Medicine and Social Justice: Essays on the Distribution of Health Care
Is health care a right? If so, what duties does this right confer on health care systems and on societies? Since an unlimited right to all services is unaffordable, even in the United States (where spending on health care in 2001 exceeded 14 percent of the gross domestic product), where, and by whom and what means, should the line be drawn? With more than 40 million U.S. citizens without health insurance, is the health care system in this country fundamentally immoral? When the medical director of a health maintenance organization or the chief executive officer of a hospital makes decisions about allocating resources, what is a fair, just, and defensible process? Bioethicists, heretofore focused on thorny issues in individual patient care, are now beginning to assess the ethical underpinnings of the allocation and distribution of resources in health policy and health care organizations. They are joined by philosophers, lawyers, economists, physicians, and political scientists in Medicine and Social Justice. This compilation brings a variety of perspectives, national settings, and disciplinary backgrounds to the topic and provides a unique survey of theoretical and applied thinking about the connections between health care and social justice. The first of the book's four sections is an introduction to various theories of justice and their connection to health care. Anyone who cares about justice in health care should read the first chapter, by Norman Daniels. His approach to fairness in health care builds on the late John Rawls's theory of justice yet is also informed by the empirical study of health insurers in action. In the second section, which examines the fairness of health care systems around the world, Bruce Vladek and Eliot Fishman offer an engaging overview of the U.S. health care system, with a particular focus on Medicare. This essay (along with Roger Crisp's, on the British National Health Service) illustrates the tensions between ideal theory and practical realities -- the problem of "partial compliance." Baruch Brody's chapter on the ethics of clinical trials in developing countries, though interesting, seems out of place here. The third section of the book addresses the special issues of vulnerable groups: minorities, women, the disabled, children, the elderly, caregivers, and poor persons. Since the problem of social justice in these groups is acute, many of the chapters in this section assess the special role (if any) of health care in the context of these social disadvantages. The final section analyzes and raises provocative questions about current and emerging challenges in health care. Should alternative medicine be included as a covered benefit? What is a fair way to organize the distribution of organs for transplantation? (Rosamond Rhodes's chapter rightly criticizes some aspects of the policy of the United Network for Organ Sharing but leaves the reader wondering whether other countries, with more "just" health care systems, also have "fairer" systems for allocating organs.) Who should have priority, those in the worst health or those with the most to gain? Dan Brock's chapter on this subject clearly lays out the issues, while Jerome Bickenbach's chapter dissects and critiques the World Health Organization framework for assessing health care systems across countries. He (and other authors) fear that disability-adjusted life-years, quality-adjusted life-years, and life expectancy may slide from usefulness as analytic tools and become unjust applications that systematically and subtly discriminate against the disabled and those in poor health. Any book with "social justice" in its title will tend to tilt to the left; libertarians will find little here to their liking, aside from Bernard Baumrin's chapter, which flatly asserts that there is no right to health care, and Paul Menzel's chapter, which offers a defense of liberty-preserving health policy. Most of the authors reside in the United States or the United Kingdom; more than half have appointments in departments of philosophy. Physicians and others interested in this field will find this book an engaging introduction to the theoretical and practical challenges pertaining to social justice and health care. Those seeking to delve deeper into the topic may find additional nourishment from Rawls's Justice as Fairness: A Restatement (Cambridge, Mass.: Harvard University Press, 2001) and Amartya Sen's Development as Freedom (New York: Knopf, 1999). The collection of essays in Medicine and Social Justice can serve as a fine primer for courses in bioethics and comparative health systems.Lewis G. Sandy, M.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.