Principle of JUSTICE

I. Notion (concept) of Justice II. Theories of Justice in Health Policy III. Allocation of Health Care Resources

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I. Notion (concept) of Justice

Fairness, desert (what is deserved), entitlement Interpretation of Justice: fair, equitable, appropriate treatment according to what is due or owed to persons Standards of justice: needed to claim rights (benefits) or burdens Injustice: wrongful act / omission involved that denies rightful benefits to people and distributes burdens unfairly
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TYPES OF JUSTICE
DISTRIBUTIVE Fair, equitable, appropriate distribution of all rights & responsibilities in society including civil and political rights CRIMINAL JUSTICE JUST infliction of punishment RECTIFICATORY JUST compensation for transactional problems ( malpractice, breach of contract)
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FORMAL vs MATERIAL: Distributive Justice

FORMAL Equals must be treated equally, and unequals be treated unequally Aristotle Problem: it does not identify in what particular respect equals are equal and ought to be treated equally. It presumes that all citizens are equal: equal political rights, access to public service, equal treatment under the law
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FORMAL vs MATERIAL: Distributive Justice

FORMAL Justice in health care hold that: Delivery programs and services are designed to assist persons of a certain class( the poor, the elderly), should be made available to all members of that class. To deny benefits to some when others in the same class receive benefit is unjust But it is also unjust to deny access to equally needy persons outside of that particular class ( workers without health insurance)

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FORMAL vs MATERIAL: Distributive Justice

MATERIAL Specifies and identifies the relevant characteristic for equal treatment Principle of Need: to each person according to need - distribution of social resources based on need is just. - only the fundamental needs ( a person will be harmed or detrimentally affected in a fundamental way if that need is not fulfilled) - Harms: malnutrition, bodily injury, nondisclosure of critical information

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FORMAL vs MATERIAL: Distributive Justice

MATERIAL Characteristic for equal treatment: To each person an equal share To each person according to effort To each person according to contribution To each person according to merit To each person according to freemarket exchanges
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Application of material principles of distributive justice

NEED Unemployment subsidies, Welfare payments, health care programs

MERIT and Awarding of Jobs and ACHIEVEMENT promotions Grounds for Higher income Free market, Superior effort, which are allowed and Merit, potential encouraged Contribution
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What happens when one tries to apply the material principles of distributive justice in society?

It creates conflicts among the principles with serious priority problems when everyone claims as equals It challenges the Moral system that aims for a coherent framework It requires of society to specify and balance these principles or they become unresolvable
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Case 1:
Mark Dalton was a histology technician employed in a large chemical firm. He was diagnosed to have chronic renal disease which may have arisen from exposure to chemicals and further exposure to it would aggravate his problem. He was an excellent worker so management found him another job with the same salary level. However 2 other employees eligible for promotion were also interested in the job. Both had more seniority and better training than Dalton and one was a woman.
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Legitimate appeal of each:

Material principle of NEED: His medical condition required that he DALTON be offered the new position or be dismissed from the company with compensation Material principles of MERIT, Employee 1 SOCIETAL CONTRIBUTION, Individual effort Man Material principles of MERIT, Employee 2 SOCIETAL CONTRIBUTION, Individual effort Woman EQUAL OPPORTUNITY, Past record USLS Col Med Bioethics 11 of promotions 2

Possible solutions
Tradition, convention, moral and legal principles, public policy can function to establish relevant properties Tradition: award due to achievement (tennis) Moral & legal: prison terms if found guilty Institute policies where non exists Develop new policies that revises established criteria
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II. THEORIES OF JUSTICE in health policy

UTILITARIAN Jeremy Bentham - proposed a way to measure consequences ( impact of decisions on the wellbeing of all affected individuals) - the greatest happiness to the greatest number - Utility measure of wellbeing
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II. THEORIES OF JUSTICE in health policy

UTILITARIAN - emphasizes maximizing public utility/ overall good for the most number of people - It favors social programs that protect public health and distribution of basic health care to ALL its citizen - Based on the RIGHT TO HEALTH - Problem: it neglects how benefits and burdens are to be distributed independently of aggregate welfare ( like the sickest, and most vulnerable: disabilities) who require more
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THEORIES OF JUSTICE in health policy

