Phil 383

M. Rorty

Week 3 Reading Notes

Reading Justice and Healthcare

SALs introduction to Allocation, Social Justice and Health Policy (pp. 173-179)
We are created equal with respect to being equally entitled to respect and dignity. We
are not created equally healthythe natural lottery gives some people good health, some
catastrophic diseases.
Nor are we equal in access to health care. Access to h/c in the US depends upon
availability of insurance, either privately purchased, through an employer, or through
government sponsored programs such as Medicaid and Medicare. As a result, the social
lotteryones financial resourcescan also contribute to inequalities. People who rely on
Medicaid can suffer from a pattern of constant reduction in reimbursement to providers, which
can imperil the quality of carehospitals that deal with a predominantly Medicaid population
are notoriously understaffed and undersupplied. In addition, there are approximately 47 million
people who are not poor enough to qualify for Medicaid but cannot afford to purchase health
insurance.
How should we think about the results of these inequalities in the natural and the social
lotteries? Are they misfortunes, or injustices?
One form this discussion takes is the question of whether there is a right to health care. Most of
the people we read this week deny that there is such a right.
(1) There may be a moral obligation on the part of a society to provide a decent minimum of
health care to citizens, and what counts as a decent minimum in a given society depends upon its
resources and technological sophistication. (cf. Presidents Commission, Daniels.) But: a decent
minimum does not necessarily equate with all the care that a person might wantor need. Nor
is health care necessarily the only contribution to equality of opportunity that a society must
concern itself withschooling, housing, nutrition and jobs also have a claim on social support.
Daniels justifies the obligation to provide a decent minimum of health care by arguing that
society does owe its citizens equality of opportunityand that health needs have a foundational
role in access to equality of opportunity.
Different concepts of equality generate different answers to that question. They suggest four
concepts of macro-level justice;
(a) the total sum of health for society;
(b) equalizing the level of health between classes;
(c) maximizing the health of the least advantaged;
(d) priority to the sickest, regardless of class.
The typical liberal position eg Rawlsean (or Daniels) liberalism--wishes to maintain that
social and economic inequalities can be allowed to exist so long as the result is not inequality in

basic liberties, and that the existence of inequalities works for the betterment of the worst off.
But if the society is too inequitable, it threatens the justice of the society.
(2) Engelhardt rejects liberal egalitarian theories of health care justice. He maintains that free and
equal individuals should not be coerced into accepting (much less paying for) others priorities in
health careor, for that matter, the social priorities of others.
The idea of a right to health care is unfounded (because it relies on one of the possible
understandings of justice, none of which are universally accepted) and dangerous (because it
threatens the rights of others with a different vision). Society has the right to tax citizens for any
purpose (including healthcare for the needy, if it chooses) but that does not give anyone a right
to such care.
(3) Growing evidence of the correlation of social indications with lower health status raises the
question of whether it is more effective to direct attention to healthcare, or to direct attention to
ameliorating the social inequalities with which lower health status is correlated. Gopal
Sreenivasans contribution to the volume raises this question explicitly.
Presidents Commission (1982) (pp. 191-199)
Aims of health care: prevention of death and disability, relief of pain and suffering and
restoration of functioning. This commission believes that access for all to an adequate level of
care without the imposition of excessive burdens is the standard against which legislation and
regulation ought to be measured.
Healthcare should not be left to market forces if it results in a significant portion of the
population being without access. Our current patchwork of coverage leaves 8-11% of the
population without access. (That was in 82; its closer to 15% since then)
Healthcare has real importance for wellbeing and opportunity, and symbolic importance
for empathy and care. Many health problems are beyond any individuals control; and their
incidence is unevenly distributed and unpredictable. We consider it fair that some level of
healthcare is available to all; but questions remain about who should bear the responsibility, what
level of care is appropriate, and how to prudently use the resources we have.
The special importance of H/C:
Healththe absence of pain, suffering or serious disabilityis a primary good however
you characterize it, comparable to education in determining the opportunities available for
pursuing life plans: and health care is instrumental in supporting health, as well as
demonstrating empathy and respect for such things as birth and death that are central to what it
means to be human.
Equitable access: cant mean equal health, or equal health-dollars, or everything
needed: but it can mean access to an adequate level of care. This acknowledges that it is not
an open-ended obligation, allows for a liberty interest in a higher level of care, and sets a
standard within the context of what people in a given society can and do expect.

