The Concept of Justice

 Justice is best explicated in terms of fairness and also closely linked to desert.
 One acts justly toward a person when that person has given what the person deserves.
Example,
If a person deserves to be awarded an M.D. degree, justice has been done if and only if
that person receives the degree.
 Justice confers entitlement whether deserved by the person.
 Justice is giving to each his due.
 One who has a claim based in justice has a claim of entitlement and in this strong sense is
due something.

Injustice
 Injustice involves a wrong one has been denied that to which one is entitled.
 It is wrong, as a matter of justice, to burden or to reward someone if the person does not
possess the relevant property.
Example,
It is unjust to reward a superior for the work of his or her subordinates when the superior
contributed nothing to their productivity.
 These examples shows that both fairness and desert are central in our sense of justice but
also that understanding justice in terms of entitlement is essential.

Distributive Justice
 It refers to just distribution in society structured by various moral, legal, and cultural
rules and principle that form the terms of cooperation for that society which individuals
are obligated to cooperate.
 Theory of distributive justice is an attempt to establish a connection between the
properties or characteristics of persons and the morally correct distribution of benefits
and burdens in society.
 Challenging problem of Distributive Justice arise only under conditions of
scarcity and competition.

 Trade-off is involved no less than in circumstances in which capital and labor are used
to produce one commodity when they could have been used to produce another.
Principles of Justice
The Principle of Formal Justice
 “Equals must be treated equally, and unequals must be treated unequally.”
-Aristotle-
 It is formal because it states no particular respects in which equals ought to be treated
the same and provides no criteria for determining whether two or more individuals are
equals.
 But how far does equality reach?
 Virtually all accounts of justice in health care hold that delivery programs and services
designed to assist persons of a certain class (Poor & Elderly), should be made available to
all members of that class.
 To deny access to some when others benefits seems unjust. But is it unjust to deny access
to equally needy person outside of the delineated class?
 Example,
Hattie Campbell, was denied access to an emergency room on grounds that she was at the
wrong hospital and should have gone to a hospital where she had been provided prenatal care.

Material Principles of Justice

 The Principle of need. Consider the principle of need, which declares that distribution
based on need is just.
 The following is a representative list of some major candidates’ position of valid material
principles of distributive justice.
1. To each person an equal share.
2. To each person according to need.
3. To each person according to effort.
4. To each person according to contribution.
5. To each person according to merit.
6. To each person according to free-market exchanges.
The problem of this principle will fall in dilemmas.
Example,
 Mark Dalton, a histology technician employed by a large chemical company. Dalton was
an excellent worker, but a week-long sick leave led company nurse to discover that he
had a chronic renal disease. It was determined that the permissible levels of chemical
vapor exposure in Dalton’s job might exacerbate his renal condition. The company
management found another job, at identical rate of pay, for which Dalton was qualified.
 However, it turned out that two other employees had more seniority and better training
than Dalton, and one was a woman.

Relevant Properties (the “Kinaiya” of the person)

 Material principles specify relevant properties that one must possess in order to qualify
under a particular distributive principle.
 Example,
Trophies are awarded (Distributed) at the end of a tennis tournament on the basis of
achievement; and achievement is determined by tradition-bound rules of tournament
tennis.
 The argument is that certain properties accepted as relevant are actually irrelevant and
that certain properties presumed irrelevant are actually relevant.
 Example,
An incompetent organ donor. In this case a forty-year-old woman’s life depends on a
kidney transplant, which here fourteen-year-old daughter offers to supply. The kidney is
fairly good match. However, the woman has a thirty-five-year-old mentally retarded
brother who is a better match. An informal survey of nurses, social workers, and
physicians who work with such patients indicated that a majority would seek a court
order to take the kidney from the thirty-five-year-old, institutionalized, mentally retarded
brother.
 These cases and questions illustrate how abstract principles of justice may provide only
rough guidelines when specific actions must be taken, so that further moral argument is
needed to fix the specific relevant properties on the basis of which a reasoned judgment
can be made. This problem frequently occurs when there are conflicting moral demands
and no clearly preferable set of properties.

