Sanitary justice in scarcity
Justic ia sanitaria e n la e sc ase z
1 Dep artam en to d e Filosofía, Fa cu lt a d d e Filosofía y Hu m a n id a d es, Un iv ersid a d d e Ch ile. Ca silla 16168, Correo 9, Sa n t ia go, Ch ile. gu a rv ie@ct creu n a .cl
M igu el Kot t ow 1
Abstract Ju st ice in h ealt h care an d t h e allocat ion of scarce m ed ical resou rces m u st be an alyz ed d ifferen t ly in a fflu en t a s com p a red t o econ om ica lly w ea k er societ ies. Th e p rot ect iv e fu n ct ion s of t h e st a t e m u st b e ex t en d ed t o cov er b a si c n eed s for t h ose t oo p oor t o m eet t h em on t h ei r ow n . M ed i ca l n eed s a re a h i gh p ri ori t y, si n ce p oor h ea lt h h a m p ers t h e a b i li t y t o secu re ot h er b a si c n eed s. Th e st at e m ay op erat e as eit h er a h ealt h care p rov id er or su p erv isor, gu aran t eein g t h at cit -iz en s b e t rea t ed fa irly by n on gov ern m en t a l in st it u t ion s. Tw o- t iered syst em s w it h a v igorou s p ri-v a t e h ea lt h ca re sect or a re com p a t ible w it h t h e ex p licit righ t t o h ea lt h ca re, p rori-v id ed t h e p riri-v a t e t ier op erat es w it h ou t d irect ly or in d irect ly d rain in g p u blic fu n d s.
Key words Healt h Righ t s; M ed ical Care; Social Ju st ice; Healt h Policy
Resumen Es p reciso h a cer u n d ist in go en t re ju st icia sa n it a ria y d ist rib u ción d e recu rsos m éd i-cos esca sos, segú n se t ra t e d e socied a d es p u d ien t es o a q u ella s q u e son econ óm ica m en t e d éb iles. La s t ra d icion a les fu n cion es p rot ect ora s d el Est a d o d eb en ex t en d erse p a ra cu b rir la s n ecesid a d es m éd ica s, q u e a su v ez t ien en p riorid a d p orq u e la sa lu d es in d isp en sa b le p a ra p od er solv en t a r ot ra s n ecesid a d es b á sica s. El Est a d o p u ed e op era r com o p rov eed or d e a t en ción m éd ica , o com o fisca liz a d or d e la ecu a n im id a d d e serv icios ot orga d os p or ot ra s in st it u cion es. El d erech o a a t en -ción m éd ica es com p a t ib le con u n sist em a p a ra lelo d e m ed icin a p riv a d a , siem p re q u e ello n o sign ifiqu e d ren ar d irect a o in d irect am en t e recu rsos d el sist em a p ú blico.
Introduction
In 1978 t h e Be lm o n t Re p o r t , issu e d b y t h e U S Na tio n a l Co m m issio n fo r th e Pro tectio n o f Hu m a n Su b jects, reco m m en d ed a n u m b er o f eth -ica l n o rm s t o b e d u ly re sp e ct e d b y b io m e d -ica l resea rch . Cla d in a ca d em ic form , th e Rep ort fa th ered wh a t even tu a lly b eca m e kn own a s p rin -c ip a lism , u n le a sh in g a -c o n t rove r sy a b o u t t h e t h e o re t ic a l st a t u s a n d p ra c t ic a l u se fu ln e ss o f t h e fo u r p r in cip le s. Th e d iscu ssio n n e ve r d ie d d own . Qu it e t o t h e co n t ra r y, it h a s b e e n co m -p o u n d e d b y d o u b t s co n ce r n in g t h e a -p -p ro -p r i-a t e n e ss o f in t ro d u c in g p r in c ip i-a lism in t o t h e b io e t h ica l t h in kin g a n d p ra ct ice o f o t h e r cu l-t u re s. All-t h o u gh a u l-t o n o m y h a s p ro b a b ly b e e n th e p rin cip le m o st su b ject to criticism , th is p a -p e r c o n c e n t ra t e s o n t h a t o f ju st ic e, sin c e it is co n ce p t u a lly t h e m o st d ifficu lt t o gra sp , e ve n a s it a ssu m e s a re le va n t p o sitio n (im m e d ia te ly o r b y d e fa u lt ) in La t in Am e r ic a n h e a lt h c a re p olicies.
Ju stice is a p olitica l a n d p h ilosop h ica l top ic t h a t is fa r t o o va st t o b e d iscu sse d h e re in a n y d e p t h . H igh ly d ive rge n t vie ws h a ve b e e n e x-p re sse d a s t o wh e t h e r ju st ic e c o n st it u t e s a n e t h ic a l issu e, a n d m a n y wr it e r s h a ve b e e n a t lo ss t o d e fin e it a s a p r in cip le. In fa ct , o n e in -t e rp re -t a -t io n h a s i-t -t h a -t -t h e p r in cip le o f ju s-t ice in t h e co n t e xt o f h e a lt h ca re p o licie s m a y we ll b e co lla p se d in to a so cia l go o d th a t ra n ks h igh b u t n o t t o p m o st in t h e ove rr id in g p r in cip le o f so cia l b e n e fice n ce ( Ve a tch , 1990). Be a u ch a m p a n d Ch ild re ss c o n sist e n t ly d e fe n d t h e e q u a l st a t u s o f a ll fo u r p r in cip le s, a lt h o u gh t h e y a c-c e p t t h e ir p rim a fa ciea n d t h e re fo re n o n a b -so lu te ch a ra cter (Bea u ch a m p, 1995).
