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Ethical Principle of Justice • principle of justice – involves giving to all persons their "rights" or "desserts" – the distribution of various resources in society often is governed by different philosophies: • • • • • to each according to their need, to each according to their merit, to each according to their worth/contribution to society to each an equal share to each according to their effort Distributive justice • Society uses various rules and principles (moral, legal, and ethical) to decide how to distribute in a just manner its benefits and burdens – process is called ‘distributive justice’ • distributive justice becomes an important issue when a resource is limited and when there is competition for it Justice • Justice – appropriate ethical framework from which to approach rationing decisions • equals should be treated equally and unequals treated unequally - Aristotle's formal Principle of Justice • implies the fair distribution of goods in society – justice in health care is usually defined as a form of fairness – logical opposite of justice is discrimination Material principles of distributive justice Material principles specify relevant criteria of equality • to each person an equal share • to each person according to individual need • to each person according to individual effort • to each person according to societal contribution • to each person according to merit • to each person according to free market exchanges – Beauchamp and Childress 2001- ‘ Theories of Distributive Justice • Egalitarian (deontological) – everyone should be treated the same • Utilitarian – what produces the most benefit for society as a whole • Libertarian – emphasize rights to social and economic liberty (invoking fair procedures rather than substantive outcomes) • Communitarian – stresses principles and practices of justice that evolve through tradition in a community • Rawls’s theory of justice – fair opportunity/fairness Rawls’s theory of "justice as fairness" • John Rawls – claimed that people are to be treated equally unless there are relevant differences among them or unless an unequal distribution would be to everyone's advantage – Rawls’ idea that a society is just or fair if and only if it is governed by principles that reasonable people would agree to if they knew nothing about their own place in society at the time of drawing up the agreement (original position) – any principles chosen in the original position (from behind the veil of ignorance) would be justified, and so any state that ran according to those principles would be justified Rawl’s Two Principles • two principles to govern the basic structure of society: – FIRST PRINCIPLE: each person has an equal right to a fully adequate scheme of equal basic liberties which is compatible with a similar scheme of liberties for all – SECOND PRINCIPLE: Social and economic principles are to satisfy two conditions: • first, they must be attached to offices and positions open to all under conditions of fair equality of opportunity (the opportunity principle); and • second, they must be to the greatest benefit of the least advantaged members of society (the difference principle). Healthcare resources • the claim to health care – health care as a right ? – health care based on justice according to need (fairness) • what is meant by healthy? – e.g. infertility treatment • inequalities of health care – age; learning disability;social class; women; access to certain treatments; rare disorders Healthcare resources issues • Risky lifestyle/detrimental behaviour by the individuals: – – – – – – – – sky-divers/high risk sports smokers alcohol-related problems drug addicts coronary artery disease obesity drug addiction sexually transmitted diseases (STD), HIV • Genetic disorders – genetic testing Allocation of health care resources • priorities for the allocation of resources for and in healthcare:. – macro-allocation • determine how much should be expended and what goods will be made available to a society; decisions at governmental level – meso-allocation • purchase plans - trusts – micro-allocation • rationing or triage • decisions determine who will receive the available resources Scarce medical resources • Ethical question is: "Who should be treated when not all can be treated?" Scarce medical resources • Selecting recipients of scarce resources: • moral principle of medical utility – use resources carefully to maximise the number of lives saved: i.e. given first to those whose chance of survival with them is very high but whose chance of survival without them is very low • chance/lottery – impersonal justified by equality and fair opportunity • first come, first served • random choice • weighing the lives in question • moral principle of social utility – social value of potential recipients • triage Economics of Health Care • Continually increasing health care costs: – inflation based on overall increase in • • • • • population increase ageing population increase demand for healthcare new technologies, new procedures personnel and other resources Some questions • How much of society’s wealth should be spent on health care ? • How should the health care funds be allocated • prevention vs. treatment • What categories of disease should have priority, • HIV or cancer? • infertility treatment • cosmetic surgery • Within each disease category, which technology or procedure should be funded? • transplants • How far can/should doctors be advocates for their patients and ignore the public and societal implications of their decisions?