The Grand Theory of Health Care Justice
Inequities in the provision and availability of health care and significant disparities in health outcomes are apparent to all of us, but there is very little agreement as to how to address health care inequities and bring about the just distribution of health care. As Beauchamp and Childress suggest, we generally understand justice as being “fair equitable, and appropriate treatment in light of what is due or owed to persons.”1 Distributive justice is “the fair, equitable, and appropriate distribution determined by justified norms.” 2 Beauchamp and Childress in Principles of Biomedical Ethics summarize several theories or frameworks that provide some guidance in health care justice. A review of these theories reveals that while each approximates a universal theory and is useful for certain applications, it depends upon the focus of the moment. They arise out of different intuitions and from different perspectives. The perceiver and the perceived cannot be separated. There is no universal theory of justice that adequately addresses health care issues. What we have instead of a single theory is a multifaceted framework or grand theory that is made up of a collection of justice theories.
Utilitarian theory focuses on maximizing social welfare.3 “It is often formulated as a requirement to do the greatest good for the greatest number.” 4 Cost-benefit considerations are incorporated in some versions of this approach.5 Utilitarianism may be a standard basis for health policy analysis as Jennifer Ruger suggests,6 but it falls short in several areas. Beauchamp and Childress point out some of these shortcomings. While subjective preferences may be maximized, there is no standard or range of acceptable preferences, thus possibly permitting immoral actions, such as the sale of organs. Secondly, it might raise some options to the level of obligations, removing free choice. Third, it permits the majority to override the interests of minorities and the sick and elderly.7
Libertarian theories focus on liberty and the free market. There is to be no redistribution of assets to be sure that all have health care. Everybody has rights. Public health programs are acceptable only if the individuals freely chose to participate.8 Jennifer Ruger points out that health care is a unique commodity and does not work in a supply and demand market.9 Such frameworks can result in a lack of service for vulnerable individuals of all kinds, including the elderly, the poor, the uninformed, those with special needs, and those who suffer as a result of bad choices. Communicable diseases and catastrophic events could expose entire segments of society to unmet health needs.
Communitarian theories focus on the community and its members. The diversity of cultural backgrounds, belief systems and views of goodness has resulted in our pluralistic society. Communitarianism stresses the connection between individuals and their local community, and the standards established in and by that community.10 Beauchamp and Childress suggest that while man is a social creature and lives in groups, it is difficult to balance communal decision making with autonomy.11 Ruger criticizes the communitarian approach by pointing out that cultural and moral relativism ignores any sense of common morality that humans share, and threatens cooperation between communities and respect for individuals.12
Egalitarian theories focus on equal distribution of health care. Using the words of Norman Daniels, the emphasis is on “fair equality of opportunity.”13 While providing everyone with an equal share of, or opportunity to access health care is laudable and matches an intuitive sense of just health care, as Ruger comments, egalitarian approaches are inadequate because many factors are missing: specifics, consideration of resources, determination of who does the allocating of services, what is to be done with those needing essentially unlimited services, where does the alleviation pain fit in, and what is meant by “adequate care.”14
Beauchamp and Childress also talk of rights based theories. These generally involve a claim that the government has an obligation to provide health to all of its citizens, are based on the general obligation of protecting and maintaining the society, and the idea that surely everybody should have an equal opportunity or access to health care. Beauchamp and Childress also remind us that one problem with such theories is the lack of specificity. What exactly does it mean to have a right to health care? Is there to be a minimum level guaranteed to everyone? If so, this could be understood in any number of ways. Maybe it would be a compromise between the utilitarian, libertarian, egalitarian and communitarian views.15 Bernard Baumrin objects to there being a right to health care. He reminds us of Kant’s dictum that “ought implies can.” One is not obligated to do the impossible. Guaranteeing everyone health care does not appear to be possible, as resources are limited.16 We do not have to get into a discussion of whether such a right would natural or man-made, as the nature and extent of any guaranteed health care is unclear and delivering it appears to be an impossibility.
Ruger proposes a theory or framework based on health capabilities. A health capabilities theory focuses on “the ability of individuals to achieve certain health functionings and the freedom to achieve those functionings.”17 The justness of health care is based on its positive effects on health capabilities, relative to the individual’s needs and the norms of the area.18 Society is to establish and maintain conditions that will enable its members to attain “ threshold levels of health, reducing the gap between health achievement and health potential.”19 While the level of services provided and the threshold level of health are relative to each individual and community, it is consistent with Aristotle’s principle that like cases should be treated alike, and unlike cases differently.20 A Health capabilities theory is sensitive to preferences, does not permit a majority to override minorities or ignore the vulnerable, is mindful of resources, and does not insist on equal health or outcomes.
