Just health: meeting health needs fairly

What does justice require with regard to population health? This is the question addressed by distinguished American philosopher Norman Daniels in his new book on justice and health. Just health is in many ways a successor to Daniels’s seminal classic Just health care (New York: Cambridge University Press; 1985). It integrates his earlier account of the special moral importance of health and health care with his interim work on the social determinants of health, the fairness of health sector reform and limit-setting in health care. As indicated by the change of title, Just health no longer focuses solely on the provision of health care, but spans all socially-controllable factors of health. The book’s ambitious aim is to provide an integrated theory of justice and health. In order to understand what justice requires for health, Daniels argues that we must address three focal questions. First, what is the special moral importance of health? Second, when are health inequalities unjust? And third, how can we meet health needs fairly when we can’t meet them all? Daniels’s answers to these questions are based on John Rawls’s theory of justice as fairness. Rawls argues that a social contract among free and equal citizens would include three general principles of justice: a principle protecting equal basic liberties; a principle guaranteeing fair equality of opportunity; and a principle limiting inequalities to those that benefit the worst off. Health and health care were not topics for Rawls, as he assumed all members of society to be healthy. Daniels extends Rawls’s theory by arguing, first, that health is of special moral importance because it contributes to the range of opportunities open to us. If we have social obligations to protect individual opportunity, promoting and restoring health is one component of fulfilling these obligations. Second, health inequalities are unjust when access to health care is inequitable and/or when the social determinants of health – such as education and income – are not distributed according to Rawls’s principles of justice. Third, although Rawls’s principles can guide our general thinking about justice and health, they are too indeterminate to solve common limit-setting problems about which reasonable people disagree. Therefore, a fair process must ensure the legitimacy and fairness of limit-setting decisions. Daniels claims that his theory provides comprehensive practical guidance that is applicable worldwide. The claims of practicality and global scope, in particular, raise a number of important questions for international health policy-makers. First, will liberal principles of justice be accepted around the globe? Daniels argues that his theory is consistent with various competing accounts of justice, and even provides a reasonable justification for a human right to health. This suggests that the theory’s worldwide acceptance is possible – although I believe more would have to be said to truly support the claim. The alleged consistency with multiple other theories also indicates how indeterminate Daniels’s own theory is: reasonable people will disagree about almost any limit-setting problem, despite the stipulated common moral ground. Second, how much practical guidance does Daniels’s theory really provide? The wealth of fascinating normative questions raised in Just health – for example, to what extent we should compromise on efficiency to reduce health inequities or to compensate people for previous medical errors – are, in the end, unanimously addressed by reliance on a fair process. However, despite Daniels’s best efforts to elucidate them, the substantive constraints of this process remain largely unclear. Third, policy-makers will want to know how much emphasis should be placed on fair process in situations of dire need. For example, the high prevalence of HIV/AIDS in some developing countries threatens social stability because young adults die prematurely. To the extent that engagement in a fair process risks delaying provision of treatment and consumes scarce resources, full-blown public accountability for reasonableness might not to be pivotal in all cases and under all circumstances. However, Daniels never addresses this question. Fourth, Daniels himself acknowledges that his theory tells us when health inequalities within a society are unjust, not when inequalities between societies are unjust. Of course, international justice is not the topic of this book, and Just health provides important ideas on how interdependent relationships and cooperative schemes might underpin justice, not charity, obligations towards members of other societies. But it remains unclear how Daniels can claim that his theory “can guide our practice with regard to health both here and abroad”. There are no easy answers to these questions. Just health provides a remarkably broad and deeply engaging treatise of justice and health, which will influence both policy-makers and bioethicists for years to come. The rich empirical and conceptual analysis, along with first-hand policy insights from both national and international contexts covering more than 20 years, is truly impressive. But as Daniels sometimes states himself, his theory remains a work in progress. ■