Chapter08

Chapter EightJustice and the

Allocation of Scarce Resources

Copyright ©2009 Delmar, Cengage Learning. All rights reserved.

American Health Care Crisis

• Over $1 trillion expenditure each year (13.7% of gross domestic product)

• Other nations seem to show equal or better results for less money spent

• 45 million Americans without adequate health insurance coverage


American Health Care Crisis (continued)

• Increases in health care coverage will only be gained at expense of money for education, defense, roads, etc.

• America the only modern industrialized nation that does not provide universal health care coverage


American Health Care Crisis (continued)

• Quandary of needing to cut back on health care costs and at the same time widen health care access

• A problem of distributive justice– How do we get there from here?


Common Methods for Distributing Goods and Services

• Which is best for the distribution of health care?– To each person an equal share– To each person according to need– To each person according to merit– To each person according to contribution– To each person according to effort– To each person according to social worth


You Play, We Pay

• In reviewing the “You Play, We Pay” case, consider the following:

• Should liver transplants be denied to those who destroyed the original through alcohol or drug abuse?


You Play, We Pay (continued)

• Should there be access ramifications for smokers, drinkers, overeaters? Extreme sports enthusiasts, cyclists without helmets, etc?

• What does justice require?


Formal and Material Justice

• The fair and equitable division of scarce goods and services is an issue of distributive justice– Formal justice– Material justice


Material Justice

• Material justice requires that criteria used must be morally relevant

• Fair opportunity rule – no person should be granted social benefits on the basis of undeserved advantages, nor denied social benefit on the basis of undeserved disadvantage


Micro- and Macro-Allocation

• Macro-allocation

• Micro-allocation

• Review the “You Play, We Pay” case– Does this require a micro or macro

answer?

• Review the “A Problem of Space” case– Is this micro or macro?


Governmental Involvement

• 1800s: A laissez-faire position toward health care practice, tending to favor rich, strong, and perhaps predatory, at expense of weak and disorganized


Government Involvement (continued)

• 1900s: Public sentiment shifts toward curbing rampant individualism. The government assumes a role in providing access to health care.

• 1935 Social Security Act

• 1959 Federal Employees Health Benefits Program


Government Involvement (continued)

• 1965 Medicare and Medicaid

• 1983 Prospective Payment System

• 1993 Task Force on National Health Care Reform

• 2003 Medicare Prescription Drug Improvement and Modernization Act


General Distribution Theories

• Egalitarianism:– Absolute equality– Right to health care

• Utilitarianism:– Greatest good for greatest number


General Distribution Theories (continued)

• Libertarianism:– Emphasis on personal rights and

economic liberties– Distribution choice must be freely

chosen


Natural Life Span Argument

• Rationing by natural life cycle

• Reduce the amount of care provided when:– One’s life work is completed– One’s moral obligations and

responsibilities are completed


Natural Life Span Argument (continued)

• Reduce the amount of care provided when (continued):– One’s death would not seem to others

to offend sensibility – Dying process is not marked by

unbearable and degrading pain


Two-Tier System and the Decent Minimum

• Two-tier system:– Every citizen is covered for basic care

and catastrophic health needs– Expanded services available on a fee-

for-service basis


Two-Tier System and the Decent Minimum (continued)

• A mixture of utilitarian and libertarian values

• Oregon system approaches the two-tier system


Proposal Review

• Exercise I in the review exercises asks for an evaluation of health care system currently in use in Singapore

• Review the system:– Which of the basic theories does it

represent (egalitarian, utilitarian, libertarian, a blend of several)?


Lifeboat Ethics

• Story of the sinking of the William Brown– Seaman Holmes – a utilitarian choice– Court decision – a matter of natural right


Lifeboat Ethics (continued)

• In Sub-Saharan Africa, some nations have an HIV rate of over 30%. In some sense, Americans are in a lifeboat on a human sea of tragedy.

• What criteria should guide our actions?


Triage

• In times of war or disaster, the practice was used to divide the wounded into three classes:– Walking wounded– Fatally wounded– Seriously wounded


A Problem of Space

• Review the “A Problem of Space” case study and determine how you would make the decision in regard to the needed beds:– Medical utility– Social utility


Managed Care

• Plans that coordinate health care through primary care generalists

• Efforts at cost containment should not place patient welfare at risk

• Plan coverage should not affect the practitioner’s duty to provide informed consent


Managed Care (continued)

• The practitioner has a duty to serve as a patient advocate

• Patients must assume responsibility for selecting their own health care plan


Health Care Crisis

• The United States, richest, most powerful nation in the world, has 45 million citizens without health care coverage– Greater number than the combined

populations of 22 states and the District of Columbia

• What is to be done?


What Is Health Care?

• It has been argued that collective social protection and the fair opportunity rule form the basis of a right to health care

• Is health care a right?


Key Concepts

• The U.S. spends over $1.3 trillion on health care and still leaves 45 million uninsured

• Micro- and macro-allocation of health care resources

• The fair opportunity rule and requirements of material justice


Key Concepts (continued)

• Social vs. medical utility

• Egalitarian, utilitarian, and libertarian systems as they relate to health care distribution

• Triage system

• Natural life span proposal for rationing health care


Key Concepts (continued)

• Problems associated with the major forms of managed care

• Current international AIDS problems in the developing world and the concepts associated with them:– Lifeboat ethics– Natural rights– Human rights

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Chapter08