Health care as a testing ground for theories of distributive justice

Political philosophy has historically been a surprisingly unreal subject and distributive justice as a sub-field has fared no better, indeed some of the primary discussions have focused on the distribution of plover eggs and claret and taken place on desert islands. There is some sense to this, abstracting away from society and normal circumstances can be an excellent method of testing the implications of principles. However there are also some dangers of this, to be frank who is that fussed by the distribution of claret and plover eggs? Given this health care distribution makes an excellent crucible for testing political theories of distributive justice. In this arena questions of distribution matter crucially for people, they are literally life or death.

So I’d like to lay down the gauntlet for my fellow political philosophers… “so you think you’ve got a good theory of distributive justice? How does it do in this context?”

  • Jason

    I would be interested in knowing what it means to be a good theory in the context of health care. What criteria do we measure theories against to determine whether they pass the test?

  • Great question Jason.

    I’m going to give some fumbling answers now and hope that someone else joins in and gives a better answer later.

    I should say the criteria for success of a theory of distributive justice I suspect is the same both inside and outside the context of health care, it is just that health care raises the stakes in a way that brings out specific problems. In other words I deny claims about the separateness of health care.

    Take the broadly Rawlsian theory of Robert Veatch for example which uses the difference principle (the idea that the distribution should be such that the person left in the worst position is in the best possible position) as a principle for distribution of health care resources.

    This runs straight into the bottomless pit objection, namely that the very worst off people will absorb almost all of our health care (and other) spending since we can almost always spend more money and make them slightly better off.

    This outcome seems absurd in this context in a way that isn’t as apparent when we are talking about income distribution but has obvious implications for the plausibility of Rawlsian approaches to distributive justice.

    So here broadly are what I think are the requirements for a successful theory of distributive justice in the context of health care:

    1. Plausibility. The first perhaps obvious criterion is that the theory has to give a plausible account of what the requirements of justice are. There are two elements to plausibility to be considered here. Firstly, that the overall intuition that the theory is based on is intuitively plausible and secondly, that there are no significant objections to the theory that remain unresolved.

    2. Plurality of Values. An adequate theory also has to deal with the fact that people value different things and have radically different ideas of what a good life is. Respecting that individuals will value things differently and reacting appropriately to these different values is an important element of an adequate theory.

    3. Flexibility. An adequate theory of distribution of health care resources has to be flexible both with respect to the types of resources available and to the level of technology available. Health care is a rapidly changing arena with new discoveries occurring constantly. Thus a flexible evolving theory which tells what we should provide in each different scenario is required.

    4. Pragmatic. An adequate theory needs to be able to provide justification for some practical matters such as who should pay for health care, and who should make health care decisions. A common complaint about political philosophers and theories of distribution of health care resources is that they don’t link up to reality. (Loughlin, 1995) A good theory will provide answers to the necessary practical questions.

    5. Consistency. A basic requirement of any ethical theory is that it treats like alike. This measure of formal equality seems entirely reasonable as a guiding principle. So an acceptable theory of distributive justice in health care will provide equal access to treatment for those who have the same illness or similar illnesses insofar as this is compossible with the constraints of the resources available in the world.

    What do you think about these as a set of criteria?

  • I think these are pretty sensible criteria. One useful source on what *moral* theories are supposed to do, which is worth comparing is chapter 1 of Brad Hooker’s Ideal Code, Real World. There Hooker argues that a good moral theory must meet the following criteria:

    (1) Moral theories must start from attractive general beliefs about morality.
    (2) Moral theories must be internally consistent.
    (3) Moral theories must cohere with (i.e. economically systematize, or, if no system is available, at least endorse) the moral convictions we have after careful reflection.
    (4) Moral theories should identify a fundamental principle that both (a) explains why our more specific considered moral convictions are correct and (b) justifies them from an impartial point of view.

    (5) Moral theories should help us deal with moral questions about which we are not confident, or do not agree.

    One key question about theories of justice is whether they are supposed to be helpful in telling us how to reform the societies we are currently living in. John Rawls famously thought of his account of justice as an ‘ideal’ theory which was not in any way straightforwardly applicable to societies as we find them. This focus on idealisation has been the norm in political philosophy ever since; but there is now an increasing chorus who think that this has simply been a mistake. As Amartya Sen put it in a recent article, “What do we want from a theory of justice” (Journal of Philosophy 2004, p. 237-8): “The world in which we live is not only unjust, it is, arguably, extraordinarily unjust. It is not frivolous to seek a framework for a theory of justice that concentrates on advancement, not transcendence, and also allows being globally interactive, rather than being intellectually sequestered. We have good reason to abstain from concentrating so fully on the program of identifying the totalist – and possibly parochial – demands of transcendental, contractarian justice. We have to move the theory of justice out of that little corner.”

  • Interesting post. I agree with David that the idealism and abstraction of contemporary theories of distributive justice make them ill-equipped for tackling practical issues like just health care.

    But I think there is an even better test of political theories of justice than how they fare with the topic of just healthcare. And that test is how they fare with *health* itself. Given that our health prospects are influenced by a wide range of variables (natural endowments, our evolutionary history, lifestyle, access to clean drinking water, education, medical care, etc.), the focus on health is where I think we really should start from. What would a fair distribution of opportunities for health look like? What policies would it bring to the fore that are currently neglected? I think these are fascinating issues that political philosophers should ponder more seriously.


  • Interesting point Colin, of course it might somewhat depend on what we might think is the/a “currency” of justice and whether health is included. Nonetheless I do agree that health distributions themselves are interesting from the point of view of justice.

    I also think though that when discussing health & health care distribution perhaps we should look wider than theories of justice.

  • great blog it’s good to see someone using a blog for what it is actually meant for look forward to seeing further comments.