Burdens cant be excessive; we need to specify a reasonable range of burdens in

achieving care. And: the government neednt do it all; its a wider societal obligation than a
government one, and since health is so unevenly distributed, we cannot expect individuals to be
solely responsible for all their care. Insurance and charity care have been the major routes of
provision of care up to now, so when the government has to step in, it can use some of those
same routes. It is clear that market mechanisms cannot possibly achieve an equitable distribution
of health care resources.
But we refuse to use the language of a right to healthcare; its not constitutionally recognized,
nor is it a logical corollary of an ethical obligation. Further, it doesnt need to be a right in any
rigorous sense in order to justify governmental intervention. [To say x has a moral right to
something is to say that x is entitled to it; and all moral rights imply corresponding obligations.
But there can be social obligations for which one cannot identify a corresponding right; and
healthcare is one such.]
So: what is that social obligation, and how can it be met? It is an obligation to a level
of adequate care: a reasoned judgment about (a) the impact of the condition on the welfare and
opportunity of the individual, and (b) the efficacy and cost of the care itself in relation to other
conditions and the cost and effectiveness of the care available for them. [The cost is to be
considered in terms of the absolute cost, and in proportion to other social needs; the benefits are
to be considered both in terms of benefit to the affected individual and in terms of social
benefits.]
Adequate care should be estimated including both positive and negative outcomes;
include what happens with alternative care (or none at all); meet standards of sound medical
practice; and be independent of the setting in which it is delivered.
Daniels(1988): Equal opportunity and health care (pp. 200-202)
The issue Daniels is considering is access to health care.
We cant figure out what principles of justice should govern access to healthcare by consulting
general philosophical theories of justice. First we need to specify what kind of good health care
IS. Is it a commodity, like computers, to be governed by market logic? Or does it have a special
status due to its fundamental effect on wellbeing?
The normal opportunity range: The normal opportunity range for a given society is the range of
life plans reasonable persons in it are likely to construct for themselves. Fair equality of
opportunity requires that opportunity be equal for persons with similar skills and talents. (This
doesnt mean equal opportunity, necessarilybut it does mean opportunity consonant with
skills and talents.) And: impairment of normal function (through disease and disability) restricts
individuals opportunities relative to that portion of the normal range their skills and talents
would have made available to them if they were healthy. Thus, considering the impact of
impairment of disease and disability suggests that the principle that should govern the design of

the health care system is the principle guaranteeing fair equality of opportunity. It should be
applied on the macro level: the moral function of a healthcare system must be to help guarantee
fair equality of opportunity.
Looking at how that might play out, we can see that it need not exclude a two-tier system. The
basic tier (a) should include services that meet important health care needs that impact the
opportunity range, and (b) should be considered a decent basic minimum, (c) to which there
should be NO obstacles (financial, racial or geographical) to access. There can still be a second
tierless important needs or preferences, like cosmetic surgery, to which there can fairly be eg.
financial obstacles. Social obligations are focused on the basic tier, the decent basic minimum.
This principle requires emphasis on preventative measures and on public health measures. It
does not give individuals a right to have all their health care needs met.
The principle of justice guaranteeing fair equality of opportunity shows that individuals have
legitimate claims or rights when their opportunity is impaired in particular waysagainst a
background of institutions and practices which protect equal opportunity.
The scope and limits of these rightswhat they can be spelled out as requiringis relative to
resource scarcity and technological development for a given society. We cannot infer from the
fact that a person has a right to healthcare that s/he is entitled to some specific service. That is
true only if it is or ought to be part of a system that appropriately protects fair equality of
opportunity.
Engelhardt (1997): Freedom and moral diversity: the moral failures of healthcare in the
welfare state (pp. 203-212)
The problem with Clintons health care plan is that it would have established a welfare
right to health care, and forbidden a two-tiered system. Engelhardt (Kasss successor as
head of Bushs Bioethics Commission) argues that (1) it is bad to establish a uniform
health care welfare right, and (2) it is wrong to forbid people to use their private
resources to purchase better-than minimum health care.
We disagree about equality, fairness and justice in this society; and there is no resolution to such
disagreements in a secular and diverse society. If/since persons are the source of secular moral
authority and it is their right to disagree, there is no right to health care.
1. medical welfare: needs do not generate rights. And health care is not basic; unlike food,
clothing and shelter, there is no limit on the amount that can be invested and no guarantee that
even with infinite resources good results will be achieved. We are finite, vulnerable and mortal.
2. bad luck, unfairness and inequality: Autonomypeoples authority over themselvessets
limits to what governments can decree about human flourishing. To be free means I can risk
death or disability by my choices. To have resources means I can spend them as I choose.

