Medical Ethics PHIL 148 @ Binghamton University, Sum 11


Lecture 06/20>Health Care and Justice

There are two main issues in the question of justice and health: access and right to health care and health care rationing. Within each of these issues, we are searching for the appropriate balance between moral issues.

Today’s week is focused on justice. But justice varies depending on how one chooses to balance the various ethical concepts and perspective. If autonomy is the most important of the ethical concepts, then justice would be the schema that best preserves everyone’s autonomy. If equality is the most important of the ethical concepts, then justice would be the schema that best preserves everyone’s equality. Of course, all of these schemes ask further questions: What kind of autonomy matters (physical, economic)?  What should be the basis of equality? What efforts can be made to achieve the baseline of justice?

There are two main issues in the matter of health care and justice: access and rationing. Access asks what right all individuals have to health care, if any, and what measures can be morally justified to guarantee that right. Rationing concerns the limited health care resources and how those resources should be distributed. Rationing is related to access because if resources are not available, then there is a question of how access can be granted. Rationing might act as a constraint on what kind of access is available to each individual, whether that lack of access is moral or not.

Take the libertarian position as a starting point. Libertarians take autonomy to be the highest good. Specifically, they define autonomy in terms of an individual’s economic activity. So, for libertarians, economic autonomy should be preserved for all individuals. This means something very specific: individuals have the sole right to the products of their labor. Depending on the severity of this position, this can range from no taxation to minimal taxation. Regardless of the severity, the libertarian position on health care access is that it should be dependent entirely on an individual’s economic goods. Even if an individual had a right to health care access, this access could not be provided by any of the means society has established because it would mean unfairly taking the fruits of another person’s labor. This matters because social redistribution should only take place when the wrong is caused by a social system itself. So, redistribution for health care access cannot be provided by the system unless the health harm is caused by the system. If the harm is caused by an individual it should be rectified by the individual and if it is caused by nature, then there is no one’s responsibility to rectify the situation. [This does not rule out donations and charity by private individuals, but this should never be forced. It might be moral for a libertarian to help another, but it is always immoral for the government to force individuals to help one another.]

The egalitarian position is very different. It favors equality in a wider sense than the libertarian conception. While the libertarian speaks of equality in moral terms, but claims that difference comes from economic status, the egalitarian thinks that equality is defined in terms of social goods. The most common egalitarian position is that individuals should be guaranteed a basic minimum—this is usually spoken of in terms of human rights. According to some egalitarians, access to basic health care is a moral right that all humans have. Depending on the form of egalitarianism (cosmopolitanism or state-centered), one’s individual moral duty to help attain this basic level of health care may extend to those in one’s community or to those on the other side of the world. [Those who support the latter argue that our way of life is based on exploitation of other’s on the other side of the world. Because we play a part in causing suffering there, we have a moral duty to help guarantee basic health care.] Because economic goods are not the sole good, it makes sense for egalitarians to have some level of redistribution of wealth to guarantee these certain goods.

As you might note, however, these two positions do not necessarily speak to the obligations of individuals. Libertarianism states that it is immoral for governments to take individual goods and egalitarianism states that this redistribution can be moral, but this does not speak to the matter of individual moral responsibility. The question now comes, then, regardless of government involvement, what moral obligation does an individual have to provide access to health care? And, if there is a moral obligation to help others, then does it make sense to have a government system that assists individuals in helping others? Of course the major problem with the last point for libertarians is that such a system would involve taxation, a necessary evil in all government programs.

Further, even if we can establish the need and morality of a minimum of health care, what does this minimum constitute? Is a minimum simply general checkups, vaccinations, and routine treatments, with no further help beyond that? Is a minimum full access to any needed health care procedures on top of regular checkups (which might serve to identify needed treatment)? The answers to these questions depend on what moral standpoint one takes and what one takes to be morally relevant (libertarianism and egalitarianism serving as two examples of what is morally relevant or justifiable).

Rationing makes the question of access even more difficult. Society does have a limited amount of resources which can be put towards health care, be this supplies, time, or personnel.  It seems that none of the options that are available seem to provide a best case solution. For example, eliminating insurance may ultimately cut down on unnecessary costs, but, on the other hand, it may also be extremely unfair to those who are in bad economic straits. Still,  insurance—and at a greater level government sponsored health care—put a greater financial burden on society as a whole. Presently, if poorer individuals do not have access to medical treatment, their treatment tends to be delayed until they are in the emergency room. At which point, the cost ends up on society anyway and the cost is much higher than it would have been had society been providing basic medical care from the start.

From all of these reasons, utilitarianism would generally seem to lean towards providing at least some form of minimal health care. On the other hand, we might take the hardnosed approach that what is better is allowing the sick to die off without treatment and prevent and burden on the system. Deontology may say that we have a duty to provide for our fellow human beings. Yet, it might also claim that forcing an individual to help is immoral. Virtue ethics might say that individuals have a moral duty to maintain their own health and that if they are unable to do this then they should be allowed to die (as mixing with such individuals would be damaging to other’s character). Alternatively, virtue ethics might hold that it is the job of society to educate and properly raise individuals to be able to care for themselves. Finally, care ethics might say that we each have duties of care to those around us and that we should care for and provide for those with which we have a relationship. Yet, it is not clear that care ethics would have anything to say about government’s role or those who are unfortunately outside of healthy, appropriate human relations.

Given all of this, the question of what is just in health care is not always attached to what is moral for the individual. Many of the moral theories we have worked with do not provide any clear cut answers on what role justice should play in health care (but then, when do they provide a clear cut answer?). To find an answer, you must be able to decide what you take to be morally relevant, what you take to be the correct ethical perspective, and determine how to balance the ethical concepts.

Key Concepts:

  • Egalitarianism
  • Libertarianism
  • Justice
  • Equality

Some Questions to Consider:

  • What do you think utilitarianism would have to say about access to health care? Deontology? Virtue ethics? Care ethics? What would they each have to say about rationing?
  • Which of this week's readings tend towards libertarianism?  Which towards egalitarianism?
  • Why is economic status considered so important for many? Should economic status impact our moral duties?
  • Is morality an individual action or can/should it be societal? Who bears moral responsibility?

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