LIBERTARIAN
Immanuel Kant - Imperative: Human beings ought to be treated with respect, as ends in themselves, not as means to another individuals ends - the basis for such respect is each human beings potential capacity for moral action; for acting on the basis of impartial rules derived from reason - Having the capacity to decide how they should live their lives (life plans), they have a right to do so - this right is derived from each individuals status as a human being and all political systems are obliged to honor them
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THEORIES OF JUSTICE in health policy

LIBERTARIAN - It adheres to a free market health care which operates on the ability to pay either directly or indirectly through insurance - people who require more have to pay more - a just society protects property & liberty by allowing persons to improve their circumstances and protect their health on their own initiative and the state cannot coercively by taking ones property to benefit another (taxation for the rich) - HEALTH IS NOT A RIGHT
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THEORIES OF JUSTICE in health policy

LIBERTARIAN - focus: unfettered operation of fair procedure and not on maximizing public utility or meeting the health needs of its citizens -Any distribution of goods including health care is justified if and only if individuals in the relevant groups freely choose it
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THEORIES OF JUSTICE in health policy

LIBERTARIAN - Robert Nozick: Entitlement Theory
Justice should affirm individual rights to create and maintain wealth acquired under free market. Governments act coercively and unjustly when they tax the wealthy at a progressively higher rate than those who are less wealthy, and then use the proceeds to underwrite state support of the indigent through welfare payments and unemployment compensation There are no welfare rights and therefore no rights or claims to health care can be based on justice
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THEORIES OF JUSTICE in health policy

EGALITARIAN John Rawls (1993)Theories of Justice
Social and economic inequalities are to satisfy 2 conditioins: - Each member of society irrespective of wealth or position have equal access to adequate ( although not maximum level) health care - When all persons have equal opportunity to access health care, the neediest get priority
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THEORIES OF JUSTICE in health policy

EGALITARIAN - persons should receive an equal distribution of goods like health care but equal sharing of possible social benefits not required - BASIC EQUALITIES among individuals and PERMITS INEQUALITIES that benefit the neediest
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THEORIES OF JUSTICE in health policy

EGALITARIAN Norman Daniels - To allow each person to achieve a fair share of the normal

range of opportunities present in that society reflective of the persons reasonable hope to pursue life plans according to his skills and talents - Society has the obligation to eliminate or reduce barriers that prevent fair equal opportunity which includes programs to to correct and compensate for disadvantages. - Disease and disability are restriction to those opportunities therefore health care is needed to ACHIEVE, MAINTAIN & RESTORE levels of functioning - The health care system designed should attempt to prevent disease, illness or injury or compensate for reductions
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THEORIES OF JUSTICE in health policy

EGALITARIAN Amartya Sen - Health is not a prerequisite for, but rather the result of choice - the state should make health care a little above the minimum available to all and leave it up to each individual the decisions about personal behavior and the use of care that determines health status - the aim is to maximize the set of capabilities available to each individual, the level of functioning is their choice - education focusing on ill effects of smoking is appropriate provided the choice to use or not is left to the individual
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THEORIES OF JUSTICE in health policy

COMMUNITARIAN - Justice is pluralistic - what is due individuals & groups depends on community derived standards - Emphasis: responsibility of the community to the individual; in contemporary policy- the responsibility of the individual to the community - Health is a component of every citizens opportunity like free speech and voting
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THEORIES OF JUSTICE in health policy

COMMUNITARIAN Language: SOLIDARITY - personal virtue of commitment - Social morality of shared values of a group (Netherlands: collective obligation to take care of its citizens especially the elderly, disabled & mentally ill) - Ezekiel Emmanuel: Citizen members in Community health programs vote which benefits to provide, which care is important, whether expensive services like heart transplants should be included/ excluded ( State of Oregon) - Justice: assurance services will be provided
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THEORIES OF JUSTICE in health policy

COMMUNITARIAN Michael Walzer - while community traditions and practices include EQUAL ACCESS to health care, one can opt out and be free to choose a different vision - 2 tiered: decent minimum for all : Free market for those who can afford
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III. ALLOCATION OF HEALTH CARE RESOURCES

Questions about whom shall receive what share of societys scare resources generate controversies in: - creating a national health policy - unequal distribution of advantages to the disadvantaged - rationing health care - notion of the RIGHT TO HEALTH - insurance:ultimately the primary economic barrier is inadequate insurance
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ALLOCATION OF HEALTH CARE RESOURCES

