Health Care Needs and Distributive Justice

  • Norman Daniels
Part of the The Hastings Center Series in Ethics book series (HCSE)


A theory of health care needs should serve two central purposes. First, it should illuminate the sense in which we—at least many of us—think health care is “special” and that it should be treated differently from other social goods. Specifically, even in societies in which poeple tolerate (and glorify) significant and pervasive inequalities in the distribution of most social goods, many feel there are special reasons of justice for distributing health care more equally. Some societies even have institutions for doing so. To be sure, others argue it is perverse to single out health care in this way, or that if we have reasons for doing so, they are rooted in charity, not justice. In any case, a theory of health care needs should show their connection to other central notions in an acceptable theory of justice. It should help us see what kind of social good health care is by properly relating it to social goods whose importance is similar and for which we may have a clearer grasp of appropriate distributive principles.


Distributive Justice Fair Share Health Care Institution Social Good Primary Good 
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  1. 2.
    I paraphrase Charles Fried, Right and Wrong (Cambridge, Mass.: Harvard University Press, 1978), pp. 126ff. See my comments on Frieds proposal in “Rights to Health Care: Programmatic Worries,” Journal of Medicine and Philosophy, IV (June, 1979), 174–91. I ignore here an issue of paternalism that Fried may have wanted to pursue but which is better raised when fair shares are clearly large enough to purchase a reasonable insurance package. Should the premium be compulsory?Google Scholar
  2. 4.
    Arrow’s classic paper traces the anomalies of the medical market to the uncertainties in it. My analysis has a bearing on the further moral issue of whether health care ought to be marketed in an ideal market. Cf. Kenneth Arrow, “Uncertainty and the Welfare Economics of Medical Care,” American Economic Review, LIII (1963), 941–73.Google Scholar
  3. 5.
    The presence of people with preferences for more-than-reasonable coverage may result in inflationary pressures on the premium for “reasonable” insurance packages. Therefore interference in the market is likely to be necessary to protect the adequacy of fair shares.Google Scholar
  4. 6.
    For emphasis, we often refer to things we simply desire or want as things we need. Sometimes we invoke a distinction between noun and verb uses of the word need so that not everything we say we need counts as a need. Any distinction we might draw between noun and verb uses depends on our purposes and the context and would still have to be explained by the kind of analysis I undertake above.Google Scholar
  5. 7.
    T. M. Scanlon, “Preference and Urgency,” Journal of Philosophy, LXXVII (November, 1975), 655–69.CrossRefGoogle Scholar
  6. 8.
    The difference might not be in the extent but in the content of the scale. An objective full-range satisfaction scale might be constructed so that some categories of key preferences are lexically primary to others; preferences not included on a truncated scale never enter the full-range scale except to break ties among those equally well off on key preferences. Such a scale may avoid my worries, but it needs a rationale for its ranking. The objection raised here to full-range satisfaction measures applies, I believe, with equal force to happiness or enjoyment measures of the sort Richard Bradt defends in A Theory of the Good and the Right (Oxford, England: Oxford University Press, 1979), chap. 14.Google Scholar
  7. 9.
    Scanlon, “Preference and Urgency,’’ p. 660.Google Scholar
  8. 10.
    David Braybrooke, “Let Needs Diminish That Preferences May Prosper,” in Studies in Moral Philosophy, American Philosophical Quarterly Monograph Series, No. 1 (Oxford, England: Blackwells, 1968), p. 90 (my emphasis). Personal medical services do not count as course-of-life needs on the criterion that we need them all through our lives or at certain (developmental) stages, but they do count as course-of-life needs in that deficiency with respect to them may endanger normal functioning.Google Scholar
  9. 11.