Critics o f p rin cip a lism a re e sp e cia lly p u n c-t ilio u s wic-t h re ga rd c-t o ju sc-t ic e (Clo u se r & Ge r c-t , 1990), t o t h e p o in t o f st a t in g t h a t “We su sp ect th at even th e p rop on en ts of p rin cip alism d o n ot p u t m u ch stock in th e p rin cip le of ju stice as an action gu id e. Th e p rin cip le of ju stice seem s to be a p rim e exam p le of a p rin cip le fu n ction in g sim -p ly a s a ch eck list of m ora l con cern s” (Clo u se r, 1995:225). On t h e o t h e r h a n d , ju st ice t o ge t h e r wit h a u t o n o m y h a ve b e e n gra n t e d le xica l p r io rity b e ca u se th e y cio n stitu te n io n cio n se q u e n tialist or p erfect d u ties an d th erefore ran k as in -vio la b le if in co n flict with u tilita ria n p rin cip les ( Vea tch , 1995). Exa ctly th e o p p o site view is es-p ou sed by Clou ser &ames-p; Gert (1994) wh en su ggest-in g t h a t ju st ice is a n id e a l ra t h e r (t h a n a r u le ) wh ic h m a y b e e n c o u ra ge d b u t n o t re q u ire d , th u s co n stitu tin g a n im p erfect d u ty a t b est.
In a p p ro a ch in g t h e La t in Am e r ica n re ce p -tion of p rin cip a lism , Gra cia (1995) h a s su ggest-e d t h a t ju st ic ggest-e a n d n o n - m a lggest-e fic ggest-e n c ggest-e a rggest-e t h ggest-e
m o st fu n d a m en ta l p rin cip les b eca u se th ey a d d re ss c o m m u n it a r ia n in t e re st s. Th u s, a n im -p o rta n t o -p in io n o n tra n s-cu ltu ra l m igra tio n o f p r in cip a lism su gge st s t h a t An glo -Sa xo n vie ws t e n d t o fo cu s o n a m o re lib e r t a r ia n , in d ivid u -a list ic , -a n d -a u t o n o m y- b -a se d kin d o f e t h ic s, wh e re a s La t in Am e r ic a n a p p ro a c h e s p re fe r a m o re co m m u n it a r ia n , ju st ice -o r ie n t e d wa y o f th in kin g. Su ch a sta tem en t, if a t a ll tru e, sh ou ld b e co n fin e d t o b io e t h ics a n d n o t e xt ra p o la t e d to p o litica l o r so cia l rea lities.
Th e a b ove-m en tio n ed ten ta tive ch a ra cterzation n otwith stan din g, North Am erican bioeth i-cists h ave been esp ecially sen sitive to th e issu e of ju stice in h ea lth ca re, p ossib ly b eca u se th ey exp erien ce th e eth ica l exp ro b lem s a n d recen tly u n ve ile d we a kn e sse s o f a d e c e n t ra lize d , fu n d a -m e n t a lly p r iva t e, p ro fit -o r ie n t e d -m e d ica l sys-t e m . Mo ssys-t su c h a u sys-t h o r s b e gin b y e xp re ssin g th e ir d isco m fo rt with h e a lth -ca re p o licie s th a t le a ve u p t o 15% o f t h e p o p u la t io n u n in su re d , wit h fin a n c ia l su p p o r t o ft e n fa ilin g in c a t a -st ro p h ic d ise a se s o r in e xp e n sive a n d le n gt h y t re a t m e n t s. Th e im p a c t o f m a n a ge d c a re o n b oth th e q u ality of m ed ical coverage an d th e in -terests of th e m ore vu ln erab le are also con cern s p ertain in g to ju stice in h ealth care. Th ese social rea lities sh o u ld b e b o rn e in m in d wh en reflect-in g o n a va r ie t y o f p ro p o sa ls b ro u gh t fo r t h reflect-in th e n a m e o f fa ir m ed ica l ser vices.
Fo u r d iffe re n t h e a lt h - c a re sc h e m e s h a ve b e e n id e n t ifie d b y t h e st ill in cip ie n t Sp a n ish -la n gu a ge b io e t h ica l lit e ra t u re, a n d a fe w m o re m u st b e b r ie fly m e n t io n e d b e fo re t a cklin g t h e issu e fro m a La tin Am erica n p ersp ective.
Health care rights in affluent societies
Sa d e (1978:574) h a s a d a m a n t ly re fu se d t o a c-ce p t a n y r igh t t o h e a lt h se r vic-ce s, a rgu in g t h a t “m ed ical care as p atien ts’ righ ts is im m oral be-cau se it d en ies th e m ost fu n d am en tal of action s t o su p p ort it.” Me d ic a l c a re, t h e re fo re, is n e i-t h e r a r igh i-t n o r a p r ivile ge, b u i-t a se r vice i-t o b e fre e ly p u rch a se d . En ge lh a rd t Jr. (1997) is a lso skep tica l th a t th e la n gu a ge o f righ ts a n d d u ties in h e a lt h c a re c o u ld b e a d va n t a ge o u sly u se d a m o n g ‘m o ra l st ra n ge r s’, b e lie vin g t h a t o n ly ve r y ru d im e n t a r y a rra n ge m e n t s co u ld b e p ro p o se d . At b e st , a vo lu n t a r y p ro gra m o f c o m -m o n ly a greed -u p o n h ea lth -ca re services -m igh t ser ve to cover certa in b a sic n eed s.
