Does Justice Require Universal Access to Health Care?

 via Standford Encyclopedia of Philosophy entry: Justice and Access to Health Care:

3.1 Health, Opportunity, and Universal Access

One prominent line of argument in favor universal access to some forms of health care builds on the contribution made by health—and derivately by health care—to the opportunities people can exercise. The most explicit version of this argument extends Rawls's appeal to a principle assuring fair equality of opportunity (Daniels 1981, 1985, 2008). Variants on that argument can be extrapolated from Sen's (1980, 1992) work on capabilities or from Arneson's (1988) and Cohen's (1989) versions of “equal opportunity for welfare or advantage,” though there will be differences among these variants in what kinds of care are covered and under what conditions.

The fair equality of opportunity argument for universal access can be sketched as follows:

1. Suppose health consists of functioning normally for some appropriate reference class (e.g. a gender specific subgroup) of a species; in effect, health is the absence of significant pathology.
2. Maintaining normal functioning—that is health—makes a significant—if limited—contribution to protecting the range of opportunities individuals can reasonably exercise; departures from normal functioning decrease the range of plans of life we can reasonably choose among to the extent that it diminishes the functionings we can exercise (our capabilities).
3. Various socially controllable factors contribute to maintaining normal functioning in a population and distributing health fairly in it, including traditional public health and medical interventions, as well as the distribution of such social determinants of health as income and wealth, education, and control over life and work.
4. If we have social obligations to protect the opportunity range open to individuals, as some general theories of justice, such as Rawls's justice as fairness, claim, then we have obligations to promote and protect normal functioning for all.
5. Providing universal access to a reasonable array of public health and medical interventions in part meets our social obligation to protect the opportunity range of individuals, though reasonable people may disagree about what is included within such an array of interventions, given resource and technological limits.

Some comments will clarify the main points in this sketch. First, the narrow concept of health does not preclude the broad range of determinants of health noted in (3), yet the narrower notion is what epidemiologists and public health planners measure and care about. This narrower concept of health avoids conflating health with well being more generally, as does the WHO definition of health (“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”) (WHO 1948). Obviously, though, normal functioning includes cognitive and emotional functioning and not just physical health, for we are complex social animals. Health remains a “limit” or “ceiling” concept, unlike income, for we cannot increase health indefinitely but must aim only for normal functioning for all.

Second, protecting and promoting normal functioning is not the only factor affecting the range of opportunities open to people. Income, education, and basic liberties, as well as other factors, do so as well. Nevertheless, the loss of functioning or premature death that may come with ill health clearly diminish the range of plans of life people can reasonably choose among in a given society. Accordingly, protecting health protects opportunity, even if it is not the only thing that does so. A crucial feature of the argument is that we are concerned about the health of all because we are concerned about protecting the opportunity range of all.

Third, we have learned much in the last several decades about the broader social determinants of health (see entry by Sreenivasan on Health inequalities and justice), especially that the presence of universal access in a society does not eliminate or significantly reduce health inequalities in it. Does the importance of other socially controllable factors that affect population health and its distribution mean that providing universal access to an appropriate set of public health and personal medical services is less important (see Sreenivasan 2007)? Suppose we learn that some expensive individual interventions contribute less to protecting the opportunity range of individuals than redistributing some other important goods that are determinants of health. That might well mean that we should spend less on health care and redefine the benefit package we provide in a universal access system. But it should not mean that we abandon universal access to care. No matter how justly we distribute the broader determinants of health, some people will become ill and others not. Universal access to reasonable care (given its relative effectiveness compared to other things we may do) is still the only way to assure people that certain health needs can be equitably met.

Fourth, the extension of Rawls's theory introduces some modification in the account of opportunity, but the modification is not inconsistent with the thrust of justice as fairness. Justice as fairness abstracts from health status differences in its assumption that agents are choosing principles to govern people who are fully functional over a normal lifespan. This simplification drew criticism from Arrow (1973) and later Sen (1980), for it means the method of judging inequality, the index of primary social goods, would fail to account for the inability of people in some health states to convert those goods into the same level of well-being as people functioning normally. Rawls's (1971) notion of opportunity is primarily geared to the strategic importance of access to jobs and offices; health, viewed as normal functioning, clearly has a bearing on access to jobs and offices, but we also need a broader account of opportunity if we are to address the impact of health on other important aspects of life. In borrowing justification for a principle assuring fair equality of opportunity, then, and then using it to apply to a broader notion of opportunity, the argument involves a modification of Rawls's own arguments. Nevertheless, he seems to have adopted this view of how to extend his theory (Rawls 1995: 184, n.14; Rawls 2001:175, n.58).

