Abstract
Although our society spends ten percent of its gross national product on health care, the benefits of this prodigious outpouring are distributed rather unevenly. Although the majority of people are insured, at least to some extent, against both catastrophic illness and some of the costs of garden-variety medical care, roughly ten percent of our population has no health insurance at all.1 A patchwork of charitable and government-sponsored programs provide care to many indigent citizens, yet a significant number of the poor, the unemployed, and the uninsured fall through the ever-widening gaps in the so-called “safety net.” In the event of serious disease or disability, these people cannot pay, and many of them fail to obtain the health care that they need.
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Notes and References
President’s Commission for the Study of Ethical Problems in Medicine and Biobehavioral Research, Securing Access to Health Care Vol 1 (US Government Printing Office, 1983).
George Gilder, Wealth and Poverty (New York: Basic Books, 1981). 3Robert Nozick, Anarchy, State and Utopia (New York: Basic Books, 1974). 4See Marc Siegler, “A Physician’s Perspective on a Right to Health Care,” Journal of the American Medical Association (October 3, 1980), pp. 1591–1596, and James F. Childress, “A Right to Health Care?” Journal of Medicine and Philosophy, 4, June 1979, 132–147.
Hume’s remark on this point is instructive: “Justice takes its rise from human conventions ... and these are intended as a remedy to some inconveniences, which proceed from the concurrence of certain qualities of the human mind with the situation of external objects. The qualities of the mind are selfishness and limited generosity; and the situation of external objects is their easy change, join’d to their scarcity in comparison of the wants and desires of men .... Encrease to a sufficient degree the benevolence of men, or the bounty of nature, and you render justice useless, by supplying its place with much nobler virtues, and more favourable blessings.” A Treatise of Human Nature 2nd edition, ed. Selby-Bigge (Oxford: Oxford University Press, 1978), pp. 494–495. Quoted in Michael J. Sandel, Liberalism and the Limits of Justice (Cambridge: Cambridge University Press, 1982), p. 32.
Allen E. Buchanan, “The Right to a’Decent Minimum’ of Health Care,” in Report of the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access toHealth Care Vol. 2 (US Government Printing Office, 1983). 7John Stuart Mill, Utilitarianism (New York: The Liberal Arts Press, 1957), p. 66. 8Ibid p. 67.
John Rawls, A Theory of Justice (Cambridge: Harvard University Press, 1971), p. 4. 10Ronald Dworkin, Taking Rights Seriously (Cambridge: Harvard Univer
sity Press, 1977), p. xi. 11Edward V. Sparer, “The Legal Right to Health Care: Public Policy and
Equal Access,“ Hastings Center Report (October 1976), p. 40. 12See Charles Fried, ”An Analysis of ‘Equality’ and ’Rights’ in Medical Care,“ Hastings Center Report 6, February 1976, 29–30 and Paul Starr, TheSocial Transformation of American Medicine (New York: Basic Books, 1982).
For excellent analytical discussions of the nature and functions of rights, see Joel Feinberg, Rights, Justice, and the Bounds of Liberty (Princeton: Princeton University Press, 1981) and Theodore M. Benditt, Rights (Totowa, NJ: Rowman and Littlefield, 1982).
The problem of allocating dialysis machines in the socialized health care system of Great Britain provides a case in point. See Arthur Caplan, “Kidneys, Ethics, and Politics: The Lessons of the ESRD Program,” Journal of Health Politics, Policy and Law 6, Fall 1981, 488–503.
Whether such market-oriented approaches would in fact take the right to health care seriously is a separate and debatable question. I have argued elsewhere at length that they will most likely fail to supply an adequate economic base to the right to health care. See my essay, “The Neoconservative Health Strategy,” in Ronald Bayer and Arthur Caplan, eds., In Search of Equity: Health Needs and the Health Care System (New York: Plenum Press, 1983).
For an excellent account of the ways in which these private interests tend to subvert the project of meeting health care needs in the name of profit, see Elliot A. Krause, Power and Illness: The Political Sociology of Health and Medical Care (New York: Elsevier, 1977). See also the thoughtful essay by Paul Starr and Gosta Esping-Anderson, “Passive Intervention,” Working Papers July—August 1979, 15–25.
Ronald Dworkin, “Hard Cases,” reprinted in Taking Rights Seriously
On the distinction between “wants” (or “preferences”) and “needs,” and the relevance of this distinction for the justification of health care rights, see Normal Daniels, “Health-Care Needs and Distributive Justice,” Philoso-phy and Public Affairs 10 (2), Spring 1981, 146–179. 19Ecclesiastes 3:3.