n e e d s (wa rs, fo r e xa m p le ) o r h a d e xp licitly e n -tered a sp ecific h ea lth -rela ted co m m itm en t, a s in p re ve n t ive ca m p a ign s re q u ir in g ce n t ra l o r-ga n iza t io n . Bu c h a n a n d id se e t h e n e e d fo r so m e kin d o f m e d ica l ca re, wh ich h e p re fe rre d t o a n ch o r a s a n im p e r fe ct d u t y o f ch a r it y. Th e m ere ca ll fo r ch a rity is in effective, h e a ckn owl-e d gowl-e d , a n d c o llowl-e c t ivowl-e p ro gra m s n owl-e owl-e d t o b owl-e worked ou t so th a t p eop le will con sisten tly d is-ch a rge th e d u ty o f is-ch a rity. His p ro p o sa l fin a lly t a ke s t h e fo r m o f a re ve n u e wh ic h , b y wa y o f Mill’s co n ce p t o f so cia l e xp e d ie n cy, b e co m e s a m a n d a to ry d u ty towa rd s th e sta te. Still, Bu ch a n a n’s sc h e m e d o e s n o t e vo lve in t o a n o b liga -tio n fo r th e sta te to u se th e ta xes th u s levied to gra n t h ea lth ca re righ ts.
Alth o u gh few p eo p le wo u ld en d o rse ra d ica l lib e ra lism wit h n o a ffir m a t ive st a t e a c t io n in h e a lt h ca re m a t t e r s, a m o re p o sit ive vie w wa s slow in d e ve lo p in g. Fr ie d (1978:583) u se d t h e term “d ecen t m in im u m” to con vey th e id ea of a b a la n c e b e t we e n p u b lic c o n c e r n fo r t h e p o o r a n d th e p re se r va tio n o f fre e a n d fle xib le so cia l co m m itm en ts. Th e n o tio n o f d ecen t m in im u m is n o t a m e re figu re o f sp e e c h , b u t a n in d is-p en sa b le co n ceis-p t th a t sh o u ld reis-p la ce a rb itra ry n o t io n s o f m e d ica l n e e d s. “Th e m ain crit erion for w h a t h ea lt h ca re serv ices sh ou ld b e m a d e available as p art of th e d ecen t m in im u m is ad e-qu acy of th e am ou n t, level, k in d , an d e-qu ality of h ea lt h ca re. Test s of a d eq u a cy w ill a t t h e lea st in clu d e w h eth er h ealth care is resp on sive to cer-t a in n eed s, for ex a m p le b a sic, u rgen cer-t , or life-th reaten ig n eed s” (Ch ild ress, 1997:252). “(...) in th e absen ce of h u m an ity, w e m ay h ave to resort to th e p olitical p rocess to d efin e th e d ecen t m in -im u m for in d ivid u als” (Ch ild ress, 1982:418).
Th e id e a o f a d e c e n t m in im u m o f h e a lt h c a re wa s t a ke n u p a n d e la b o ra t e d b y D a n ie ls (1981), p ro b a b ly th e m o st in flu e n tia l write r o n t h e su b je c t . He re m a rke d q u it e p ro p e r ly t h a t t h e sco p e o f a r igh t re q u ire d a d e fin it io n o f it s o b je ct , e n d o rsin g Bo o rse’s ch a ra ct e r iza t io n o f h ea lth a s th e a d eq u a te fu n ctio n in g o f th e in d i-vid u a l in a c c o rd a n c e wit h st a n d a rd s o f t h e sp ecies. Illn ess m ean s n ot b ein g ab le to com p ly wit h t h e se n o r m s a n d t h e re fo re lo sin g o u t in t h e b a sic so cia l p o sit io n o f se cu r in g e q u a l o p -p ortu n ities to -p u rsu e on e’s id ea of th e good life. All t h e se p h ilo so p h ic a l a p p ro a c h e s h a ve h ad n o m ajor im p act on actu al h ealth care p olic ie s, b u t t h e y d o a p p e a r a s p la u sib le a n d olic o h eren t th eo retica l fra m ewo rks fo r lib era l co u n -tries. It is fa r less evid en t th a t th ey ca n b e rele-va n t t o so c ie t ie s wit h su b st a n t ia lly d iffe re n t cu ltu ra l a n d p o litica l rea lities. A m a jo r p o in t o f d ive rge n c e lie s in t h e so c ia l c o m p o sit io n o f North Am erica n com m u n ities, wh ere a n u m
er-o u s m in er-o r it y er-o f p e er-o p le la ck su fficie n t m e d ica l ca re, wh e re a s le ss p ro sp e ro u s so cie t ie s h a ve a m a jo r it y o f t h e ir p o p u la t io n livin g o n low in -com es, with n o h ea lth in su ra n ce a n d relia n t on gro ssly u n d e r fin a n ce d p u b lic p ro gra m s. Un -d er su ch con -d ition s, th e -d en ia l or restriction of h e a lt h ca re r igh t s le a ve s va st se gm e n t s o f t h e p o p u la tio n sta n d in g in th e ra in .
Even th e m ore ju stice-orien ted sch em es a re d ifficu lt to fit in to a Th ird World reality. Dan iels, for exa m p le, a p p ea rs to b elieve th a t orga n ism ic n orm a lcy is th e m a jor a sset th a t m a kes a ll p eop le fit to eop a rticieop a te in society’s eq u a l oeop eop ortu -n ity clim a te. Th erefo re, if ‘d ece-n t’ m ed ica l ca re is p rovid e d , p e o p le will e n joy e n o u gh su p p o rt t o e n ga ge in a sa t isfa c t o r y life p la n . Bu t wh a t a b o u t ed u ca tio n to b e co m p etitively q u a lified ? Wh y a re n’t h o u sin g o r p e r h a p s e ve n c lo t h in g c o n sid e re d n e c e ssa r y a sse t s t o b e c o m e m o re a t t ra c t ive jo b c a n d id a t e s? Fu r t h e r m o re : h ow go o d is t h e fit b e t we e n in d ivid u a l p r o gr a m s a n d sp ecies-a d ju sted n o rm a lcy?