    McCloskey, unlike Braybrooke, is committed to distinguishing a narrower noun use of need from the verb use. See H. J. McCloskey, “Human Needs, Rights, and Political Values,” American Philosophical Quarterly, XIII (January, 1976), 2f. (my emphasis). McCloskey’s proposal is less clear to me than Braybrooke’s; presumably our natures include species-typical functioning but something more as well. Moreover, McCloskey is more insistent than Braybrooke on leaving room for individual natures, though Braybrooke at least leaves room for something like this when he refers to the needs that we may have by virtue of individual temperament. The hard problem that faces McCloskey is distinguishing between things we need to develop our individual natures and things we come to need in the process of what he calls “self-making,” the carrying out of projects one chooses, perhaps in accordance with one’s nature but not just be way of developing it.Google Scholar
  10. 12a.
    The account here draws on a fine series of articles by Christopher Boorse; see “On the Distinction Between Disease and Illness,” Philosophy and Public Affairs, V (Fall, 1975) 49–68; “What a Theory of Mental Health Should Be,” Journal of the Theory of Social Behavior, VI, no. 1, 61–84; “Health as a Theoretical Concept,” Philosophy of Science, XL (1977), 542–73.Google Scholar
  11. 12b.
    See also Ruth Macklin, “Mental Health and Mental Illness: Some Problems of Definition and Concept Formation,” Philosophy of Science, XXXIX (September, 1972), 341–65.CrossRefGoogle Scholar
  12. 13.
    Boorse, “What a Theory of Mental Health Should Be,” p. 77.Google Scholar
  13. 14.
    “Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. “From the Preamble to the Constitution of the World Health Organization. Adopted by the International Health Conference, New York, 19 June-22 July, 1946, signed 22 July, 1946. Official Record of the World Health Organization, II, no. 100. See Daniel Callahan, “The WHO Definition of ‘Health’,” The Hastings Center Studies, I (1973), 77–88.CrossRefGoogle Scholar
  14. 15.
    See H. Tristram Engelhardt, Jr., “The Disease of Masturbation: Values and the Concept of Disease,” Bulletin of the History of Medicine, XLVIII (Summer, 1974), 234–48.Google Scholar
  15. 16.
    Boorse’s critique of strongly normative views of disease is persuasive independently of some problematic features of his own account.Google Scholar
  16. 17.
    For example, we need an account of functional ascriptions in biology. See Boorse, “Wright on Functions,” Philosophical Review, LXXXV (January, 1976), 70–86. More specifically, we need to be able to distinguish genetic variations from disease, and we must specify the range of environments taken as “natural” for the purpose of revealing dysfunction. The latter is critical to the second feature of the biomedical model: for example, what range of social roles and environments is included in the natural range? If we allow too much of the social environment, then racially discriminatory environments might make being of the “wrong” race a disease; if we allow all socially created environments, then we seem not to be able to call dyslexia a disease (disability).CrossRefGoogle Scholar
  17. 18.
    Anyone who doubts the appropriateness of treating some physiognomic deformities as serious diseases with strong claims on surgical resources should look at Frances C. MacGreggor’s After Plastic Surgery: Adaptation and Adjustment (New York: Praeger, 1979). Even where there is no disease or deformity, there is nothing in the analysis I offer that prevents individuals or society from deciding to use health care technology to make physiognomy conform to some standard of beauty. But such uses of health technology will not be justifiable as the fulfillment of health care needs. Google Scholar
  18. 19.
    My account has the following bearing on the debate about Medicaid-funded abortions. Nontherapeutic abortions do not count as health care needs; therefore if Medicaid has as its only fuction the meeting of the health care needs of the poor, we cannot argue for funding the abortions just like any other procedure. Their justifications will be different. But if Medicaid should serve other important goals, like ensuring that poor and well-off women can equally control their bodies, then there is justification for funding abortions. There is also the worry that not funding them will contribute to other health problems induced by illegal abortions.Google Scholar
  19. 20.
    One issue here is to avoid “hijacking” by past preferences, which themselves define the effective range. Of course, effective range may be important in microallocation decisions.Google Scholar
  20. 21.
    Presumably, he must also claim that we improve satisfaction more by treating and preventing disease than by finding ways to encourage people to adjust to their conditions by reordering their preference curves.Google Scholar
  21. 22.
