Models of Justice in Medical Care Systems

D. John Doyle MD PhD

April 2004

djdoyle@hotmail.com

Societies need to figure out how to distribute benefits (and burdens) among their members. This note describes on what basis medical resources might be distributed "fairly" using, (1) a utilitarian justice approach, (2) a libertarian justice approach, and (3) an egalitarian justice approach.

It is in justice that the ordering of society is centered.

Aristotle (384 BC - 322 BC)

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Justice is the basic principle that deals with fairness and equitable entitlement in the distribution of resources, goods and services.  Distributive justice is concerned with deciding who gets what resources when those resources are limited or scarce. The notion of distributive justice figures prominently in the allocation of health care resources, which are almost always scarce to some degree. Concern for medical social justice is one of the three fundamental principles of the American College of Physicians (http://www.annals.org/issues/v136n3/full/200202050-00012.html):

Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

Three theories or models of distributive justice in the allocation of health care have been described. These are:

Utilitarian model -  where goods and services are provided to those who are likely to benefit the most

Libertarian model -  where individuals rights and resources govern access to goods and services

Egalitarian model -  where individuals have equal access to goods and services

Which model of distributive justice one agrees with most will depend to some extent on whether one views health care primarily as a right (implying a right to universal access to health care), views health care primarily as a need  (where people with the greatest need have highest priority and  people with similar needs treated similarly ), or  views health care primarily as a market commodity.

Utilitarian Model

In the Utilitarian model, goods and services are provided to those who are likely to benefit the most. This notion may be viewed either in terms of medical utility (who is most likely to obtain clinical benefit?) or sometimes in terms of social utility (who is most useful or valuable to society?). In the medical utility model, justice refers simply to the principle of utility, broadly applied to medical procedures. For instance, attempts at quantifying the utility of a medical procedure may developed be in terms of Quality Adjusted Life Years (QALY) (or other measure) associated with a particular medical intervention in a particular patient.

Some medical utilitarians hold up the Oregon Health Plan (OHP) as a particularly good example of a utilitarian public health care policy. The Oregon Health Plan rations public medical resources by a system of prioritizing funding for health care. This is done through a process of systematically ranking publicly offered medical services, an approach that has drawn substantial international interest as a rational model of medical resource allocation.

In 1989, Oregon enacted legislation to provide basic health care to all residents on Oregon Medicaid, their public health care system. This required that services be prioritized to determine what would or would not be covered – effectively establishing a rationing plan. To do this, the Oregon legislature created a Health Services Commission charged with producing a list of health care services ranked in priority “according to comparative benefits of each service to the entire population being served.” They heard testimony from numerous panels of physicians from every specialty to assess how well each treatment that might be funded affected quality of life. From this they established a “cost-effectiveness value” for each “condition-treatment pair”. The final product was a priority list of 709 condition-treatment pairs in ranked order. Based on the available state funds, a line was drawn on the list - any treatment above the line was covered; any treatment below the line was not. This turned out to be at the 587th condition-treatment pair.

 

Libertarian Model

Libertarianism holds that the government should only regulate against force or fraud. Other than that, libertarians hold, the state should not be involved in our lives. In the libertarian model we are entitled to no more than minimal protection by the state (i.e. police and military/intelligence services), and we are individually responsible for everything else, including education and health care. Under libertarianism the state is not permitted to raise revenue for anything more than minimal protective services. There should be no social services from the government. . There should be no redistribution of wealth. As a result, taxes will be minimal. On the other hand, individuals will have to pay for almost all services needed, including education and health care.

Libertarianism also holds that provided we acquire and transfer our assets and holdings without the use of force or coercion, justice requires that we are entitled to choose freely what to do with our belongings. Thus, a just distribution of resources is whatever happens to result from these free-market exchanges.

In this context, medical services are merely a market commodity subject to free-market conditions, and a fair distribution of medical resources occurs as long as they are distributed without force or fraud in a free-market economy. Under libertarianism, an individual is no more entitled to automatic heath-care than he is to other necessities of life like food, clothing or shelter. This is not to say that various charities cannot exist to help meet the needs of the less advantaged, simply that these charities would not be run by the government.

Objections to libertarianism are numerous, but usually center on disagreements on the role (or lack of role) of the government in helping to redistribute wealth to ensure that the disadvantaged are at least minimally cared for. Also, many individuals argue that to view clinical care is a mere market commodity or service is to detach it from its underlying dignity and humanity.

Egalitarian Model

In the Egalitarian model of social justice, one gives equal consideration to all interests while treating everyone as equals. As a result, individuals have equal access to goods and services, usually according to their need. While this concept is close in nature to Karl Marx’s maxim “From each according to his abilities, to each according to his needs”, in the egalitarian model of social justice as implemented in most socialist health care systems, the emphasis is primarily on the “to” part and less so on the “from” part of Marx’s maxim.

In the single-tier Egalitarian model of health care, there is only one health care system for basic services. In the two-tier Egalitarian model of health care (which arguably is not really egalitarian at all), users may choose between the basic system or pay extra to use the private system. The Canadian system is primarily an example of the former, while the British system (with the National Health Service and its parallel private system) is an example of the latter.

The advantages of the single-tier Egalitarian model to the disadvantaged members of society are obvious. The disadvantage of this model to the members of society who are well to do is that when they are faced with long waits for medical procedures as a result of systemic underfunding, they are not allowed to use their own money to obtain these services without leaving the country. Many individuals find it ironic that in Canada one can spend one’s money on unnecessary luxury items like SUVs but cannot spend one’s own money in Canada on getting a clinically valuable item like a knee MRI.

One final note. One question that sometimes arises in the discussions concerning social justice is “Does one have a right to health care?” From the above discussion it should be apparent that in the Utilitarian and Egalitarian models of social justice, the answer is “YES”, while in the Libertarian model of social justice the answer is “NO”.

 

Resources

 

Larry R. Churchill, Rationing Health Care in America, Notre Dame, University of Notre Dame Press, 1987.

Norman Daniels, Just Health Care, New York, Cambridge University Press, 1985.

Norman Daniels, Seeking Fair Treatment: From the AIDS Epidemic to National Health Care Reform, New York, Oxford University Press, 1995.

Norman Daniels, Donald W. Light, & Ronald L. Caplan, Benchmarks of Fairness for Health Care Reform, New York, Oxford University Press, 1996.

Andrew Edgar, Sam Salek, Darren Shickle, and David Cohen, The Ethical QALY: Ethical Issues in Health Care Resource Allocations, Haslemere, Euromed Communications, 1997.

Paul Menzel, Strong Medicine: The Ethical Rationing of Health Care, New York, Oxford University Press, 1990.