As much as I might like the health capabilities approach and the way it avoids some of the problems of other theories discussed by incorporating considerations from each, it also falls short. Ruger is well aware of the difficulties involved in a society reaching agreement on social welfare issues, as she discusses Kenneth Arrow’s impossibility theorem at some length and then talks about how “incompletely theorized agreements” on central and non-central health capabilities can be attained and result in a functioning health capabilities system.21 Ruger spends the second half of Health and Social Justice suggesting how some of the central and non-central capabilities could be selected and prioritized, and how the public discussions would take place and include scientific elements. However, the theory depends upon these discussions taking place and agreements being reached. Universal agreement is unlikely and becomes more unlikely as we increase the size of the community. While the focus on incompletely theorized agreements is a valiant attempt to overcome Arrow’s impossibility theorem, it is either unsuccessful or unworkable on any large scale. If it is not on a large scale, then health capabilities becomes a modified, albeit improved or detailed, communitarian approach and is susceptible to the same criticisms.
Still others, like Jeffrey Sachs in The End of Poverty22, propose that if we were to focus on poverty and effectively eliminate it, people would be able to better afford care, education and other benefits that encourage and support health. While this sort of approach does improve health in affected regions, it is not clear that it is just, or that it addresses the health care short comings or needs of all regions. Relatively wealthy societies also have health care inequities.
While there are many theories of justice that approximate a universal framework, help to improve health care in a just manner, and are useful in various situation and applications, there does not yet seem to be a universal theory of justice that addresses all health care issues. One size does not fit all. This, however, is not necessarily bad or unusual.
Stephen Hawking and Leonard Mlodinow tell us in their book, The Grand Design, we find in modern physics that descriptions based on observations do not tell us very much or increase our understanding. Instead, models of the physical world are created to help us understand things better. The atom is such a model. We cannot see atoms, but they help us to understand and explain what we see and experience in the world. Models that accurately describe and explain events are attributed as being real. The current problem is that as of yet, there is no single model or theory that includes and explains everything from ancient observations, the planets and gravity, to quantum theory. Stephen Hawking and Leonard Mlodinow propose that M-Theory might be the answer. M-theory is not a single theory, but is rather a collection of theories that effectively describe and explain the physical world, each within its own range or limited focus. The regions covered by the theories may overlap and butt up against each other, just as maps that make up the greater map of the earth do. All of the maps or theories are needed to understand the earth or the physical world.23 As Hawking and Mlodinow describe the situation in physics:
It could be that the physicist’s traditional expectation of a single theory of nature is untenable, and there exists no single formulation. It might be that to describe the universe, we have to employ different theories in different situations. Each theory may have its own version of reality, but according to model-dependent realism, that is acceptable so long as the theories agree in their predictions whenever they overlap, that is, whenever they can both be applied.24
The same might well be the case for justice and health care. There is no universal theory of justice that adequately addresses all health care issues. While each approximates a universal theory and is useful for certain applications, it depends upon the problem or focus of the moment. They arise out of different intuitions and from different perspectives. What we have instead of a single theory is a multifaceted framework or grand theory that is made up of a collection of justice theories.
John Rawls describes moral theories, theories of justice, as arising out of or being compared to intuitions, or senses of justice. Reflective equilibrium is the process we go through as we compare and modify our theory of justice and intuition or view of justice in the world to reach a judgment or make a decision regarding an action. Rawls describes the process:
When a person is presented with an intuitively appealing account of his sense of justice (one, say, which embodies various reasonable and natural presumptions), he may well revise his judgments to conform to its principles even though the theory does not fit his existing judgments exactly. He is especially likely to do this if he can find an explanation for the deviations which undermines his confidence in his original judgments and if the conception presented yields a judgment which he finds he can now accept. 25
He defines a moral theory as being:
…a theory of moral sentiments (to recall an eighteenth century title) setting out the principles governing our moral powers, or, more specifically, our sense of justice. There is a definite if limited class of facts against which conjectured principles can be checked, namely, our considered judgments in reflective equilibrium.”26
As Ruger points out, the tests of whether or not a framework is just are connected with each respective theory.27 We ultimately have to proceed through reflective equilibrium to determine whether or not the theory of justice and its application adequately address health care issues and concerns.
The reason for the difficulty is that the subject and the object, the perceiver and the perceived, are closely connected and cannot be separated. The ancient philosophers have been criticized for not separating metaphysics (what is real) from epistemology (how we come to know). However, it is more likely that they knew that one cannot separate what is real from how one comes to know it. Metaphysics and epistemology are the flip sides of the same coin. There must be something to be known for one to come to know, but without the ability to know, one is isolated from what there is to be known. The term metaphysics was first used by the person who organized and categorized the writings and notes of Aristotle. The writings and notes were collected, and those that seemed to be related Physics, but did not quite fit, were put into a section called “after the physics,” metaphysics. The ability to know is useless without there being something to know. What is perceived is useless or meaningless without the perceiver.
It is a matter of perspective, location, function, need, and situation, like the story of the blind monks. Each one accurately describes a part of an elephant they touch directly in front of them, but none offers a full picture grasp of the entire elephant. We understand that we must keep in mind the other perspectives of the elephant or of health care justice, but the one that really counts is the one that is right in front of us. If one is behind a mule or cow, it is understood that the animal eats food at the other end and processes food in a certain way. However, our real concern is the fly that is irritating the rear end and the tail that is swishing and a leg that might kick. So it is with health care. The real concern is the inequity or injustice in the distribution of health care that is in front of us or that might be our focus at any given time.
