism — understood as its own theory and not just as a form of prioritarianism — offers unique advantages in population ethics, and would have been a valuable complement to the other theories Tännsjö considers. (shrink)

A basic human right to the delivery of health care, even to the delivery of a decent minimum of health care, does not exist. The difficult with talking of such rights should be apparent. It is difficult if not impossible both to respect the freedom of all and to achieve their long-range best interests. -/- Rights to health care constitute claims against others for either their services or their goods. Unlike rights to forbearance, which (...) require others to refrain from interfering, rights to beneficence require others to participate actively in a particular understanding of the good life. Rights to health care, unless they are derived from special contractual agreements, depend on the principle of beneficence rather than that of autonomy, and therefore may conflict with the decisions of individuals who may not wish to participate in realizing a particular system of health care. If the resources involved in the provision of health care are not fully communal, private owners of resources may rightly have other uses in mind for their property than public care….[T]he principles of autonomy and beneficence that lie at the foundations of justice will spawn conflicts within any portrayal of a just allocation of health care resources. (shrink)

The new South African constitution commits the government to guarantee "basic health services" for every child under 18. Primary health care for pregnant women and children under six and elements of essential primary health care have received priority. At present, there is little analysis of the moral considerations involved in making choices about more advanced or costly health care which may, arguably, also be "basic". This paper illustrates some of the tensions in setting (...) priorities for a just macro-allocation of children's health care, given the realities of need and scarce resources, and the commitment to equality of basic opportunities. (shrink)

With the introduction of general management and then of planned markets into the National Health Service (NHS), health care in the UK has gone through a massive amount of change. The effect on those working for the NHS has been ‘challenging’ and often confusing. This paper aims to clarify what is happening by taking an ideological perspective: what ideologies exist, how they are changing and the strategies being used to ensure their survival. Ideologies are basically about power. (...) The relationship between market, managerial and professional ideologies is analysed using charters, codes of conduct and other associated documents. A tentative conclusion is reached that professional ideologies are able to adjust to the overriding market/consumerist ideology. However, the managerial ideology is having difficulty in gaining any real ground against the professional ideology and is having to move strategically by using audit, not just of finance, but also of clinical judgement, to gain power. (shrink)