Protective functions of the state
A d ist in c t io n m u st b e m a d e b e t we e n we a lt h y so cieties a n d th o se th a t o p era te in sca rcity. So -cie tie s in sca rcity a re n o t n e ce ssa rily p o o r, b u t th eir wea lth is p ola rized a n d th eir p olitica l la n gu a ge d o e s n o t co n t e m p la t e d e e p re d ist r ib u -t ive ch a n ge s. Th e y m a y h a ve e xce lle n -t sch o o ls a n d u n iversities, even o u tsta n d in g resea rch fa -cilities. Th ey h a ve a n a ttra ctive th ou gh restrict-e d jo b m a rkrestrict-e t , a n a gilrestrict-e co n su m restrict-e r m a rkrestrict-e t , a n d a ge n e ra l c lim a t e o f we ll b e in g. Bu t t h e y re -m a in p rofou n d ly d ivid ed in to th ree cla sses: th e wea lth y, th e strivin g b u t fra gile a n d vu ln era b le m id d le c la ss, a n d t h e d e st it u t e, wh o a re n u -m ero u s a n d a p p a llin gly p o o r.
Eve n th e m o st lib e ra l p o litica l th o u gh t re o gn ize s t h a t a m in im a l st a t e will o ffe r p ro t e c-t io n c-t o ic-t s cic-t ize n r y, sin ce vio le n ce n e e d s c-t o b e c u r t a ile d a n d d isc ip lin e d in t o a ‘la w a n d o r -d e r’ p o lic y. Se c u r it y- p ro n e st a t e s o rga n ize a m ilit a r y fo rc e a ga in st e xt e r n a l vio le n c e, a n d t h e p o lic e fo rc e su b d u e s in t e r n a l a ggre ssio n , wh ile re m a in in g o b livio u s t o o t h e r p le a s fo r p rotection .
-t io n in m a -t -t e r s -t h a -t c a n b e so lve d b y p r iva -t e m ea n s. Even m o re so cia lly o rien ted p o liticia n s will o ft e n re fe r t o t h e su b sid ia r y st a t e, a n a r ra n ge m e n t wh e re st a t e in t e r ve n t io n is re -se r ve d fo r c irc u m st a n c e s t h a t go b e yo n d t h e p ro b lem -so lvin g ca p a cities o f th e in d ivid u a l o r sm a ll grou p.
Ju st ic e in a c o n t e xt o f sc a rc it y d e m a n d s a n e w a p p ro a ch t h a t will re co gn ize t h a t a ggre ssion m u st b e d efin ed a ccord in g to th e econ om ic p o ssib ilit ie s o f t h e cit ize n r y. In we a lt h y n a -t io n s, in -t e r n a -t io n a l se cu r i-t y, n a -t io n a l la w a n d o rd e r, a n d c e r t a in b a s ic s e r vic e s like u r b a n d e ve lo p m e n t o r e m e rge n cy fu n d s m a y su ffice a s gove r n m e n t a l a t t r ib u t e s. Ea r t h q u a ke s a n d flood s affect p oor n eigh b orh ood s m ore h eavily, b u t th e loss of crop s m ay b e eq u ally d evastatin g fo r r ich a n d p o o r. Wh e n in d ivid u a l e ffo r t s a re in su fficie n t , t h e cla m o r fo r st a t e in t e r ve n t io n a n d su p p o r t b e co m e s u n ive rsa l. In co u n t r ie s with a la rge p o p u la tio n o f u n d erp rivileged a n d p oor, th e state m u st exten d its p rotection to en -su re m ed ica l ca re, ed u ca tio n , h o u sin g, a n d fa ir la b o r o p p o rtu n ities.
Jo n e s (1983) h a s p u b lish e d a p ro p o sa l a lo n g th ese lin es, b u t h e co n ten d s th a t n a tio n -a l p ro te ctio n -a g-a in st fo re ign e n e m ie s is e q u iv-a len t to h eiv-a lth civ-a re fo r d iseiv-a ses th iv-a t co n stitu te a so cia l m en a ce. Th u s, ca rd iova scu la r d isea ses kill m ore p eop le p er yea r th a n th e Vietn a m Wa r, so h e con sid ers th em a p rob lem th e solu tion to wh ich m u st b e fu n d e d b y t h e st a t e. Acco rd in g t o Jo n e s’ vie w, sin ce Down’s syn d ro m e is n o t a d ire c t kille r a n d c yst ic fib ro sis a ffe c t s o n ly a ‘fa ir ly sm a ll’ se gm e n t o f t h e p o p u la t io n , t h e t wo d ise a se s m igh t n o t q u a lify fo r st a t e su p -p o r t e d m e d ic a l se r vic e s. On t h e o t h e r h a n d , a cu te a p p e n d icitis wo u ld , sin ce th e sta te h a s a t ra d it io n fo r t a kin g c a re o f e m e rge n c y sit u a -tion s. Desp ite th is ea rly con trib u -tion , it h a s n ot b e e n fir m ly e st a b lish e d wh a t t yp e o f m e d ic a l n e e d s, if a n y, a re t o b e p rovid e d b y t h e st a t e a n d to wh o m .