Theories of Justice
Utilitarian Theories
 It emphasizes a mixture of criteria so that public utility is maximized, comparable to the
way public health policy has been formulated in Western nations.
 Utilitarian argue that justice is not a principle independent of the principle of Utility.
 In the distribution of health care, utilitarians commonly see justice as involving trade-offs
and balances. In devising a system of public and private benefit, predicted costs savings,
the probability of failure, the magnitude of risks and so on.
  Utilitarians generally accept political planning to realize justice, including the
redistribution of goods and wealth through taxation in order to benefit those who are
genuinely needy, whenever redistribution would produce the greatest good for greatest
number.
 This theory is to promote the well-being of a person or his/her happiness.

Libertarian Theories
 These theories emphasize rights to social and economic liberty (Invoking fair procedures
and systems rather than substantive outcomes.)
 The United States has largely, though not exclusively, accepted the free-market rule that
distribution of health-care services and goods are best left to the marketplace, which
operates on the material principle of ability to pay invokes some form of libertarian
theory of justice as its justification.
 From this perspective, justice consists not in some distributed result, such as increasing
public utility, but rather in the unhindered working of fair procedures.
 Example,
In one case a patient arrives at his physician’s office accompanied by his cousin, who is
willing to “donate” his kidney to the patient. As it turns out, the prospective “donor” is
competent to make decision but is motivated to do so by a sum of money offered by his
cousin. The physician discusses with both parties whether the motive to provide a kidney
is proper, but both are happy with the bargain they have struck.
 In this system individuals may view the prices of available policies as too high, or as
unaffordable, but the libertarian insists that in true circumstances of free-market
competition the price cannot be unfair. It is simply unfortunate, not unfair, if one cannot
afford to pay for health insurance.
 The libertarian theory has been defended in an influential book by Robert Nozick, who
refers to his social philosophy as an “entitlement theory” of justice.
 She had freely made an arrangement with another physician and health-care facility, had
not made any arrangement with the county hospital, and therefore was denied admission
to the latter facility. (This is the case of Hattie Campbell)

Egalitarian Theories
 These theories emphasize equal access to the goods in life that every rational person
desires (often invoking the material criterion of need as well as equality).
  Egalitarian theories of justice propose that persons should be given an equal distribution
of at least some goods and services.
 In its radical form, egalitarianism holds that distributions of burdens and benefits in a
society are just to the extent that they are equal, and that deviations from absolute
equality in distribution are unjust.
 According to John Rawl’s theory, just distribution of health care is based centrally in a
principle of needs and seeks achieve “Fair equality of Opportunity,” which we are
required by justice to guarantee.
 Needs are understood in this account as the means necessary to reach our goals, and
disease and disability are viewed as underserved restrictions on a person’s opportunity to
meet those goals.
 The distribution would proceed on the basis of need, and needs would be met by equal
access to services. Better service, such as luxury hospital rooms and expensive but
optional dental work, would be made available for purchase at personal expense by those
who are able to and wish to do so. Yet everyone’s basic health needs would be met at an
adequate level.

Fair opportunity
 The relevant properties and material principles that inform our judgments about
distributive justice have thus far been our preoccupation. Consider those properties that
might and often do serve as basis of distribution but nevertheless should not consider
relevant as a matter of justice.

 Sex, race, religion, IQ, accent, national origin, and social status are examples of
properties that can be consider relevant in some limited and anomalous contexts.

Example:
“If a script calls for an actor in a male role, then females are properly excluded. But we
do not acknowledge general rules such as “To each according to sex” or “To each according to
IQ” as valid principles for justice.
 The most widely reason why we exclude such properties it’s because of the differences of
the individual and they are not responsible for that property or they do not deserve that
property.

 The fairness-based reason holds that differences between persons are relevant in
distributional rules only if those persons are responsible for and deserve these
differences.
The fair opportunity rule
 This account of unfairness in distribution can be formulated as a rule of just social
distribution.

