SYLLABUS: JUSTICE AND HEALTH CARE (Phil. 3650)
Fall 2014
Professor John D. Arras
Nick Frank (Graduate Assistant)
OFFICE HOURS: Regular office hours with John Arras will be held in Room 5367 in
Barringer Wing (Medical School) from 1:30-3:00 PM on Tuesdays and 11:30-1:00
PM on Thursdays. Alternative hours available by appointment. Drop-ins are usually
welcome. Office phone: 924-7863; home phone: 970-1712.
The Graduate Assistant/Reader for this course is Philosophy graduate student, Nick Frank
< npf2nz@virginia.edu>. Office hours TBA.
REQUIRED TEXTS:
Reading Packet (available at N.K. Print & Design located at 7 Elliewood Avenue (where
Brillig Books used to be). 434-296-9669
COURSE OBJECTIVES: This course is designed to provide an account of health care
institutions and practices viewed from the perspective of justice. Roughly the first half of
the course inquires into the nature, justifications, and limits of the (purported) right to
health care; the second half examines the value conflicts posed by the demands of cost
containment and explicit rationing.
In addition to the above objectives, the course aims to:
•
Show the ways in which health care institutions and practices (e.g., the use of
"hidden" forms of rationing in Medicare) and various cost-containment tools (e.g.,
cost-benefit and cost-effectiveness analysis) are amenable not merely to the usual
economic and political forms of evaluation, but also to a searching inquiry into
their compatibility with justice, fairness, and democratic ideals.
•
Expose the partial truth and partial inadequacy of commonly encountered and
highly influential slogans bearing on the "pricelessness of life," the "right to health
care," and, of course, “death panels.”
•
Articulate some major contemporary theories of justice (e.g., libertarianism,
utilitarianism, Rawlsian contractarianism, communitarianism, etc. and chart their
implications for a right to health care and health care reform.
•
Examine the scope and limits of the usefulness of ethical theory in assessing the
highly complex, non-ideal, messy world of health care. Where does philosophy
leave off and democratic decision making begin?
•
Better equip students in their role as citizens to intelligently and critically assess
proposals to fix the perennial health care "crisis" in the US, such as the Obama
Healthcare Plan.
COURSE REQUIREMENTS: All students are required to attend class regularly and to
keep up with assigned reading. Since the quality of the course depends in large measure
on the quality of our discussions, it is crucial that students come prepared.
There will be two examinations and two papers. The exams will be given at mid-term
and finals. They will each consist of 2 in-class, closed-book essays selected from a set of
4 questions that will be distributed a week before each exam. The first paper will be due
roughly one month into the course. This will be a relatively short paper (4-5 pages) that
will stress analytical skills and give students a good warm-up exercise for the term paper.
The term paper should consist (ideally) of a closely reasoned, well-researched
philosophical argument on a (relevant) topic of your choice. Length should fall between
10 and 15 pages. An information sheet on the paper will be distributed separately; an
optional evening session on paper writing will be provided. Both JDA and Gwen Nally
stand ready to help you develop and write your papers. Make good use of this resource
by contacting us early and often.
GRADING: The midterm is worth 20% and the final exam is worth 30% of your final
grade. The first paper will count for 10% of the final grade, while the term paper will be
worth roughly 40%; late papers will be penalized. Preparation for class and participation
in class discussions can positively affect your grade.
FINAL EXAM DATE: Tuesday, December 9, 2-4:15 PM. Please schedule your
holiday travel accordingly! (Note, however, that both of our exams may be taken from
anywhere on a computer.)
HONOR POLICY:
I trust every student in this course to fully comply with all of the provisions of the UVa
Honor System. By enrolling in this course, you have agreed to abide by and uphold the
Honor System of the University of Virginia, as well as the following policies specific to
this course.
 All graded assignments must be pledged
 You may not access any notes, study outlines, problem sets, old exams, answer
keys, or collaborate with other students without my explicit permission
 When given permission to collaborate with others, do not copy answers from
another student
 Always cite any resources or individuals you consult to complete an assignment
 Violations may be forwarded to the Honor Committee and, at my discretion, you
may receive an “F” on a particular assignment or for the entire course, regardless
of any action taken by the Honor Committee.
If you believe you may have committed an Honor Offense, you may wish to file a
Conscientious Retraction (“CR”) by calling the Honor Offices at (434) 924-7602. For
your retraction to be considered valid, it must, among other things, be filed with the
Honor Committee before you are aware that the Act in question has come under suspicion
by anyone. More information can be found at www.virginia.edu/honor.
Phil 3650 READING ASSIGNMENTS:
All of the readings listed below, except for one or two, can be found in this reading
packet and/or on Collab.
I.
Theories of justice and their relevance to access to health care
A.
The uninsured as a moral problem
“Rural Medical Camp Tackles Health Care Gaps” (Collab)
J. Cohn, Sick, ch. 1
D. Amsden, “The Young Invincibles” (Collab)
Consumer Reports, “Second Class Medicine”
Chesleigh, “Uninsured, Unwanted, Unworthy?”
B.