A devoted egalitarian would prioritize research on the health of men, children, the poor and
people of low status [whatever that means]. But not everyone would agree with that policy,
because we dont all have the same understanding of equality.
Three worlds (=three concepts of equality): equality of outcomes, equality of envy, equality of
altruism. (p.206) Even if you could settle on one of these different concepts, like equality of
outcomes, youd still have to specify which outcomes were the relevant ones. To say nothing of
problems in determining what the range is of things that government is allowed to control.
An outcome can be unfortunate without being unfair. Which outcomes are unfair rather than just
unfortunate, and who should decide that? And why should governments (rather than
organizations on other levels) be responsible for welfare?
3. healthcare welfare: a uniform right to health care involves endorsing and establishing one
among a number of competing concrete moralities of life death and equality. It risks medically
politicizing all elements of personal conduct, and constraining free choice of those with
disposable resources.
4. Why we are not one moral community: The attempt to develop a uniform, encompassing
healthcare welfare right reveals our moral differences concerning the proper understanding of
reproduction, suffering and death. Secular morality is procedural, and its legitimacy is limited by
the consent of those who participate in common endeavors.
WHO: (2003) Social Determinants of Health: The Solid Facts (pp. 213-221)
Much of the variation between (and within) nations in health data is explained not by access to
health care, but by independent social factors that constitute a wider material disadvantage: being
poor, unemployed, socially excluded, or otherwise stigmatized. The report compares nations
with and without universal access to health care in terms of a variety of social factors.
1. Life expectancy is shorter and most diseases are more prevalent in the lower steps of
the social ladder.
2. Stessful circumstances lead to worry, anxiety and inability to cope, damage health and
may lead to premature death.
3. Maternal and infant healtha good start in lifehave profound implications for later
health.
4. Life is short where is quality is poor. Poverty, social exclusion and discrimination
cause hardship and resentment and shorten life.
5. Unemployment : job security increases health, well being and job satisfaction.
6. Friendship, good social relations and strong supportive networks improve health.
7. Drug use is a response to social breakdown and a contributing cause to it.
8. Good diet and adequate food supply are crucial: a diet of fruits, vegetables and
legumes.
The article contains social policy recommendations around each of the factors discussedand
has some GREAT graphs!!
Daniels: (2001) Justice, Health and Healthcare (pp. 231-234)

Daniels has been arguing for 30 years that Rawls theory of justice
provides justification for special attention to health care. Although
considerable attention to social determinants of health in recent decades
appears to weaken that conclusion, Daniels argues here that the theory,
especially the difference principle, remains an important argument for health care.
There are three questions a theory of justice for health care must answer: (1) Is health care
special? (2) When are health inequalities unfair? (3) How can we ration fairly?
Daniels answers the first question by claiming that the role of healthcare is to maintain normal
functioning; disease and disability restrict the range of opportunities open to individuals. In the
last 20 years it has become increasingly clear that social inequalitiesrace and class effectsare
as important to maintaining health and reducing disability as health care. In particular: universal
access to health care is not a magic bullet.
So how can Daniels/Rawls maintain their argument that his theory of justice is the best solution
to the particular problem of unfair distribution of health?
Rawls theory of justice argued that equal basic liberties, guaranteeing equal political
participation, and limiting inequalities to those that benefit the least advantaged promote social
and political wellbeing. Daniels applies this to health outcomes, although Rawls himself didnt
specifically do so, and argues that promoting social justice also promotes health. He supports this
by empirical evidence of correlation of income inequality and health outcomes. Other correlated
factors are literacy rates and high school drop-out rates, social capital and political participation.
Rawls difference principle inequalities are justified only if they result in benefit to the least
well offsuggests that the inequalities that contribute to worsened health incomes are not
among those that benefit the least advantagedon the contrary, they are among those for which
there is the best justification for remediation.
Daniels points out that his position converges with that of Amartya Senns (and Nussbaums)
capabilities-based account of the proper target of justice.
Sreenivasan: Opportunity is Not the Key (pp. 235-236)
Daniels argues that health care is special because health is special. Health is special because it is
required in order for an individual to have a fair opportunity for the goods of the society. Daniels
connects health with healthcare, which he interprets as requiring universal access.
But: IF introduction (or presence) of universal health care (as in the UK) does not alter a
societys gradient in health status; and IF introducing a universal health system would seriously
erode the societys capacity to deal with the other determinants of health status (like poverty or
education)is a society really required to devote a disproportionate amount of the societys
funds to a small percentage of the societys membersthe diseased or disabled??
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The language of rights is very tricky, and most of the readings are careful about its use. Strictly
speaking someone does not have a right to something unless there is a party or institution with an
obligation to provide it. Daniels suggests that there may be obligations, eg., of a society to its

membersfor which there are no corresponding rights. In this weaker sense the citizens may
have an expectation, but not a claim.