Unit 3: Chapter 11

Distributive justice

Fair societal distribution of benefits and burdens

* Justice regarding the fair distribution of society’s advantages and disadvantages, or benefits and burdens, including income, property, employment, rights, taxes, and public service

Egalitarian theories of justice

Important benefits and burdens equally shared; affirm that important benefits and burdens of society should be distributed equally

* To achieve greater equality, the egalitarian (unlike the libertarian) would not be averse to mandating changes to the distribution of society’s goods or to interfering in the workings of a free market
* Unlike the utilitarian, would not allow utility to be the ultimate overriding consideration in a system of distribution
* To achieve greater equality, the egalitarian would not be averse to mandating changes to the distribution of society’s goods or to interfering in the workings of a free market
* E.g.
* Systems that give equal access to all legitimate forms of health
* That offer a guaranteed minimal level of health care for everyone
* Provide care only to those most in need

Libertarian theories of justice

Best distribution is the one naturally occuring from fair free market participation; benefits and burdens of society should be distributed through the fair workings of a free market and the exercise of liberty rights of noninterference

* The role of government is to protect the rights of individuals to freely pursue their own interests in the economic marketplace without violations of their liberty through coercion, manipulation, or fraud
* Beyond these protections, the government has no obligation to adjust the distribution of benefits and burdens among people
* Distribution is the responsibility of free and autonomous individuals
* People may have equal rights or equal worth, but that does not entitle them to an equal distribution of society’s benefit
* Universal healthcare would be a coercive violation of people’s right to use their resources as they see fit
* Would accept a system of health care only if it is freely endorsed and financed by those who participate in it
* Acquired through free choice by a group of private citizens to meet their own healthcare needs is acceptable
* Will likely deny there is a right to healthcare, for they generally accept negative rights and disallow positive rights

Managed care

A system for providing care to a particular group of patients (members of the system) using regulatory restraints to control costs and increase efficiency

* People who enroll in a managed care plan—such as a health maintenance organization (HMO) or a preferred provider organization (PPO)—get health care at discounted prices from the plan’s network of providers (physicians, hospitals, etc.)
* Managed care plans try to control costs by influencing the kind and amount of care that providers offer and by restricting the choices that members have
* There is concern that for the sake of economical medicine, providers may cut corners, decide not to order necessary tests, pay less attention to patients’ needs, or refuse to treat certain serious health problems

Utilitarian theories of justice

Just distribution of benefits and burdens is one that maximizes the net good (utility) for society

* Might endorse a system of universal health care insurance, or a qualified right to health care, or a two-tiered plan (like the U.S. arrangement)
* In which government-supported health insurance is combined with the option of privately purchased health coverage for those who can afford it

Christine deMeurers

* A problem of managed care


* Christine deMeurers had breast cancer
* Every standard treatment available had been used, but with no apparent effect
* After standard treatments failed, Dr. Mahesh Gupta promised a new treatment, a bone marrow transplant; in violation of Health Net rules on referrals (HMO), Dr. Gupta referred Christine directly to an expert at the Scripps Clinic
* The Scripps doctor, however, was reluctant to help them or even provide them with information about the transplant
* By the time, they had consulted with other doctors about the treatment, Health Net resolved that the company would not pay for the transplant because it was disallowed under the investigational clause in Christine’s contract
* A different physician, Dr. Glapsy found himself conflicted
* As her physician, he felt a responsibility to help her get the transplant
* As a Health Net physician, he was also required to uphold the regulations of the HMO
* After discussion between Health Net administrators and UCLA physicians, they concluded with UCLA agreeing to pay for Christine’s operation
* Another panel also ruled that Health Net should’ve paid for the transplant, but instead it had improperly interfered in the doctor-patient relationship

Human rights approach

We can best achieve just distributions of health and health care by ensuring that human rights in general are respected

* Fair treatment, freedom from coercion, nondiscrimination, protection from abuse, equality, and other entitlements contribute to well-being and health
* Enjoyment by everyone of the highest attainable standard of physical and mental health is in itself a recognized human right

Negative rights

Duties not to interfere with that person’s obtaining something

Positive rights

Duties to help that person in her efforts to get something

* E.g. Those who insist that an individual has a right to health care and society is obligated to provide that benefit in some way