 The fair opportunity rule, as it may be called:

“No persons should be granted social benefits on the basis of undeserved advantaging
properties.” (because no persons are responsible for having these properties)
“No persons should be denied social benefits on the basis of undeserved disadvantaging
properties.” (because they are also not responsible for these properties).
Example:
The mentally retarded or slow learner with special reading problems are not owed the
same amount of money, training, or resources as other pupils. They should receive what for them
is quality education. Even if it costs more, the fair opportunity rule requires that they receive
these benefits in order to improve his/her special problems.

The Right to Health Care

 More than one thousand dollars per person is spent annually for health care in the US, yet
the poor and the uninsured often cannot afford or find access to minimally adequate care.

 Many traditional proposals of social assistance to alleviate this situation have been based
not on justice but on the virtues of charity, compassion, and benevolence toward sick
person.

 In former eras health care for the needy was primarily handled through social practices
such as charity hospitals that had been founded on these aspirations of virtue.

 But in a new era of high technology and commensurately high costs, these older
approaches have proved inadequate to the task of meeting many health care.

 The Fair Opportunity Rule proves that each person has his own right to health care.

Example:
A child that has a severe dengue illness, he was brought to the hospital but the hospital
did not accept him because he is not registered in that hospital, then the fair opportunity rule
applies.

Can individuals forfeit the right to health care?

 The idea is not that a person yields the general right to health care, but only that the
person could forfeit the right to certain forms of care.
  The relevant sense of forfeit, is the loss of a claim as a result of one’s personal neglect or
misdeed. These questions of forfeiture rest on individual’s personal life-styles or
individual actions.

Example:
Patients with AIDS as a result of sexual activities or intravenous drugs use, patients with
lung cancer as a result of smoking cigarettes, and patients with liver disease as a result of heavy
consumption of alcohol.
 A person may forfeit his or her right to liberty by criminal actions that violate basic social
responsibilities and some argue, a person similarly may forfeit his or her right to health
care by failing to act responsibly.

PRIORITIES THE ALLOCATION OF HEALTH –CARE

RESOURCES
Macroallocation and the limits of ethical theory
 In this section we will examine these questions of macroallocation, reserving
microallocation for the following section on rationing health care. The line between
macroallocation and microallocation is not distinct and absolute.

 But in general, macroallocation decisions determine how much should be expended and
what kinds of goods will be made available in society, as well how it is to be distributed.
 These decisions are made by congress, state legislatures, health organizations, private
foundations and health insurance companies.

 When the overall social system is only relatively just, and no system appears to be
perfectly just, questions about just health policy may seem somewhat misplaced.

 Whether the social system is relatively just or relatively unjust in civil, political, and
economic matters, there will be disputes about just health policies, because policymakers
must determine the allocation of funds for and within health care.

PROBLEMS OF MACROALLOCATION
 Health is not our only value, and expenditures for other goods inevitably compete with
health care for limited resources.
 A vital question is whether priority should go to prevention or to critical care.
  Even for illnesses and injuries in which prevention is more effective and efficient than
critical care, concentration on prevention might neglect needy persons who could directly
benefit from critical care.

 Gene Outka has argued that it is more “just to determinate by virtue of categories of
illness… rather than rich ill and poor ill.”
 It is reasonable for a society to turn to fair, democratic political procedures to make a
choice among just alternatives.

RATIONING HEALTH CARE

The language and practice of rationing health care

 Whatever language is used, the necessity of selecting patients under conditions of

scarcity is common.
 Rationing is a problem within various health care systems. Because health needs and
desires are virtually limitless, any system must face relative or if not absolute scarcity.
 We will seek to determine which policies are just or unjust but also which policies satisfy
or violate other principles.

Medical utility and social utility

 In judgements of medical utility, physicians and others try to maximize the welfare of
patients.

 Whereas in judgement of social utility they try to maximize the welfare of society.

 Final selection of patients for particular treatments. “First come, first served”

MEDICAL UTILITY
 Selection should also try to save as many lives as possible through the available
resources. Hence, in patient selection, medical utility requires attention to the effective
and efficient uses of scarce medical resources.

SOCIAL UTILITY
 Whatever the difficulties of application-and they are considerable-medical utility is
important in the selection of recipients of scarce medical resources.