Friedrich Nietzsche, The Gay Science tr. Kaufmann (New York: Vintage Books, 1974), sec. 338: “[T]he path to one’s own heaven always leads through the voluptuousness of one’s own hell.”
Eric J. Cassell, “The Function of Medicine,” Hastings Center Report December 1977, 16–19.
An apparent exception proves the rule. When asked about the effect of a progressive motor—neuron disease on his career, the eminent cosmologist Stephen Hawking is said to have replied that it had enhanced his career by freeing him from the responsibilities of teaching, thereby leaving him free simply to think about theoretical physics. New York Times Magazine (Jan. 23, 1983), p. 16 ff. Tragically, Dr. Hawking’s disease also threatens to cut short his life, and hence his theorizing.
Daniels, “Health-Care Needs and Distributive Justice.” Pn 158 ff.
Readers familiar with this topic will immediately wonder why I have omitted the distinctively “contractarian” theory of justice developed by John Rawls. The short answer is that a full-blown analysis of the various “Rawisian” approaches to the right to health care would require a separate, lengthy essay. The long answer, which I cannot pursue here, is my hunch that the two major Rawlsian arguments for health care rights can be reduced without significant remainder to the positive “natural rights” thesis that I develop later in this essay. See John Rawls, A Theory of Justice for the basic theoretical structure; Jeffrie Murphy, “Rights and Borderline Cases,” Arizona Law Review 19, 1, 1977, 228–241, for an argument to the effect that health care is a “primary good,” and that rational contractors in Rawls’s “original position” would choose to guarantee access to such a good; and Norman Daniels, “Health-Care Needs and Distributive Justice” for a rejection of the “primary good” approach in favor of an argument based on equality of opportunity. A useful survey of various “Rawlsian” approaches to health care rights is provided in Norman Daniels, “Rights to Health Care and Distributive Justice: Programmatic Worries,” Journal of Medicine and Philosophy 4, June 1979, 174–191.
Richard Brandt, A Theory of the Right and the Good (Oxford: Oxford University Press, 1979), pp. 381–319.
R. M. Hare, “Justice and Equality,” Justice and Economic Distribu-tion John Arthur and William Shaw, eds. (Englewood Cliffs, NJ: PrenticeHall, 1978), pp. 124–125.
Jeremy Bentham, “Anarchical Fallacies” reprinted in A. I. Melden, ed., Human Rights (Belmont: Wadsworth Publishing Company, 1970), p. 32.
Mi11, Utilitarianism ch. 5 (“On the Connection between Justice and Utility”).
See, for example, Charles Fried, “Health Care, Cost Containment, Liberty,” in John Arras and Robert Hunt, eds., Ethical Issues in Modern Medi-cine 2nd ed. (Palo Alto, CA: Mayfield, 1983), pp. 527–532.
Tom L. Beauchamp and Ruth R. Faden, “The Right to Health and the Right to Health Care,” Journal of Medicine and Philosophy 4, June 1979, 129.
Nicholas Rescher. “The Allocation of Exotic Medical Lifesaving Therapy,” Ethics 79, April 1969, 173–186.
Jeremy Bentham, The Principles of Morals and Legislation (1789).
“The Right to Health and the Right to Health Care,” p. 128.
This point is confirmed by A. K. Sen, On Economic Inequality (New York: Norton, 1973), p. 16 and Richard Posner, The Economics of Justice (Cambridge: Harvard University Press, 1981). These observations should not be taken as a global assault on cost—benefit analysis in the formulation of health policy. To the contrary, it is evident that our failure honestly to confront the moral issues posed by rising health care costs has contributed to the staggering irrationality and injustice of our system. To take an extreme but telling example, we currently spend roughly 22% of our total hospital expenditures on patients who are deemed terminally ill. In 1977, $16 billion (out of a total of $73 billion) was spent on people who were to die in a matter of weeks or months. Even those who would balk at the way utilitarianism tends to slight the equal needs of the elderly cannot but gape at such figures. See John C. Fletcher, “Ethics and the Costs of Dying” (manuscript).
Immanuel Kant, Groundwork of the Metaphysic of Morals tr. H. J. Paton (New York: Harper and Row, 1964), p. 96.
Nozick, Anarchy, State and Utopia pp. 32–33.
Ibid., p. 33.
Ibid.
Philip Petit, Judging Justice: An Introduction to Contemporary Political Philosophy (London: Routledge and Kegan Paul, 1980), pp. 35–38. See also Rawls, A Theory of Justice pp. 20–21.
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Arras, J.D. (1984). Utility, Natural Rights, and the Right to Health Care. In: Humber, J.M., Almeder, R.T. (eds) Biomedical Ethics Reviews · 1984. Biomedical Ethics Reviews. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-440-5_2
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