    I draw on Rawls’s “Social Unity and the Primary Goods,” in Amartya Sen and Bernard Williams, eds., Beyond Utilitarianism (Cambridge, England: Cambridge University Press, 1982).Google Scholar
  22. 23.
    Here again the utilitarian proponent of the satisfaction scale may issue a typical promissory note, assuring us that maximizing satisfaction overall requires institutional arrangements that act to minimize social hijacking.Google Scholar
  23. 24.
    The division presupposes, as Rawls points out in response to Scanlon, that people have the ability and know they have the responsibility to adjust their desires in view of their fair shares of (primary) social goods. See Scanlon, “Preference and Urgency,” pp. 665–66.Google Scholar
  24. 25a.
    Satisfaction scales leave us no basis for not wanting to he whatever person, construed as a set of preferences, has higher satisfaction. To borrow Bernard Williams’s term, they leave us with no basis for insisting on the integrity of persons. See Rawls, “Social Unity and the Primary Goods.” The view that issues here turn in a fundamental way on the nature of persons is pursued in Derek Parfit, “Later Selves and Moral Principles,” Philosophy and Personal Relations, ed. by Alan Montefiore (London: Routledge & Kegan Paul, 1973), 137–69;Google Scholar
  25. 25b.
    Rawls, “Independence of Moral Theory,” Proceedings and Addresses of the American Philosophical Association, XLVIII (1974–1975), 5–22;CrossRefGoogle Scholar
  26. 25c.
    and Daniels, “Moral Theory and the Plasticity of Persons,” Monist, LXII (July, 1979), 265–87.Google Scholar
  27. 26.
    See A Theory of Justice (Cambridge, Mass.: Harvard University Press, 1971), p. 302.Google Scholar
  28. 27.
    Rawls, “Social Unity and the Primary Goods.”Google Scholar
  29. 28a.
    Some weighting problems will have to be faced anyway: see my “Rights to Health Care” for further discussion. Also see Kenneth Arrow, “Some Ordinalist Utilitarian Notes on Rawl’s Theory of Justice,” Journal of Philosophy, LXX (1973), p. 245–63.CrossRefGoogle Scholar
  30. 28b.
    Also see Joshua Cohen, “Studies in Political Philosophy” (unpublished Ph.D. thesis, Harvard University, 1978), esp. part III and appendices.Google Scholar
  31. 29.
    Cf. Ronald Greene, “Health Care and Justice in Contract Theory Perspective,” in Ethics & Health Policy, ed. by Robert Veatch and Roy Branson (Cambridge, Mass.: Ballinger, 1976), pp. 111–26.Google Scholar
  32. 30.
    The primary social goods themselves remain general and abstract properties of social arrangements—basic liberties, opportunities, and certain all-purpose exchangeable means (income and wealth). We can still simplify matters in using the index by looking solely at income and wealth—assuming a background of equal basic liberties and fair equality of opportunity. Health care is not a primary social good—neither are food, clothing, shelter, or other basic needs. The presumption is that the latter will be adequately provided for from fair shares of income and wealth. The special importance and unequal distribution of health care needs, like educational needs, are acknowledged by their connection to other institutions that provide for equality of opportunity. But opportunity, not health care or education, is the primary social good.Google Scholar
  33. 31.
    Here I shift emphasis from Rawls, when he remarks that health is a natural as opposed to social primary good because its possession is less influenced by basic institutions. See A Theory of Justice, p. 62. Moreover, it seems to follow that where health care is generally inefficacious—say, in earlier centuries—it loses its status as a special concern of justice and the “caring” it offers may more properly be viewed as a concern of charity.Google Scholar
  34. 32.
    The ways in which disease affects normal opportunity range are more extensive than the ways in which it affects opportunity to pursue careers, a point I return to later.Google Scholar
  35. 33.
    Of course, the effects of family background cannot all be eliminated. See A Theory of Justice, p. 74.Google Scholar
  36. 34.
    Rawls allows individual differences in talents and abilities to remain relevant to issues of job placement, for example, through their effects on productivity. Therefore fair equality of opportunity does not mean that individual differences no longer confer advantages. Advantages are constrained by the difference principle. See my “Merit and Meritocracy,” Philosophy ir Public Affairs, VII (Spring, 1978), 206–23.Google Scholar
  37. 35.