Despite this modification, the approach preserves a key feature of Rawls's original idealization away from consideration of health states: in aiming to keep all in a population functioning normally over a normal lifespan, we aim to keep the real world as close to the idealization as possible. A crucial consequence of this is that we are not simply focused on equalizing opportunity, but on promoting the broadened range of opportunity that comes with normal functioning for everyone. The view aims at promoting population health and not simply equalizing it: equally bad health is not the goal of the argument. Put another way, the ultimate goal of health policy is that all people function normally: but that means the ultimate goal is both egalitarian and maximizing (though short of the ultimate goal, we face important trade-offs).

Finally, we must consider how we can meet health needs fairly when we cannot meet them all. The question is especially difficult because we have reasonable disagreements about what interventions to include in a universal access system. This is true even if we accept the principle of fair equality of opportunity principle as the appropriate principle to govern health and health care.

The problem is that the fair equality of opportunity principle is too general and indeterminate to address a family of “unsolved rationing problems” (Daniels 1993). For example, when we are thinking of investing in a new service or technology, we may agree that we should give those who are worst off in their health some priority over those who are better off. But we may wonder how much priority we should give them if we can produce much bigger improvement in health for those who are somewhat better off. Similarly, we may agree not to allow many trivial benefits to outweigh significant ones, but we may still disagree about when do modest benefits for larger numbers of people outweigh significant benefits for fewer people. In these and other problems, reasonable people—people seeking reasons that can form the basis for a mutual justification of policy—will disagree about how to make the tradeoffs among the competing values at issue, even if they agree that the overall goal of health policy should be to protect opportunity. We lack prior agreement on more fine-grained principles that tell us how best to protect opportunity in this context. Because we lack a consensus on such principles, we should engage a form of procedural justice or fair process to yield fair outcomes.

One version of such a process is called “accountability for reasonableness” (Daniels and Sabin 2002). It requires a search for mutually justifiable reasons, publicity about the grounds for decisions, revisability of decisions in light of new evidence and arguments, and assurance that the process is adhered to. The specific features of such a fair process would have to be adapted to the institutional level at which it is used to make decisions about what to cover. Specifically, decisions about the content of a universal access benefit package should be specified through a fair, deliberative process that conforms to these general conditions. In Section 5 we shall return to consider in more detail what kinds of interventions are in general supported by this account.

Accountability for reasonableness is appropriately thought of as a form of pure procedural justice (Rawls 1971) because we lack prior consensus on the fine-grained principles needed to resolve disputes about these resource allocation issues, though we may arrive at mutually acceptable justifications through deliberation about specific cases. At the same time the appeal to process is constrained by some prior moral principles. For example, an outcome should not contradict what fair equality of opportunity requires by discriminating against some subgroup on by race or gender. A local decision-making body could not engage in gender or race bias and consider that a fair outcome. Though fair equality or opportunity, including non-discrimination, constrains acceptable outcomes of fair process, it is too general an idea to settle what counts as an acceptable outcome. That requires agreement, in general by a range of stakeholders, on reasons for thinking an allocation is an acceptable way to meet needs fairly and so protect opportunity for those involved. The point behind insisting on what we call the “relevance” condition is to search for mutually justifiable reasons for thinking that a particular resource allocation is an acceptable way to aim at fair equality of opportunity. The condition takes us beyond mere consistency with fair equality of opportunity since that principle does not determine what to do in the face of disagreements about priorities, aggregation, and other problems.

The argument for universal access sketched earlier specifically embraces Rawls's fair equality of opportunity principle. It is worth remarking that the variations on this argument might retain steps 1–3 but modify the principle that is appealed to in 4, provided there is a reasonable connection between any substituted principle and the central observation in 3, that health affects the opportunity range open to people. For example, Sen has argued that the appropriate target of concerns about equality is a space of capabilities, thought of as functionings we can choose to exercise. A principle requiring us to protect the range of capabilities for people (either equally or to some sufficient level) would also provide a basis for keeping people functioning normally through universal access to interventions that reduce the health risks to them or that treat them for departures from normal functioning. Though Sen has not developed this account into a theory of justice that articulates a set of principles of justice, the central point here is that a concern to protect a space of functionings we can choose to exercise is equivalent to the focus of the earlier argument on protecting opportunities that it is reasonable for people to exercise (Daniels 2009b).

A third alternative version of the earlier argument might (in 4) invoke a principle assuring equal opportunity for welfare or advantage (Arneson 1988; Cohen 1989). Arguably, such a principle would also support a universal access system that included a broad range of preventive and treatment services. This particular principle, however, will differ in terms of what is covered for it more explicitly leaves room to exclude coverage for conditions for which an individual is substantively responsible. It says we do not owe each other assistance or compensation for bad “option” luck in the way we do for bad “brute” luck. Still, this is a universal access system, even if it excludes coverage for conditions for which society holds individuals responsible (see Daniels 2009a).

Posted via email from Jim Nichols