Health Care And Philosophy: Adding Justice To The Debate

Abstract

Justice is frequently in the background of debates about health care access, financing, and delivery in the United States and elsewhere. Is it just to have as many uninsured citizens as we do? Are disparities in health care access between ethnic and social groups fair? Does an employer-based approach to health insurance qualify as just when not everyone works for an employer that provides it? These are just a few of the fundamental questions that can be, and are, asked of health care in the United States. Although often implicit, the idea of what a just approach to health care looks like isn’t often explicitly discussed. Perhaps this is because the focus tends to be upon single issues, such as the uninsured, rather than looking at U.S. health care in its entirety. Another impediment is that the concept of justice itself is open to debate. Conservative, liberal, libertarian, and utilitarian views of justice continue to be advanced and refined by philosophers and social thinkers. Even so, continuing increases in medical costs and the number of uninsured people, along with growing concerns about disparities in access to treatment, might bring justice to the fore in the health care debate. Waiting to be determined is whether health care is a fundamental right and what allocation of this presumably limited resource is socially just. A good starting point for this consideration is Social Justice, which argues for a liberal theory of social justice and applies it to public health and health policy. Madison Powers directs the Kennedy Institute of Ethics and is an associate professor of philosophy at Georgetown University. Ruth Faden is a professor of biomedical ethics and director of the Berman Bioethics Institute at the Johns Hopkins University. Influenced by the theory of the late John Rawls, they see social justice as foundational to the moral justification of public health. They argue that a just approach to health care must attend to certain basic human needs and that particular attention must be paid to meeting the needs of the least advantaged. Six essential dimensions must be considered when looking at social justice: health, personal security, reasoning, respect of others, attachment, and self-determination. Social justice in this context has the job of “securing a sufficient level of each dimension for each individual, insofar as possible” (p. 192). Concern for the least-advantaged members of society is closely tied to this view of social justice and its companion concept, well-being. These are the ones who have the hardest time securing a sufficient level within each of these dimensions. This “sufficiency theory” focuses less on the most appropriate distribution of goods in a particular society and more on “securing and preserving a level of sufficiency for each of the dimensions of well-being” (p. 59). Securing a level of sufficiency, they argue, points to problems of justice in U.S. health care. The employer-based system of health insurance exacerbates existing disadvantages B o o k R e v i e w s