    For example, appeals to equality of opportunity have historically played a conservative, deceptive role, blinding people to the injustice of class and race inequalities in rewards. Historically, appeals to the ideal of equal opportunity have implicitly justified strongly competitive individual relations. More concretely, we often find institutions, like the U.S. educational system, praised as embodying (at least approximately) that ideal, whereas there is strong evidence that the system function primarily to replicate class inequalities. See my “IQ, Heritability and Human Nature” in Proceedings of the Philosophy of Science Association, 1974, ed. by R. S. Cohen (Dordrecht, Netherlands: Reidel, 1976), pp. 143–80; and (with J. Cronin, A. Krock, and R. Webber) “Race, Class and Intelligence: A Critical Look at the IQ Controversy,” International Journal of Mental Health, III, no. 4, 46–123; and S. Bowles and H. Gintin, Schooling and Capitalist America (New York: Basic Books, 1976).Google Scholar
  38. 36a.
    See E. J. Mishan, “Evaluation of Life and Limb: A Theoretical Approach,” Journal of Political Economy, LXXIX, no. 4 (1971), 687–705;CrossRefGoogle Scholar
  39. 36b.
    Jan Paul Acton, “Measuring the Monetary Value of Life Saving Programs,” Law and Contemporary Problems, XL (Autumn, 1976), 46–72;CrossRefGoogle Scholar
  40. 36c.
    Michael Bayles, “The Price of Life,” Ethics, LXXXIX (October, 1978), 20–34.CrossRefGoogle Scholar
  41. 37.
    It would be interesting to know whether this age-relativized opportunity range yields results similar to that achieved by the Rawlsian device of a veil. If people who do not know their age are asked to design a system of health care delivery for the society they will be in, they would presumably budget their resources in a fashion that takes the special features of each stage of the life cycle into account and gives each stage a reasonable claim on resources. Cf. my “Am I My Parents’ Keeper?” Midwest Studies in Philosophy, VII (1982), pp. 517–540.Google Scholar
  42. 38.
    Using medical technology to enhance normal capacities of functions—say strength or vision—makes the problem easier: the burden of proof is on proposals that give priority to altering the normal opportunity range rather than protecting individuals whose normal range is comprises.Google Scholar
  43. 39.
    See Fried, Right and Wrong, chap. 5. The problem also worries Braybrooke, “Let Needs Diminish.’’Google Scholar
  44. 40.
    It is not clear to me how much Fried’s side-constraints resemble Nozick’s.Google Scholar
  45. 41.
    See footnote 19 above.Google Scholar
  46. 42.
    Except where conditions of extensive scarcity leave basic health care needs unmet, so that there is no room for less important uses of health care services, or where the existence of a market-based health care system threatens the ability of the basic system to deliver its important product. Cf. my “Equity of Access to Health Care: Some Conceptual and Ethical Issues,” Milbank Memorial Fund Quarterly/Health and Society, Vol. 60, no. 1 (1982), pp. 51–81.Google Scholar
  47. 43.
    I discuss these difficulties in “Conflicting Objectives and the Priorities Problem,” Income Support: Conceptual and Policy Issues ed. by Peter G. Brown, Conrad Johnson, and Paul Vernier (Totowa, N.J.: Rowman and Littlefield, 1981), pp. 147–64. My Justice and Health Care Delivery develops some applications in detail.Google Scholar
  48. 44.
    The strongest objections to such mixed systems is that the upper tier competes for resources with the lower tiers. See Claudine McCreadie, “Rawlsian Justice and the Financing of the National Health Service,” Journal of Social Policy, V, no. 2 (1976), 113–31.CrossRefGoogle Scholar
  49. 45.
    See Avedis Donabedian, Aspects of Medical Care Administration (Cambridge, Mass.: Harvard University Press, 1973).Google Scholar
  50. 46.
    I ignore the crudeness of such measures. For fuller discussion of these manpower distribution issues, see my “What Is the Obligation of the Medical Profession in the Distribution of Health Care?” Social Science and Medicine, Vol. 15F, no. 4 (December, 1981), pp. 129–133.Google Scholar
  51. 47a.
    See Avedis Donabedian, “The Quality of Medical Care: A Concept in Search of a Definition,” Journal of Family Practice, IX, no. 2 (1979), 227–84;Google Scholar
  52. 47b.
    and Daniels, “Cost-Effectiveness and Patient Welfare,” Ethics, Humanism and Medicine, ed. by Marc Basson (New York: Liss, 1981), 159–71.Google Scholar

Copyright information

© The Hastings Center 1983

Authors and Affiliations

  • Norman Daniels
    • 1
  1. 1.Department of PhilosophyTufts UniversityMedfordUSA

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