Each theory of justice has appropriate and effective uses, but none is going to fit every situation. It is likely that several theories, either independently or jointly, can be useful in approaching and improving the level of just health care in a given location. The utilitarian approach is a fairly standard approach that results in an overall balance of health care distribution. Some locations and economies might have relatively little sophisticated health care available with everyone being at an equivalent economic level, and might benefit from a libertarian system of health care delivery. Here bartering for various goods and services, along with a need and increasing demand for health care could help improve the general level of health. A communitarian approach can work well for areas with clear cultural preferences and requirements. An egalitarian approach might fit a wealthy socialist oil rich area where every citizen receives significant compensation and benefits by being a member of the society. A health capabilities approach might work well in many settings, but perhaps best where the economy is a thick blend of free market and socialism, like Great Britain. Here there might be a right to health care, with health capabilities serving as a reasonable and effective balancing point between market conditions and benefit deliveries. A country like Haiti might benefit initially most from a focus on the elimination of poverty.
Some might object to this proposal that there is no single universal theory of justice that adequately addresses health care, and that what we have instead is multifaceted framework or grand theory that is made up of a collection of justice theories. We have what seems to be a natural understanding of justice or fairness, or as stated earlier: “fair equitable and appropriate treatment in light of what is due or owed to persons.” Surely there is a theory that captures this.
While we do have an intuitive or natural sense of justice or fairness, we do not have a natural right to health care. We have a natural right to breathe, eat what is available, and expel waste, as these take place naturally without much thought. A right to health care must be man-made and could fit any model or framework we might choose. A theory that fits our intuition or sense of justice and our world is not going to be just any theory or proposal. We have to go through a reflective equilibrium process to determine what might fit best.
Some might complain that Ruger’s health capabilities proposal makes for as good fitting a theory as possible. It is sensitive to preferences, locations, needs, as well as the elderly and the young and the disabled, without insisting on equal outcomes for all.
While a health capabilities theory does give us something that appears to be workable, the unlikelihood of being able to reach agreements on central and non-central capabilities and acceptable threshold levels of health, and the selection and allocation of resources, make it impractical. Would health capabilities theory wind up being communitarian theory with limited regional applications? The fact is that our world is shrinking into one community, but at the same time maintaining what seem like intractable location-sensitive and cultural differences that make agreements and distributively just benefit deliveries nearly impossible.
So where do go from here? We have a multifaceted framework or grand theory that is made up of a collection of justice theories. Although many of us feel that there must be a theory that explicates what underlies and overlaps all of these theories, it has not yet been discovered. Such a theory might well have to do with reason. We do seem to have a common sense of justice and fairness. Plato’s notion of justice, the appropriate balance of the rational, appetitive, and spirited parts, might still be a framework that we have in common.28 If something is out of balance in what is in front of us or in our focus, it can be recognized and addressed by one or more of the current theories, depending on the situation. Meanwhile the search for a single universal theory of justice may continue.
1) Beauchamp, T.L., Childress, J.F. Principles of Biomedical Ethics. New York: Oxford University Press; 2009. p. 241.
2) Beauchamp. P. 241.
3) Beauchamp. p. 245.
4) Beauchamp p. 337.
5) Jennifer Prah Ruger. Health and Social Justice. Oxford: Oxford University Press; 2010. p. 20.
6) Ruger. p. 19.
7) Beauchamp, pp. 341- 342.
8) Beauchamp. p. 246.
9) Ruger. p. 32.
10) Beauchamp. P. 246.
11) Beauchamp, p. 361.
12) Ruger, p. 25.
13) Beauchamp. p. 247.
14) Ruger. p. 26-30.
15) Beauchamp. pp. 258-260.
16) Bernard Baumrin. Why There is No Right to Health Care. In: Rosamond Rhodes, Margaret P. Battin, Anita Silvers, editors. Medicine and Social Justice. Oxford: Oxford University Press; 2002. pp. 78-82.
17) Ruger. p. 81.
18) Ruger. p. 140.
19) Ruger. p. 141.
20) Ruger. p. 141.
21) Ruger. pp. 66-77.
22) Jeffrey D. Sachs. The End of Poverty. New York: Penguin Books; 2006.
23) Stephen Hawking, Leonard Mlodinow. The Grand Design. New York: Bantam Books; 2010. pp. 7-8.
24) Hawking. p. 117.
25) John Rawls. A Theory of Justice. Cambridge: Harvard University Press; 1978. p 48.
26) Rawls. p.51.
27) Ruger, xvii.
28) Plato. Republic-Book IV. Edith Hamilton and Huntington Cairns, editors. Plato: The Collected Works. Princeton: Princeton University Press; 1969. Pp. 676-686.