Derivative rules

A rule ultimately justified by assessments of utility

* Utilitarians can admit a right to health care through these rules

Rawl’s “fair equality of opportunity”

Rawls maintains that everyone is entitled to an equal chance to obtain the basic goods of society, though there is no guarantee of an equal share of them

* A just society would ensure equal opportunities to its citizens

Decent minimum of healthcare

* May assume it includes such things as immunizations, annual physical exams, and “routine” medical care

Rationing

Parceling out important limited goods

* Due to the fact that people’s health care needs are virtually boundless, yet the supply of health care re- sources is ever limited
* E.g. Medicare and Medicaid allot health care to the elderly and the poor
* E.g. HMOs limit medical procedures, tests, and access to doctors to control costs
* E.g. Hospitals restrict the use of intensive care units, emergency departments, organ transplants, etc.
* Brings up questions like “who should get what share of limited health care good and services?; who should live and who must die?”
* Policies for rationing try to take into account success of treatment (e.g. organ transplants) or the urgency of the patient’s needs
* Insufficient resources arises both on…
* The scale of the total health care system
* Concerning what portion of society’s resources should go to health care and how this allotment should be used
* The scale of individual patients and provides
* Regarding who should receive specific resources

Macroallocation

Concerning what portion of society’s resources should go to health care and how this allotment should be used

Strong claim: People have a positive moral right to healthcare

* Libertarians:
* Utilitarians:
* Egalitarians:
* Human Rights:

* Libertarians: Reject the view; government shouldn’t be allowed to interfere
* Utilitarians: Maybe, depending on the benefits minus the costs (utility) of becoming involved; endorse a derivative right to healthcare
* Egalitarians: Yes, everyone deserves healthcare because it’s important; favor a bona fide entitlement to a share of society’s healthcare resources
* Human Rights: Yes, everyone should be able to enjoy life on a fundamental level, and that would include mentally, emotionally, and physically

Buchanan

Rejects the idea of a right to a decent minimum of care, but understands its attractions

* There is no individual right but there may be a societal duty
* People have special rights (not universal rights) to healthcare
* E.g. Rights of restitution to certain groups for past wrongs
* E.g. Rights of compensation for “those who have suffered unjust harm or who have been unjustly exposed to health risks by the assignable actions of private individuals or corporations,”
* E.g. Rights to health care for honorable service to society (for wounded soldiers, for instance)
* Certain basic forms of healthcare may also make for productive labor forces or improve the fitness of the citizenry for national defense
* Moral obligations
* E.g. Charity

Microallocation

Regarding who should receive specific resources

* E.g. Deciding who gets organ transplants

Utilitarian approach to rationing care

Measure objectively the benefits that a treatment is likely to give each patient, then selectively treat particular patients or conditions to maximize total benefits

* The objective measure of benefits that has often been used in such calculations is known as QALY, or quality-adjusted life year
* One QALY is equivalent to one year of life in good health, and a year of life in poor health is equal to less than 1 QALY
* But critics have charged that relying on QALYs to allocate or ration health care can lead to morally unacceptable decisions
* E.g. Discriminates against older people in the context of organ transplants (e.g. saving the lives of younger people)
* Another criticism is that these objective measurements cannot accommodate the subjective nature of people’s assessments of the value of their own lives
* A paraplegic may value his life and think its quality extremely high despite his disability; a perfectly healthy person may think her life miserable despite a lack of physical ailments

Social value

If given the chance to live—are expected to contribute most to the good of society; what services can be rendered by the patient considering their age, talent, training, and past record of performance

Egalitarian/Kantian perspective

All persons have equal worth

* Things like social value would not be a sound argument
* E.g. A med student is not more worth saving than a poet
* Trying to treat people with humanity

Bioethical principle: Justice

* Mainly distributive
* Advocating fair allocation of medical resources
* Advocating for the fair and equal treatment of all patients regardless of SES

Bioethical principle: Autonomy

* Respect what taxpayers want to happen with their taxes
* Respecting free market and the consumer decision for insurance

Why hasn’t the government helped fully

* Cost
* Limited medical capability and medical resources
* Rationing
* Government obligation
* Pos/neg rights

Ethics of care

Contemplating relationships and dependencies of humans

Rule utilitarianism

Trying to create and follow laws that promote the most good