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)

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 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)

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)

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.

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.

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.

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)

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)

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)

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)

Health care reforms, in particular the expansion of public and/or private health care benefit coverage to some or all population groups, is becoming an increasingly hot topic for discussion—and in some cases for action—at all levels of government. With almost 16% of Americans estimated to be uninsured for at least part of the year, opinion polls show health care near the top of the general public’s list of concerns. Little wonder that presidential candidates for (...) the 2008 election are incorporating ‘‘universal health care coverage’’ proposals in their campaign platforms. Will ‘‘cradle-to-grave’’ coverage for all become a reality or will they just experience cradle-to-grave debates over this issue? That is essentially one of the questions posed in the following discussion on the role of nonprofit health care organizations in promoting, and operating under, universal health care coverage. (shrink)

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)

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)

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)

From the late 1970s through the mid-1980s, a number of philosophers carefully worked out theories of justice in health care. Most of those still working on these issues have turned to clinical applications of the philosophical frameworks developed earlier. Although theories have not received much recent attention in this debate, this paper will offer a new theoretical framework for approaching issues of justice in health care. There are two reasons for thinking that returning to theory would (...) be worth- while. One concerns the fact that our society remains very far from realizing justice in health care. While there are several well-argued theories of just health care whose implementation would take us into the neighborhood of justice, it would also seem - in pluralistic spirit - that adding to the arsenal is helpful. The more good arguments there are for a given conclusion, the more likely it is to be correct and, ultimately, to persuade. -/- It will be contended that a limited right to health care can be grounded in self-respect. The argument will exploit Rawls' key insight that self-respect is a primary social good and will depend on the assumption that, at least in moderately affluent nations, one has a right to the primary social goods. This assumption is not defended here. But it should be noted that a right to the primary social goods is not of interest only to Rawlsians and other liberal deontologists; an enlightened utilitarianism might also vindicate it. The second reason for advocating a return to theory is that self-respect is especially fruitful as a focal concept for addressing issues of justice in health care (and other issues). (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)

This chapter contains section titled: I Equality of Resources II Justice in Health Care III Why Universal Access Requires In‐kind Transfers IV Conclusion Acknowledgement.

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)

Equality is a concept that is often used in health care discussions about the allocation of resources and the design of health care systems. In secular discussions and debates the concept of equality is highly controverted and can take on many different specifications. One might think that Christians hold a common understanding of equality. A more careful study, though, makes it quite clear that equality is just as controversial among different Christian communities as it is (...) in the secular world. (shrink)

It is well documented that the higher the socioeconomic status (SES) of patients, the better their health and life expectancy. SES also influences the use of health services—the higher the patients' SES, the more time and specialised health services provided. This leads to the following question: should clinicians give priority to individual patients with low SES in order to enhance health equity? Some argue that equity is best preserved by physicians who remain loyal to ‘ordinary medical (...) fairness’ in non-ideal circumstances when health disparities persist; ie, doctors should allocate care according to needs only and treat everyone with equal regard by being neutral with respect to patients' SES. This paper furthers a discussion of this view by questioning how equitable needs relate to SES. To clarify, it distinguishes between four versions of ‘healthcare need’ and approaches an acceptable conceptualisation of the notion supported by Norman Daniels' theory on health equity. It concludes that doctors should remain neutral to patients' SES in cases in which several patients require the same health care. However, equitable health care requires considerations of the impact of socioeconomic factors (SEF) on patients' capacity to benefit from the care. Remaining neutral towards patients' SES in this respect does not promote equal regard. It follows that priority setting on the basis of SEF is required in fair clinical distribution of care, eg, through allocating more time to patients with low SES. In order to advance equity accurately, the concept of ordinary medical fairness should be amplified according to this clarification. (shrink)

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and to purchase (...) medication; and, primary care is free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing. (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 ….

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of (...) health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (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)

The debate about justice and health care has occurred largely at a remove from the institutions it concerns; it has been about our most general moral principles, and about what things we value. This debate has foundered. But if the debate is turned in another direction, toward some moral principles that are widely accepted within those institutions, and toward principles that have to do with control over allocation decisions rather than with actually how to make those decisions, agreement (...) may be nearer at hand. (shrink)

We are well into the political season that guarantees the election of a new president. Actually, this season, the election cycle began in November 2006, as soon as the off-year election ended. Not surprisingly, health care and reforming health care are major issues for the election — although somewhat less important than they were before late 2007.I use the phrase “not surprisingly” because there are easily understandable reasons why health care tends to be an (...) election issue whenever we are electing a new president. One obvious reason is that, for several decades, we have been plagued by sizeable numbers of people without health insurance and even more importantly, by unsustainable increases in health care spending and substantial numbers of people experiencing patient safety and clinical appropriateness problems. I regard the unsustainable spending and safety and quality problems as especially important because they affect all of us — not just the 15% of the population that is without health insurance. (shrink)

An ethics concerned with health care developments and systems must be historically continuous, especially as it concerns the application to managed structures of key moral-epistemic concepts such as care, love and empathy. These concepts are traditionally most at home in the personal, individual domain. Human beings have non-instrumental worth just because they are human beings and not by virtue of their capacities. Managed health care systems tend to abstract from this worth in respect of (...) both individuals' distinctness and individual identity. The first, a common feature of quantitative approaches to health care assessment and delivery, is avoidable. The second, by contrast, is necessarily sacrificed in impersonally managed structures. Failure to distinguish the two encourages confusion and distress, and the demand for impossible medico-moral relationships. (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)

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)

This paper applies an Intersectionality Based Policy Analysis Framework to Ontario’s current mental health plan – The Roadmap: A Plan to Build Ontario’s Mental Health and Addictions Services – in order to identify the contextual influences, underlying values and assumptions, which promote or undermine the uptake of human rights and equity as a mental health policy priority in Ontario. We found that dominant framings of the “problem” of mental health (as lack of access, coordination or integration, (...) as a fiscal drain, as an economic burden, and as a clinical or medical problem) served to obscure and ignore the underlying social and structural conditions that impact mental health and the human rights violations that routinely occur in the context of “care.” We discuss the implications of The Roadmap ignoring social and structural determinants of health, and by way of contrast, explore how citizen engagement and activism can support rethinking mental health policy so that it is more just and equitable. (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)