It is h a rd ly su r p r isin g t h a t c o n se n su s o n p re ve n t ive p u b lic h e a lt h m e a su re s d a t e s b a ck n o m ore th a n a h u n d red yea rs, wh en it b eca m e clea r th a t n o sewa ge system wou ld work u n less a ll h o u se h o ld s we re c o n n e c t e d t o it , a n d t h a t n o im m u n iza t io n p ro gra m wa s e ffe ct ive u n t il th e en tire vu ln era b le p o p u la tio n wa s va ccin a t-e d , t h u s c o n st it u t in g a st a t t-e o b liga t io n a n d a righ t fo r a ll citizen s.
Th e ra p e u t ic m e d ic in e h a s fa re d so p o o r ly a s a c a n d id a t e fo r u n ive r sa l c ove ra ge fo r t h e sa m e re a so n s. Th e fir st m e d ic a l in su ra n c e sc h e m e s we re d e sign e d b y Bism a rc k fo r t h e Ge r m a n Em p ire, b u t t h e ir o n ly a im wa s t o m a in ta in a h ea lth y a n d p ro d u ctive la b o r fo rce.
In fa ct, th e ea rly d eca d es of th e Gesu n d h eitsw e-sen we re re st r ic t e d t o wo rke r s, t h e ir fa m ilie s b ein g exclu d ed fro m h ea lth -ca re b en efits.
Th e b a sic a t t it u d e o f givin g n o m o re t h a n lip se r vic e t o t h e la n gu a ge o f r igh t s in h e a lt h ca re m a tters h a s lea d to on ly ru d im en ta ry p u b lic h ea lth ca re fa cilities, co existin g with a h igh -ly so p h istica te d p riva te -tie re d m e d ica l syste m t h a t a b so r b s a m a jo r p o r t io n o f t h e re so u rce s in vested in h ea lth ca re.
A h e a lt h ca re sch e m e t h a t d e n ie s a cce ss t o th e p o o r a n d th a t rem a in s o b livio u s to th e fa ct t h a t ju st ic e in h e a lt h c a re re q u ire s ju st ic e in o th er a rea s to o, is n o th in g b u t a th eo retica l ex-e rcisex-e. A m o rex-e co m p lex-e x co n cex-e p t o f h ex-e a lt h ca rex-e ju stice in a co n text o f sca rcity n eed s to evo lve.
Justice in scarcity
Th is p ro p o sa l m a y a p p e a r a t first gla n ce t o re -ed it u n p op u la r a n d in efficien t socia liz-ed m -ed i-c in e si-c h e m e s, b u t in fa i-c t it d iffe r s fro m su i-c h ob solete con cep ts in a n u m b er of wa ys. First of a ll, it d o e s n o t lim it t h e e xt e n t o f m e d ica l covera ge, b u t d efin es th e p o p u la tio n th a t m a y a p -p ly. Th is m e a n s th a t th o se lia b le to b e a ffe cte d m u st receive fu ll covera ge, a n d n ot on ly p rim a -r y ca -re a s o ft e n h a p p e n s. Th e -re is n o co n vin c-in g e t h ica l a rgu m e n t t o co n ce d e t h e b a sics o f m e d ic a l se r vic e s b u t t o d e n y so p h ist ic a t e d su rge r y, e xp e n sive m e d ica t io n , o r o t h e r fo rm s o f h e a lt h c a re t h a t a re b e yo n d t h e fin a n c ia l rea ch o f th e n eed y.
Ju st ic e d e m a n d s t h a t m e d ic a l se r vic e s b e a va ila b le t o a ll wh o n e e d t h e m a n d a re u n a b le to p a y. In stea d o f p la cin g lim its o n th e a m o u n t o f m e d ica l e xp e n d it u re s, it is m o re im p o r t a n t t o d e fin e t h e p o p u la t io n t h a t will re q u ire fu ll s t a t e s u p p o r t , a n d t h o s e w h o m a y n e e d c a re o r su b sid ies fo r m o re co stly b u t n ecessa r y p ro -c e d u re s. St a t e - fin a n -c e d m e d i-c in e is e t h i-c a lly a c c e p t a b le o n ly if it c o ve r s a ll t h e re a l n e e d s o f t h e u n d e r p r ivile ge d a n d gu a r a n t e e s t h a t su ch su p p o rt will b e a va ila b le. In o th e r wo rd s, a r igh t t o h e a lt h ca re is a ckn owle d ge d a n d re -la te d to m e d ica l n e e d s a n d th e in a b ility to p a y for th em .
Ea ch society will d evelop its own gu id elin es con cern in g th e d egree a n d efficien cy it a ccep ts a s u n d e n ia b le. Su ch lim its will ch a n ge a cco rd -in g to th e system s’ solven cy a n d rea p p ra isa ls of th e b en efits o f th e trea tm en ts in q u estio n . Dis-crim in a tio n b a se d o n th e se ve rity o f d ise a se is a vo id ed , a n d trea tm en t is a llo tted a cco rd in g to efficien cy ra th er th a n co st. Ra tio n in g b eco m es a n exp licit, fa ir, a n d clin ica lly so u n d p ro ced u re (Mech a n ic, 1978).
