Stanford PHIL 383 - Justice and Health Care

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Phil 383 Lecture Notes M. Rorty Sept 15 2009 (part 2)Justice and Health CareI spoke at the beginning of the term about three levels on which the values we discuss herehave implications—the micro-level of individual cases and decisions—ethics at the bedside,clinical ethics; the macro-level of society as a whole; and in between, the meso- level: theorganizations and institutions of our society that mediate between the individuals and that largersociety. And the question of justice may very well have different effects, depending upon whatlevel it is addressed.There are several ways of thinking of justice. Two very important ones are fairness, anddesert. Fair distribution of health resources is an important subject in health care ethics. Desertrelates to what is a legitimate claim on resources; what entitles us to receive social goods.We are of course NOT equal; there are natural and social “lotteries” distributing the goodsthat make for success and happiness. The concern for justice is about making up for the failuresof the natural lottery, of charity, of the market. The questions that arise concern the price of thisequalizing—its cost and burden, and upon whom that burden should fall.Think about justice on the micro level. I want to live in a just society. That means, at least,that I as a member of that society will be treated fairly, justly—and that others will as well—bythe laws of the society, and by its principles of distribution—and by the institutions on the meso-level.As conditions of our social contract, I might argue that my society should, ideally, providefor me safety (internal and external), education, work—and access, opportunity, to compete forwhatever goods are on offer—including, for our purposes, health and well-being.So: what does ‘justice’ for me, as an individual, mean?I: a formal principle of justice: treat equals equally.But: what are the relevant characteristics which justify equal treatment? In whatmust individuals be equal in order to merit/deserve equal treatment?Some candidates for material principles of justice:to each person an equal shareto each according to needto each according to effort/contributionto each according to merit/desertto each according to free market exchange….Each of these candidates represents a prima facie obligation for distribution of social goods.Different principles apply to different areas, different kinds of goods.[The best source I know for a discussion of the importance of differentdistributive principles in different contexts is Michael Walzer’s Spheres ofJustice]II: On the meso-level: imagine you are the admission person in charge of one of theorganizations that represents my society’s means of providing health care to individuals: aresidential assisted living facility. An opening has become available, and there are fivecandidates for it:A demented man with a degenerative disease and no family or means of supportA well loved local politician whose wife has just diedThe wife of your most generous donor/philanthropistThe person who’s been on the waiting list longestThe ONLY person on the list who keeps kosher (and it’s an Orthodox facility)There might well be ‘material’ principles of justice that would speak for each of the candidates.How to choose among them?III: On the macro level: health and well-being are not the ONLY things which my societyneeds to provide to its members, What about those other things—education, public safety andinfrastructure are also social responsibilities, and the resources of the society need to bedistributed among them. How should society decide how to allocate its resources, its publicfunds? One of the worries about health care is the percentage of the GDP it consumes—an d therate of increase in that percent.Different theories of justice try to reconcile our competing intuitions, telling us how toprioritize them.[In this class you are more likely to be told that we are pluralists withrespect to material principles, and you are required to balance them inlight of the context of the case you are considering.]Theories of justice:Some general types of justice theories: egalitarian, utilitarian, libertarian.Libertarian theories of justice recommend the unhindered working of fair procedures; theyemphasize choice and liberty; choice determines our contractual arrangements, and contractdetermines our entitlements. The important procedural rules govern acquisition, transfer andrectification of property or other contracts. Cf. in our reading for this week the article byEnglehart, who is described by SAL astaking a libertarian position on the distribution of health care resources.Egalitarian theories emphasize equal access. Justice is defined less in terms of desert andmore in terms of fairness. (cf. John Rawls’ article “Justice as Fairness”) Some basic equalitiestake precedence over kinds of difference. All vital economic goods and services should bedistributed equally, unless an unequal distribution works to the advantage of everyone.Norman Daniels is a bioethicist/philosopher who applies Rawlsean theory to theparticular area of health care: Justice requires fair equality of opportunity. Diseaseand disability restrict our ability to meet our needs. So: healthcare needs are whateveris necessary to achieve, restore or maintain adequate levels of functioning. [=fairopportunity] – as measured against human normal.A principle of fair distribution: nobody should be granted social benefits on the basis ofundeserved advantaging properties (or deprived of them on the basis of undeserveddisadvantaging properties)—by which we mean those distributed by the natural and sociallotteries: IQ, race, gender, ethnicity…II: Where does justice fit in?From the point of view of philosophers: there are some types of ethical theory for whichjustice is the central concept; all other terms of ethical approbation [morally good, right,obligatory, duty…] are defined in terms of the central concept. All other types of ethical theorymust typically account for justice in terms of their dominant concept.From the point of view of this class: we typically work from the bottom up (not from thetheories down). Starting with actual case situations (or at least the descriptions of them, aspresented in our case scenarios) we work up through analogous cases, rules which we invoke tojustify our decisions in particular cases—and sometimes get as far up as what Beauchamp andChildress call


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