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:
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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:
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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
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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?