Usin g so m ewh a t u n tid y rh eto ric, a n u m b er of a u th ors h a ve exp ressed th eir fea r th a t a righ t to m ed ica l ca re wo u ld b e o p en -en d ed , d evo u r-in g ever-r-in crea sr-in g a m ou n ts of resou rces, era s-in g t h e lim it s b e t we e n t h e n e c e ssa r y a n d t h e d e sira b le, o p e n in g th e d o o rs to fre e rid e rs a n d gen era lly tu rn in g a well-m ea n in g socia l service in to a fu zzy a n d u n co n tro lla b le free-fo r-a ll. All t h e se a re p ro c e d u ra l a rgu m e n t s wit h n o su b -st a n t ive fo rce t o a ffir m o r d e n y a r igh t . It m a y b e d iffic u lt t o m a ke a r igh t t o m e d ic a l c a re work in p ra ctice, b u t th a t is a q u estion of socia l a d m in ist ra t io n . Fu r t h e r m o re, t h e fin a n c ia l wo e s o f m e d ica l se r vice s a re la rge ly cre a te d b y th e h ea lth -ca re in d u stry a n d by p rofit-orien ted p rovid e rs, so it se e m s q u it e u n fa ir t o u n q u e s-t io n a b ly a cce p s-t s-t h e se p ra cs-t ice s a n d u se s-t h e m a s a rgu m en ts to im p in ge u p on th e righ ts of th e n eed y.
Public health and medical services
Est a b lish in g t h e p r io r it y o f se r vin g m e d ica l n eed s m ay go a lon g way to ju stify fiscal exp en -d itu re s in p u b lic h e a lth , b u t it -d o e s n o t su ffice t o d e fin e w h a ta ct u a lly co u n t s a s a ge n u in e m ed ica l n eed . Aga in , th is m a y d ep en d o n fin d -in g a d ef-in ition of h ealth / d isease th at will satisfy all p arties, b u t th ere is m u ch m ore in a d efin -ition th an m eets th e eye. Th e m ost p op u lar an d wid e ly u se d ch a ra ct e r iza t io n o f h e a lt h co m e s fro m t h e Wo rld He a lt h Orga n iza t io n ( WH O), b u t its scop e is so b road as to en com p ass social services th at go b eyon d m ed ical care. If m ed ical n eed s were to b e reco gn ized fo r a ll wh o a re n o t h e a lt h y a cco rd in g t o WH O st a n d a rd s, so cie t y wou ld h ave to p rovid e h ou sin g, ad eq u ate lab or, le isu re co n d it io n s, a n d m u ch m o re t o p rovid e ‘p h ysica l, so cia l, a n d m e n ta l we llb e in g’. Me d -ica l se r vice s wo u ld b e m e re ly o n e wa y o f d e a lin g wit h n e e d s wh ich sh o u ld re a lly b e co n sid -ered so cia l n eed s in su ch a va st scen a rio.
Th e p re ce d in g d iscu ssio n su gge sts th a t th e d e fin it io n o f m e d ic a l n e e d s d iffe r s n o t o n ly with p olitica l fa ctors b u t a lso with th e econ om -ic sta tu s o f a give n so cie ty. Afflu e n t co m m u n i-t ie s m a y n a r row i-t h e ir d e fin ii-t io n o f m e d ic a l
n e e d s t o sp e c ific c lin ic a l sit u a t io n s, wh e re a s t h e u n d e r p r ivile ge d will in c lu d e m a n y fu n c -tio n s wh ich a re n o t sp ecifica lly clin ica l b u t still im p in ge o n p h ysic a l d e ve lo p m e n t , fu n c t io n , a n d we llb e in g. Exp a n d in g m e d ica l n e e d s b e -yo n d st r ict ly d e fin e d d ise a se cr it e r ia h a s b e e n re sist e d b y m o st c o u n t r ie s, ove r lo o kin g t h a t th e origin s of p u b lic h ea lth lie in socia l en d ea v-o r s t v-o c v-o m b a t d ise a se t h rv-o u gh n v-o n - m e d ic a l m e a su re s, like se wa ge syst e m s, wa t e r su p p ly, a n d h ea lth in sp ecto rs.
It sh o u ld c o m e a s n o su r p r ise t h a t p o o r co u n trie s co n tin u e to re q u ire a va rie ty o f n o n -m e d ic a l -m e a su re s t o c ove r p h ysic a l n e e d s o r c o m b a t d e fic ie n c ie s. Co n se q u e n t ly, sp e c ific m e d ica l se r vice s m u st b e vie we d in a b ro a d e r se n se th a n a s a m e re ca ta lo gu e o f clin ica l co n -d it io n s t o o e xp e n sive o r t o o in fre q u e n t t o b e trea ted o n a p riva te b a sis.
Th e righ t to h ea lth ca re en su es from th e sit-u a tio n o f sit-u tter d estitsit-u tio n o f th e sick a n d p o o r. Th e re fo re, wh o e ve r is sic k a n d u n a b le t o p a y fo r m e d ic a l c a re h a s a r igh t fu l c la im t o st a t e -su p p o rt e d m e d icin e. Th is m e a n s d e fin in g d is-ea se (em p loyin g Bo o rse’s criteria , fo r exa m p le) a n d sp e cifyin g wh a t is u n d e rsto o d b y in a b ility to p a y: n ot b ein g a b le to d ivert m on ies towa rd s m e d ic a l se r vic e s wit h o u t le a vin g o t h e r b a sic n eed s like fo o d o r sh elter u n a tten d ed .
Socialized or two-tiered systems?
A t e n t a t ive co n clu sio n a t t h is p o in t is t h a t t h e p o o re r a c o u n t r y is t h e le ss it c a n a ffo rd t o lea ve clin ica l, b ro a d er h ea lth rela ted , a n d o th -er sim ila r so cia l n eed s in p riva te h a n d s.
