HLTH 380 Distributive Justice

Distributive Justice

How scarce goods can be distributed most fairly within a society, or within particular societal institutions
- Questions of justice arise when we make a choice about the distribution of resources

Macro/Meso/Micro Health Care System Allocation

Macro:
- Government Policies (provincial, federal)
- Decides budget for different aspects
Meso:
- Hospital Public Health Unit
- Given the budget, had to assign allocation
Micro:
- Family Doctor
- How long you see each patient, how many you see

Why is the allocation of resources is a problem

- New technology - more expensive
- Demographics (age, disease status)
- New treatments - expensive
- Public Attitudes
- Defining needs versus wants

Goals of Medicine

- Relieve Suffering (pain management)
- Prolong Life
- Improve Quality of Life

Defining Medical Needs

Inherent Needs:
- Something we all agree we need
- Ex. Clean water
Subjective Needs:
- We may disagree
- Desires
- Ex. nose jobs should be covered
Socially Induced Needs:
- Not inherent needs
- Collectively we decide we need cause we all agree its important
- Ex. Computers for students

Distribution of Healthcare Resources

Market
Utilitarian
Kantian
Virtue
Feminist

Market Distribution

Rare in developed countries
- Health and healthcare are defined as goods that can be consumed
- Produces social inequality
- Those most in need cannot afford healthcare

Utilitarian Approach

Promotion of the greatest good for the greatest number of people

The medical resources should be:
- Used to ensure that everyone has access to some socially determined level of basic healthcare
- Distribution above this level would be in accordance with social worth

Social Worth

The contribution the person can make for the happiness and wellbeing of others

Utilitarian Critique

Hard to define
Doesn't take prognosis and outcomes into consideration
Unfair
Can create distrust

Kantian Approach

Universally equal approach to all
- First come first served basis OR random lottery

Benefits:
- people believe its fair
- promotes trust between the patient and HCP
- potential for quicker resolution of shortages

Critique:
- Not very equitable
- Accessibility
- Inefficient use of resources

Virtue Ethics

Different approach about medical resources allocation
- Focus on the goals of medicine
- How to help people die well (instead of who to say)
- How to make suffering meaningful
Encourages excellence in decision-making of resources allocation
Encourages individual responsibility in demanding specific resources
Consideration of social context

Critique: Lacks strict guidelines

Feminist Approaches

Marginalization of certain population
Allocation of resources as the mechanism for social inclusion/exclusion

Critique:
No guide for resource allocation
Reflect on decisions - look for bias

Liberal Approaches

Focus on equal access
Procedures - for access to resources
Transparency - how resources are allocated
Individual Autonomy

Approaches for distribution of resources

Callahan
Life Cycle
Daniels

Callahan

Aging and the Ends of Medicine
Money Spent on elderly would require trade-offs BUT economic concerns are not the only ones

Death is inevitable; its not a 'disease'

THREE things to do
1. Aging and dying can be meaningful
2. Shift in cultural views on aging and medicine
3. Natural span - chronological and social/biographical

Callahan Approach Healthcare Implications

Government has to;
1. Help people to live out their natural lifespan but not to prolong life beyond this point
2. Provide life-extending technology and medicine to achieve and serve the end of a natural lifespan
3. Provide only a relief from suffering to those who acheived the end of their natural lifespan

Life-Cycle Allocation Principle

Emmanuel and Wertheimer
- Situated medical decisions within the person's whole life
- Allows for limitation in the use of healthcare resources at both the lower and upper ends of life
- If we would budget our own resources, we would invest more in childhood and less in old age
Investment refinement: considers not only the years of a person has left to live but also the amount already invested in creating life
- In emergency situations, the priority should be given public order
- Egalitarian Principle - we all die

Daniels: Prudential Lifespan Account

Rawl's Theory of Justice
Access to healthcare is a requirement of justice under the principle of "fair equality of opportunity" (We assume everyone has equal opportunity - so we have to allow access to resources to all- no discrimination)
- Healthcare - obligation for protecting and restoring normal functioning of the individuals

Normal Functioning

The capacities that are appropriate and expected for individuals in particular age groups (20, 50, 90) - very specific
- Allocation of resources promotes normal functioning

Steps for Prudential Lifespan Account

- We don't know how old we are
- We allocate the healthcare services over our lifespan (how much money we should get for each stage/situation - like having a baby)
- Once allocated, the choice cannot be undone
- Age is a universal trait and thus can be used for the allocation of resources

Summary of Callahan, Emmanuel, Daniels

Callahan: maximize natural lifespan - prioritize the youngest
Emmanuel: societies investment in you - more social investment for older people
Daniels: agreed upon categories - situational

Daniels 4 conditions for accountability of reasonableness

Must meet a:
Publicity Condition:
- decisions about how healthcare goods/services are allocated must be accessible by the public
Relevance Condition:
- decision making is legit as long as people who are cooperative, reasonable and fair say that it is (does not require universal agreement)
Revisions and Appeals Condition:
- There must be dispute resolution and revision of policies available, must be able to challenge decisions, responsive to rational arguments and new evidence
Regulative Condition:
- The process must be regulated to ensure the first three conditions are met