Social justice and equal access to health care.

Abstract

SOCIALJUSTICE AND EQUAL ACCESS TO HEALTH CARE* GENE OUTK/it Consider the question, Is it possible to understand and tojustify morally a societal goal which increasing numbers of people, including Americans, accept as normative? The goal is the assurance of comprehensive health services for every person irrespective of income or geographic location. Indeed, the goal now has almost the status of a platitude. Currently in this country politicians in various camps give it at least verbal endorsement [1, 2]. I do not propose to examine the possible sociological determinants in this emergent consensus. I hope to show that whatever these determinants are, one may offer a plausible case in defense of the goal on reasonable grounds. To demonstrate why appeals to the goal get so successfully under our skins, I shall have recourse to a set of conceptions of social justice. Some of the standard conceptions, found in a number ofwritings onjustice, will do. By reflecting on them it seems to me a prima facie case can be established, namely, that every person in the entire resident population should have equal access to health-care delivery. The case is prima facie only. I wish to set aside as far as possible a related question which comes readily enough to mind. In the world of "suboptimal alternatives," with the constraints, for example, which impinge on the government as it makes decisions about allocation of resources , what is one to say? What criteria should be employed? Paul Ramsey, in The Patient as Person [3, p. 240], thinks that the large question of how to choose between medical and other societal priorities is "almost, if not altogether, incorrigible to moral reasoning." Whether it is or not is a matter which must be ignored for the present. One may simply observe *Much of the research for this paper was done during the fall term, 1972-73, when I was on leave in Washington, D.C. I am very grateful for the two appointments which made this leave possible: as Service Fellow, Office of Special Projects, Health Services and Mental Health Administration, Department of Health, Education, and Welfare; and as Visiting Scholar, Kennedy Center for Bioethics, Georgetown University. Another version of this essay appeared in theJournal ofReligious Ethics (Spring 1974), and the parts incorporated here are used with permission of the editor. tAssociate professor of religion, Princeton University, Princeton, New Jersey 08540. Perspectives in Biology and Medicine · Winter 1975 | 185 in passing that choices are unavoidable, nonetheless—as Ramsey acknowledges—even where the government allows them to be made by default, so that in some instances they are determined largely by which private pressure groups prove to be dominant. In any event, there is virtue in taking up one complicated question at a time, and we need to get the thrust of the case for equal access before us. It is enough to observe now that Americans attach an obviously high priority to organized health care. National health expenditures for the fiscal year 1972 were $83.4 billion [4]. Even ifsuch an enormous sum is not entirely adequate, we may still ask, How are we to justify spending whatever we do in accordance as far as possible with the goal of equal access? The answer I propose involves distinguishing various conceptions of social justice and trying to show which of these apply or fail to apply to healthcare considerations. Only toward the end of the paper will some institutional implications be given more than passing attention, and then in a strictly programmatic way. Which then among the standard conceptions of socialjustice appear to be particularly relevant or irrelevant? Let us consider the following five: (1) to each according to his merit or desert, (2) to each according to his societal contribution, (3) to each according to his contribution in satisfying whatever is freely desired by others in the open marketplace of supply and demand, (4) to each according to his needs, and (5) similar treatment for similar cases. In general I shall argue that the first three of these are less relevant because of certain distinctive features which health crises possess. I shall focus on crises here not because I think preventive care is unimportant...