Righ ts a n d socia l ob liga tion s certa in ly n eed to b e sp e cifie d . Wh o ca n m a ke a va lid cla im to m e d ic a l se r vic e s, a n d wh a t m e d ic a l se r vic e s m a y b e c la im e d ? Th e su b st a n t ive a sp e c t s o f t h e se q u e st io n s sh o u ld b e a d d re sse d b r ie fly, fo r th e p ro ced u ra l p a rt b elo n gs elsewh ere.
Th e righ t to m ed ical care for citizen s of soci-eties with scarce resou rces are h ard ly am en ab le t o o rd in a r y c r it ic ism . A r igh t e n su e s fo r a ll t h o se wh o su ffe r d ire n e e d s t h e y a re u n a b le t o m e e t a n d p rovid e d t h a t t h e re e xist s a le ve l ca -p a b le o f -p a llia tin g o r coverin g th ese n eed s. Bein g sick p re clu d e s t h e d e ve lo p m e n t o f st ra t e -gie s t o c ove r o t h e r n e e d s. Ph ysic a l we a kn e ss a n d su fferin g keep s th e a fflicted fro m wo rkin g, p u rch a sin g fo o d , ca r in g fo r h o u sin g n e e d s, o r p u rsu in g a n e d u ca t io n . Me d ica l n e e d s sh o u ld b e co n sid ered b a sic a n d o f th e h igh est p rio rity in o rd e r t o fo st e r t h e p u r su it o f o t h e r b a sic n eed s (Arra s, 1984).
Seco n d ly, if m ed icin e is tech n ica lly ca p a b le of treatin g d isease an d p u b lic fu n d s can fin an ce m ed ica l ca re, th ere rem a in s little rea so n to d e-n y th e p oor th eir legitim a te righ t to h ea lth ca re. Su ch a va st so cia l su p p o rt n etwo rk req u ires p re cise re cru it m e n t p o licie s a n d le a ve s a va ri-a b le p ro p o r t io n o f cit ize n s o u t o f t h e sch e m e, d e p e n d in g o n h ow so lid t h e co u n t r y’s e co n o -m y is. A fu n d a -m e n t a l d iffe re n c e in re ga rd t o s o c ia lize d m e d ic in e is t h e o ffic ia l t o le r a n c e o f a t w o - t ie re d s ys t e m , a p u b lic o n e fo r t h e n e e d y a n d a p r iva t e o n e fo r t h o se wh o ca n a f-ford it a n d wh o d o n ot q u a lify for sta te su p p ort. Twofold m ed ica l system s h a ve b een rejected by p u rists wh o b e lie ve th e y vio la te th e e sse n ce o f e q u a l a c c e ss, a n d t h a t su c h a n a r ra n ge m e n t wo u ld d ra in re so u rc e s a n d e xc e lle n t se r vic e s fro m t h e p u b lic t o t h e m o re re wa rd in g p r iva t e a rea . It h a s even b een a rgu ed th a t eq u a l a ccess t o h e a lt h ca re re q u ire s t h e p ro h ib it io n o f p r i-va te m e d icin e (Gu tm a n n , 1981; En ge lh a rd t Jr., 1997), a s if e q u a lit y m e a n t t h a t n o o n e ca n e a t a n yt h in g b u t p o t a t o st e w, in st e a d o f in sist in g t h a t e ve r yo n e sh o u ld a t le a st h a ve a c c e ss t o p o t a t o st e w b u t c a n we ll e n joy ro a st la m b if t h e y ca n a ffo rd it , p rovid e d n o b o d y is t h e re b y d ep rived of h is stew.
Ne ve r t h e le ss, t h e p r iva t e t ie r ca n n o t fu n c-t io n fro m a laissez fairea p p ro a ch , fo r t wo re a -so n s. Fir st , o p t in g o u t o f p u b lic sc h e m e s m e a n s u sin g a n d su p p o r t in g p ro fit - o r ie n t e d p riva te m ed ica l services th a t ten d to d ism a n tle
t h e p u b lic syst e m b y a t t ra ct in g p e rso n n e l a n d re so u rce s. Pr iva t e e n t re p re n e u r s a re p ro n e t o m ix t h e so p h ist ic a t e d wit h t h e su p e r flu o u s, t h u s o ffe r in g h e a lt h c a re t h a t is sp le n d o ro u s a n d e xp e n sive wit h o u t n e ce ssa r ily im p rovin g m e d ic a l c a re. Se c o n d ly, a s m e n t io n e d a b ove, th e p u b lic h e a lth co m p o n e n t o f m e d icin e is to a grea t exten t a m a n d a tory govern m en ta l fu n c-t io n c-t h a c-t b u rd e n s a n d b e n e fic-t s a ll a like. Eve n t h o u gh a ll cit ize n s p a rt a ke o f, sa y, h e a lt h e d u -c a t io n o r va -c -c in a t io n p ro gra m s, t h e y a re n o t p a yin g e q u a lly, fo r su c h c a m p a ign s a re fi-n a fi-n c e d b y t h e p u b lic h e a lt h syst e m t o t h e d e t r im e n t o f it s own cu ra t ive h e a lt h ca re p ro -gra m s, wh ile th e p riva te system th rives u n b u r-d en er-d b y su ch p u b lic exp en ses.
Bo t h t h e se re a so n s su gge st t h a t o p t in g o u t o f th e p u b lic system sh o u ld b e ta xed . Wh en eve r so m eve o n eve eve n teve rs a p riva teve m eve d ica l ca reve co n -t ra c -t , h e c o n -t in u e s -t o re c e ive p u b lic h e a l-t h b en efits. He is also b ein g in stru m en tal in d ra in -in g re so u rc e s t owa rd s t h e p r iva t e a re a wh e re h ea lth ca re p rovid ers a re th rivin g. Movin g in to t h e p r iva t e a re a sh o u ld b e t a xe d a c c o rd in gly, ju st a s sta yin g in th e p u b lic tier wh ile n ot q u a l-ifyin g a s n e e d y sh o u ld b e t a xe d t o a vo id fre e rid in g.