The problem with the RIGHT to HEALTH care is how to specify the precise entitlements and limits to that right - EQUAL ACCESS? - RIGHT TO DECENT MINIMUM? The problem of health inequalities does exist
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ALLOCATION OF HEALTH CARE RESOURCES

Macroallocation -What kinds of health care services to provide? - Who will deliver them? - How will the burdens of financing be distributed? - How will the power and control of those services be distributed? Microallocation - Who will receive particular scarce resources and on what basis
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Macroallocation: Triage ( Rationing)

Allowance, share, portion Recently: linked to limited resources, crisis management, priority setting 3 primary meanings: 1. Market limits- rationed by ability to pay 2. Social policy limits govt determines an allowance and individuals are denied access beyond the allotted amount 3. Allottment / allowance is determined and distributed equitably, but those who can afford additional goods are not denied access beyond the allotted portion
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Triage ( Rationing)
People believe that macroallocation is about priority setting in the health care system Health care costs have risen due to - good insurance - new technology - longer life expectancy in the aging population Issues - allocation by excluding expensive treatment - setting priorities ( Oregon health) - rationing by excluding a particular age group
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A. Rationing by excluding expensive technology

Assessing health technology when introduced to community Parameters 1. Reducing burden of disease 2. Improve quality of life 3. Reduce mortality

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B. Strategies for setting priorities in Public Health care

1. Health benefits are measured in terms of anticipated health gains and costs are measured in expenditure of resources - Cost effective analysis ( CEA) - Cost utility analysis ( CUA) - Impact of intervention to length and quality of life (QALY) - Time trade off ( TTO) - Standard Gamble ( Yes/ No tree) - Health Unit Index ( HUI) - VAS Utilitarian goal: the greatest health benefit for money expended Discriminates against infants, elderly, disabled
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B. Strategies for setting priorities in Health care

2. Publicly accessible decision making ( and justification), backup processes of review and appeal ( Norman Daniels) Problem: majority preferences even if well informed will result in unjust outcomes

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B. Strategies for setting priorities in Health care

3. Cost value analysis Citizen preferences concerned with personal benefit, QOL, Quantity ( how much service he can get) Problems - assessing validity

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C. Age - based Rationing

May involve positive entitlements senior citizen policy, May involve exclusion based on age ( or lower priority ( kidney transplants) based on the ff: - success of treatment (medical utility) - survival ( QALY) - assigning higher unit index for younger patients to get higher priority Fair innings Youngest are given preference to reduce harms
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C. Age - based Rationing

Communitarian ( Daniel Callahan) - Society should help the elderly live out a full and natural life span in which their lifes possibilities have been achieved and death becomes a relatively acceptable event - we should seek to relieve them of suffering rather than extend life - we should provide long term care & support as a basic minimum PROBLEM: they get blamed for higher health costs
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Microallocation: Rationing of scarce treatment to patients

2 Approaches Utilitarian strategy social efficiency and maximal benefit Egalitarian strategy equal worth of persons and fair opportunity Standards for selection Pool of recipients Final selection
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Microallocation: Rationing of scarce treatment to patients

Screening potential recipients 1. Social factors: Contituency (citizenship), capacity to pay 2. Progress of science: participation in research 3. Medical factors: Prospect of success, equity of age,

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Microallocation: Rationing of scarce treatment to patients

Countries with highly developed systems of organ allocation like Europe (EUROTRANSPLANT) & the US (UNOS) place all patients in a waiting list and patient specific organ allocation is based on: 1. Medical criteria: compatibility 2. Medical fairness: urgency of sickest first, waiting period, equal opportunity without discrimination 3. Medical usefulness (outcome): survival rate of patient/ organ, QOL age, cost benefit relationship of transplant 4. Willingness to donate Bioethics 2 USLS Col Med 39

Microallocation: Rationing of scarce treatment to patients

The various criteria are converted to points and calculated with the help of a computer algorithm. Advantages of the point system: 1. It can take into consideration an array of criteria & ethically evaluate them using the different ethical principles 2. It eliminates favoritism ( requests for special consideration from physicians) 3. It is deemed fair and independent by patients, families and physicians
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Essay
Comment on your present health care system and how best to allocate health care /resources for health care What standard / s of justice would best serve your ideal system If you were a policy maker, how would you allocate kidneys for transplant
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