Just health care (II): Is equality too much?

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence [1]. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that these claims are really matters of justice proper, where justice is conceived along moderate egalitarian lines, such as those suggested by Rawls and Daniels, rather than strong egalitarian lines. Further, given the empirical complexity associated with the distribution of contemporary health care, I argue that what we really need to address the relevant policy issues adequately is a theory of health care justice, as opposed to an all-purpose conception of justice. Daniels has made an important start toward that goal, though there are some large policy areas which I discuss that his account of health care justice does not really speak to. Finally, practical matters of health care justice really need to be addressed in a ‘non-ideal’ mode, a framework in which philosophers have done little.     

In the world but not of it: managing the conflict between Christian and institution.

Christian physicians, nurses and other health care workers must manage a daily conflict of conscience between their Christian faith and predominantly secular health care institutions. This essay examines various efforts for managing these conflicts: a turn towards social justice or a seeking of holiness. Seeking social justice, however, is theologically empty. Traditionally, the Christian requirement that we be "in this world but not of it" requires a journey along a narrow path to holiness. Christian medical morality must, therefore, be understood within this light. However, just as there cannot be generic health care, but rather health care for a particular person's needs and problems there cannot be generic holiness, but only a holiness grounded in worshiping God rightly. In so worshiping the Christian will be assisted in negotiating the inescapable and perilous vocation of being in the world but not of it.     

A right to health care? Participatory politics,progressive policy,and the price of loose language

This article begins by clarifying and noting various limitations on the universal reach of the human right to health care under positive international law. It then argues that irrespective of the human right to health care established by positive international law, any system of positive international law capable of generating legal duties with prima facie moral force necessarily presupposes a universal moral human right to health care. But the language used in contemporary human rights documents or human rights advocacy is not a good guide to the content of this rather more modest universal moral human right to health care. The conclusion reached is that when addressing issues of justice as they inevitably arise with respect to health policy and health care, both within and between states, there is typically little to gain and much to risk by framing deliberation in terms of the human right to health care.     

论影响卫生资源分配公平性的因素

公平分配卫生资源是促进社会公正的重要方面.观念、体制与政策是影响卫生资源公平分配的重要因素.重医疗、轻预防的观念使宏观卫生资源分配失去公平,而城市尤其是大中城市优先的制度安排、按医疗项目付费方式的弊端、医疗保障体制的不公平等体制与政策因素则使微观卫生资源分配失去公平.从观念因素、体制与政策因素两个方面入手,改进卫生资源分配的公平性,是我国提高全民健康水平、促进社会公正的必由之路.     

Fair equality of opportunity and decent minimums: a reply to Buchanan

Responding to criticism by Allen Buchanan in a Winter 1984 Philosophy and Public Affairs article on "The right to a decent minimum of health care," Daniels defends his thesis that if justice requires protecting equality of opportunity, then health care institutions should be governed by the principle of fair equality of opportunity because impairments of normal functioning, seen as impediments to opportunity, are obviated by good health care. He defines his concept of normal opportunity range, which is relative to certain social considerations, and shows that health care services affect the distribution of opportunity, but not the normal opportunity range, among individuals. He agrees with the criticism that his argument does not guarantee minimum health care or solve problems of resource allocation.     

Justice, health, and healthcare

Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health and healthcare with an account of fair process for setting limits of rationing care. This account is provided by three conditions that comprise "accountability for reasonableness."     

Justice,Health, and Healthcare

Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health and healthcare with an account of fair process for setting limits or rationing care. This account is provided by three conditions that comprise "accountability for reasonableness."     

论丹尼尔斯医疗保健公正理论

诺曼·丹尼尔斯将罗尔斯的正义理论应用到医疗资源分配公正领域,他的理论认为医疗保健的道德重要性就在于它保护正常的功能从而保护机会,平等机会不仅提供医疗保健权利的基础,它也帮助我们确定这个权利的承诺限度。此外我们应该依靠公平的程序达到医疗保健公正的分配。     

Just health care (I): Is beneficence enough?

Few in our society believe that access to health care should be determined primarily by ability to pay. We believe instead that society has an obligation to assure access to adequate health care for all. This is the view explicitly endorsed in the President's Commission Report Securing Access to Health Care. But there is an important moral ambiguity here, for this obligation may be construed as being either beneficence-based or justice-based. A beneficience-based construal would yield a much weaker obligation with respect to the distribution of health care. In the first section of this paper I argue that the President's Commission is committed only to this weaker construal of this obligation. In the second section I argue that such a beneficence-based obligation is really rooted in a libertarian conception of justice, similar to that recently articulated by Engelhardt, and that this conception is seriously flawed when it comes to effecting a just distribution of health care.     

Health care and the prospective Pareto principle

Issues of social justice in access to health care are examined from the standpoint of the "prospective," or "ex ante," Pareto principle, an ethical principle which holds that one policy is to be preferred over another if it betters the prospects of some persons while the alternative betters no one's prospects. It is suggested that this principle may validate a form of utilitarianism in health policy decisions, with equity demanding that everyone have access to a decent minimum of care but not necessarily to all highly expensive treatments.     