Conclusions
Presen ted h ere a re a n u m b er of a rgu m en ts th a t sh o u ld h e lp co n st r u e a co n ce p t o f h e a lt h ca re ju st ic e in so c ie t ie s wit h se ve re ly lim it e d re -so u rc e s. Fir st , t h e we ll- a c c e p t e d p ro t e c t ive fu n ct io n o f t h e st a t e m u st b e e xp a n d e d t o in -clu d e certa in b a sic welfa re services th a t a re b e-yon d th e b u yin g p ower of la rge segm en ts of th e p o p u la t io n . Se c o n d , m e d ic a l c a re m u st b e a p r io r it y a m o n g t h e se se r vic e s, fo r h e a lt h is a p re re q u isit e t o a llow a cce ss t o o t h e r b a sic se r-vices. Th ird , ju stice d em a n d s th a t m ed ica l cov-e ra gcov-e b cov-e cov-e xt cov-e n d cov-e d t o a ll t h o scov-e wh o ca n n o t a f-ford to p a y for it, a n d to th e exten t n ecessa ry to e ffe c t ive ly t re a t t h e ir d ise a se s. Th e r igh t t o h e a lt h c a re sh o u ld n o t b e lim it e d t o c e r t a in typ es of d isea ses or d ep en d on trea tm en t costs, b u t sh o u ld b e ta ilo re d a cco rd in g to th e d e gre e o f n e e d . Fo u r t h , su c h a h e a lt h c a re p ro gra m m a y b e e it h e r d ire ct ly p rovid e d b y t h e st a t e o r gu a ra n teed a n d con trolled th rou gh fisca l ch a n -n e ls. Fift h , t h e st a t e -su p p o r t e d r igh t t o h e a lt h ca re is p erfectly co m p a tib le with p riva te-tiered m e d ic a l sc h e m e s. Ma kin g u se o f t h e p r iva t e t ie r p u t s d ire c t o r in d ire c t t e n sio n o n p u b lic fu n d s a n d sh o u ld t h e re fo re b e c o m p e n sa t e d fo r th ro u gh a p p ro p ria te ta xa tio n .
Th e righ t t o h e a lt h ca re a n d t h e st a t e’s ro le in p rovid in g m ed ica l ser vices a re o ften b itterly o p p o sed , n o t so m u ch o n p rin cip le, b u t o n th e b a sis o f co n t in ge n t a n d e m p ir ica l a rgu m e n t s. Th is is fa lla cio u s, fo r a p o ssib le r igh t m u st b e a n c h o re d in t h e le git im a c y o f a c la im ra t h e r t h a n o n t h e a va ila b ilit y o f m a t e r ia l re so u rce s. Th e re is a lso n o p r in c ip le d a rgu m e n t a ga in st
t wo - t ie re d m e d ic a l syst e m s, wh ic h m a y b e con ceived in su ch a wa y th a t n o on e’s righ ts a re re st r ict e d , a t t h e sa m e t im e re q u ir in g t h e sys-tem to a llow a m a xim u m of in d ivid u a l freed om fo r a ll citizen s.
St a t e su p p o r t e d h e a lt h ca re h a s t ra d it io n -a lly b e e n b -a se d o n so lid -a r it y -a n d co n st r-a in e d b y t h e n e e d fo r ra t io n in g. Two -t ie re d sch e m e s a re cu rren tly b ein g d iscu ssed on a tria d of p rin cip le s: se lf re sp o n sib ilit y, so lid a r it y, a n d su b -sid ia rity (Sa ss, 1995). Th ere seem to b e n o eth i-ca l q u a lm s with su ch a d evelo p m en t, p rovid ed th a t th e “basic tier is u n iversally accessible an d is based on th e valu e of h u m an itarian solid ari-ty” ( Ter Meu len , 1995:607).
Th is is n o t t o d e n y t h e e n o r m o u s t e n sio n b etween a sta te-fu n d ed , eq u a lity-b a sed service a n d t h e va ga rie s o f fre e -m a rke t d yn a m ics, b u t th e effo rts o f Eu ro p ea n welfa re sta tes go a lo n g wa y to sh ow th a t two-tiered system s a re via b le. Fo r e c o n o m ic a lly we a k c o u n t r ie s, it is o f u t -m o st i-m p o r t a n c e t o a c c e p t a n d d e ve lo p su c h syst e m s, le st t h e m o re a fflu e n t a n d in flu e n t ia l d en y sta te-b a sed m ed ica l ca re for fea r of losin g t h e ir p r ivile ge s t o p u r su e p r iva t e m e d ic a l a t -ten tion .
Th e su b st a n t ive a sp e ct s o f e q u a l a cce ss t o m e d ica l ca re in d e stitu te so cie tie s a re fa r fro m ea sy to a gree u p o n a n d m u st b e tra n sla ted in to p ro ce d u re s th a t will n o t d isto rt th e u n d e rlyin g con cep ts. Good ru les a re n ecessa ry b u t n ot su fficie n t, a n d o n e d o e s we ll to re m e m b e r Fre e d -m a n’s (p e rso n a l co -m -m u n ica t io n ) a d -m o n it io n t h a t “Wh a t is n eed ed is a t h eory w h ich a t t h e lea st a llow s on e t o b e a good p erson w h ile en -gagin g as an actor w ith in a d istribu tive system.”
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