The Concept of a Right to Health Care
Wenar, "Rights" (Stanford Encyclopedia of Philosophy, SEP,
http://plato.stanford.edu/entries/rights/. PDF available on Collab.
Buchanan, “The Right to a Decent Minimum of Health Care,” 55-59
"Resolved: Americans have a fundamental right to health care,” Miller
Center Debate (Collab)
C.
Utilitarianism
Goodin, “Utilitarianism as a Public Philosophy”
Rawls, “Utilitarianism and the Distinction Between Persons”
Daugherty, “Utilitarianism and Health Care”
D.
Libertarianism
Sade, “Foundational Ethics of the Health Care System: The Moral and
Practical Superiority of Free Market Reforms”
Lomasky, "Medical Progress and National Health Care"
E.
Liberal Equality
Nussbaum, “The Enduring Significance of John Rawls” (Collab)
Daniels, Just Health, pp. 29-63.
Allen, “Growth Hormone Therapy for the Disability of Short Stature”
Daniels, “The Genome project, Individual differences, and Just Health
Care”
F.
Communitarianism
Stone, “The Struggle for the Soul of Health Insurance” 288-294.
Walzer, from Spheres of Justice
Andre, “Blocked Exchanges”
Menzel, “The Realistic Moral Right to a Basic Minimum of Accessible
Health Care” pp. 1-12
G.
Wrapping Up: The Importance and Limits of Rights Talk Regarding
Access to Health Care
Brody, "Why the Right to Health Care is Not a Useful Concept for Policy
Debates"
Arras, “The Right to Health Care”
II.
From Just Health Care to Just Health
“Unnatural Causes: Is Inequality Making Us Sick?” (Video on reserve)
Scott, “Life at the Top in America Isn't Just Better, It's Longer” (NYT)
Starfield, “Is US Health Really the Best in the World?”
Wilkinson and Marmot, "The Social Determinants of Health: The Solid Facts"
Daniels, et al., "Justice is Good for Our Health"
Sreenivasan, “Opportunity is Not the Key”
III.
The Ethics of Allocation and Rationing Health Care
A.
Case studies in health care irrationality and rationing
1.
High tech diagnostics
Berenson and Abelson, “Weighing the Cost of a CT Scan’s Look
Inside the Heart” (NYT)
B.
2.
High Cost, Last-Chance Therapies
London, “Bone Marrow Transplants for Advanced Breast Cancer:
the Story of Christine DeMeurers”
Kolata and Pollack, “The Evidence Gap: Costly Cancer Drug
Offers Hope, but Also a Dilemma”
Millman, “How do you pay for a drug that costs $84,000?” Wash
Post, July 15, 2014.
3.
Is Rationing Necessary? Is It Ethical?
Nat Hentoff, “Health Care Rationing Obama Believes In”
Peter Ubel, “What is Rationing and Why is it Necessary?” (Collab)
The Rationer’s Toolkit: Theories, principles, and procedures
1.
Utilitarian Cost Effectiveness Analysis
Gardiner Harris, “British Balance Benefit vs. Cost of Latest
Drugs”
Eddy, “The Individual vs. Society: Resolving the Conflict”
Peter Singer, “Why We Must Ration Health Care”
Paul Menzel, "Allocation of Scarce Resources." (Begin reading at
p. 309 in original.)
C.
IV.
2.
Rationing by Patient Choice (both hypothetical and actual)
Dworkin, “Justice and the High Cost of Health”
Menzel, “The Realistic Moral Right to a Basic Minimum of
Accessible Health Care,” pp. 12-27
Robert Steinbrook, “Imposing Personal Responsibility for Health”
A.W. Cappelen and O.F. Norheim, “Responsibility in Health Care:
A Liberal Egalitarian Approach”
3.
Fair Procedures in Rationing Health Care
Daniels and Sabin, “Last Chance Therapies and Managed Care:
Pluralism, Fair Procedures, and Legitimacy”
Sabik and Lie, “Principles versus procedures in making health
care coverage decisions: addressing inevitable conflicts”
Microallocation of Health Care
Brock, “Pandemic Flu: Scenarios for Planning and Teaching” (Powerpoint
display on Collab)
Arras, “Rationing Vaccine During an Avian Influenza Epidemic: Why It
Won’t Be Easy”
Persad, Werheimer, Emanuel, “Principles for allocation of scarce medical
interventions”
Health Care Reform, the Affordable Care Act, and the Constitution
Patient Protection and Affordable Care Act (2010): Detailed Summary (Collab)
Dworkin, “A Bigger Victory Than We Knew”
Hall, “The Affordable Care Act Survives, for Now”
Jost, “A Mutual Aid Society?”
Nichols, “Justice Roberts’s Health Care Stewardship”
Menzel, “Saved from Themselves”
Pauly, “Lessons to Improve the Efficiency and Equity of Health Reform”
Taylor, “The Carelessness of Affordable Care”
Sade, “Foundational Ethics of the Health Care System,” Sec. VII & Conclusion:
Designing an ideal health care system” 488-492)
Sage, “How Many Justices Does It Take to Change the U.S. Health System?”