西方国家医疗公正基本理论论析

西方国家医疗公正基本理论分为内容的公正和形式的公正。在内容公正方面西方国家有三种重要的医疗公正理论,它们是功利主义、极端自由主义、平等主义。它们对于西方国家制订医疗政策有很大影响。在形式公正方面,近来医疗程序公正理论影响很大。     

United States and Canadian approaches to justice in health care: A comparative analysis of health care systems and values

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and health care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms.     

The Space That Difference Makes: On Marginality,Social Justice and the Future of the Health Humanities

Feminist theorist and educator, bell hooks, asserts that to seek true liberation one must choose marginality. One must choose to occupy the space outside the binary between colonizer-colonized, hegemonic center-periphery, and us-them in order to create a location of possibility. This essay will reveal the practice of social justice as the navigation of the space that difference makes and argue that choosing marginality provides a framework for health humanities work towards social justice in health care. The space of the launderette that is depicted in Hanif Kureishi’s 1986 film, My Beautiful Laundrette, provides an example of choosing marginality and illustrates how difference structures both real and imagined spaces, which influences how individuals ultimately perceive one another. We will draw from the work of bell hooks; political geographer, Edward Soja; and Marxist philosopher, Henri Lefebvre, to demonstrate the importance of the health humanities’ position at the margin to traditional health care education.     

我国医疗卫生改革中的伦理缺席

“中国的医疗卫生体制改革从总体上说是不成功的”结论的发表在社会上引发了对卫生改革的种种议论,从卫生改革的设计、实施和评估三方面论述了由于政府的缺位和伦理学的缺席,将卫生改革引向功利主义的死胡同,使得卫生改革背离了公正的目标而导致失败。但退回计划经济体制下的办医模式同样没有出路,在今后的深化改革中,必须强调医学目的,贯彻以人为本的指导思想,加大政府的投入,围绕公正目标,建立覆盖全民的医疗保障体制。     

The Significance of the Concept of Disease for Justice in Health Care

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well.     

Inequalities in health, inequalities in health care: four generations of discussion about justice and cost-effectiveness analysis

The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed the philosophical landscape and encouraged some in bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice.     

Justice and Long-Term Care: A Theological Ethical Perspective

The relevance of justice for the current debate on long-termcare is explored on the basis of demographic and economic data,especially in the U.S. and Germany. There is a justice questionconcerning the quality and availability of long-term care fordifferent groups within society. Mapping the justice debateby discussing the two main opponents, John Rawls and RobertNozick, the article identifies fundamental assumptions in boththeories. An exploration of the biblical concept of the "optionfor the poor" and its influence on a new "ecumenical socialteaching from below" leads to the conclusion that a Christianethical account of long-term care will argue for a system thatguarantees decent care to every citizen. The German model ofSoziale Pflegeversicherung is presented as one possible optionfor putting this ethical guideline into political practice.In a final reflection, the role of religious affiliation forlong-term care is discussed by looking at empirical data andby naming seven dimensions of faith-driven long-term care.     

幽门螺杆菌cagA基因多态性对临床结局的影响:东亚菌株和西方菌株

CagA蛋白是幽门螺杆菌最重要的毒力因子之一.目前已证实cagA基因存在东亚及西方两种亚型.幽门螺杆菌产生CagA蛋白,注入胃上皮细胞后在其羧基端EPIYA重复序列区进行酪氨酸磷酸化,进而与SHP-2酪氨酸磷酸化酶相互作用,参与上皮细胞的信号传导,导致细胞骨架结构的重排,引起细胞表面形状的改变和细胞动力的增强,造成细胞异常的增殖和运动,在胃癌的发生中起了主要作用.cagA基因的羧基端EPIYA重复序列被认为是区分东亚型和西方型菌株的分子标记,东亚型CagA与SHP-2亲和力大于西方型,最终影响着不同CagA+菌株感染的临床表现.     

The Right to Health Care as a Right to Basic Human Functional Capabilities

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in jeopardy of falling beneath the threshold has a legitimate claim to justice. People’s entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold).     

Contemporary justice research: A new look at familiar questions

Research on organizational justice has flourished in the last 30 years. During that time, researchers have generally sought to answer three questions: (1) Why do people care about justice? (2) What affects justice judgments? and (3) What outcomes are associated with justice judgments? The papers in this special issue of Organizational Behavior and Human Decision Processes on organizational justice reflect how these three questions are explored in contemporary justice research. This introduction to the special issue considers how the papers represent trends and developments in current justice research. Several themes are identified: the role of justice in a broader model of group engagement, the empirical examination of justice as a moral virtue, the effect of social context on justice judgments, and the darker reactions to injustice. Thus, the special issue provides insight not only to familiar justice questions but also to the evolution of the field and its future direction.