Medicine, Health Care and Philosophy1: 155–161, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

Scientific Contribution

Is health care a need??

Eric MatthewsUniversity of Aberdeen, Department of Philosophy, AB24 3UB, Aberdeen, Scotland, UK

Abstract. This paper aims to provide an argument for saying that a publicly funded health care system, availableto all free at the point of delivery, is morally superior to a market system, and to provide a framework for decidingquestions about which forms of health care should be included in such a public system. The argument presentshealth care as a ‘head’, in the sense of something to which human beings are morally entitled as a necessarycondition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Danielsand Buchanan, are critically examined and rejected.

Key words: health care, entitlement, non-market provision

Introduction: moral issues in health care delivery

The current debate in all economically and techno-logically advanced countries about the best system ofdelivery for health care raises a fundamental moral andphilosophical question: why should health care not bethought of as a commodity like any other, to be boughtand sold in the market place, and with a price deter-mined simply by the ordinary mechanisms of supplyand demand? Even to pose such a question would seemto many, especially in Europe, to be shocking, andI would include myself in that number. But we needto ask why we find it shocking, and whether we arejustified in finding it so.

The aim of this paper is to address some of theissues which arise when we seek to answer such ques-tions. It is not my intention to make detailed policyrecommendations about whether particular forms ofmedical care should, or should not, be provided as partof a publicly funded health care system. The purposeof the paper is simpler, and twofold: first to provide anargument for saying that a health care system avail-able to all free of payment at the point of deliveryis morally justified, indeed required; and second, toprovide a framework within which discussions aboutwhich forms of health care might be included withinthe scope of such a publicly funded system could beconducted. This framework will not, in itself, afforda means of ranking priorities within such a system,

? I am grateful to two graduate students, Peter (‘Bo’) Rut-ledge and Chris Smith, for discussions of the material ofthis paper which have been very helpful in formulating myargument.

although it is possible that such criteria of rankingcould be developed from it.

The title of the paper is ‘Is health care a need?’. Ihave chosen this formulation because it is often saidto be an important virtue of publicly funded healthcare systems, such as the British National Health Ser-vice, that they deliver health care on the basis of‘need’, independently of the ability to pay. There isan implication in such statements that the status ofhealth care as a ‘need’ is what makes its provision asa mere marketable commodity morally inappropriate.The argument, therefore, seeks to explore the moralityof private (market) versus public provision of healthcare by seeing whether health care is, at least to someextent, a ‘need’ in some sense which would justify thesense of shock at the very idea of a market-based sys-tem of health care provision which was referred to inthe opening paragraph.

Markets in health care: for and against

In this Section, I shall consider what kinds of argu-ments might be adduced in favour of or against apurely market system of health care delivery. Thereare, of course, purely economic reasons for doubtingthe full applicability of the standard market mecha-nisms to health care delivery. The nature of health-care as a ‘commodity’ is rather different from most:demand for it is irregular and unpredictable, and itcarries a high financial cost. Furthermore, the ulti-mate ‘consumer’, the patient, normally does not haveenough information to be able to judge on the quality

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of the ‘product’, but has to rely on the doctor to makethe judgement.1 These economic problems, however,are not the reason for the sense of shock referred toin the first paragraph. That comes rather from a feel-ing that there is somethingmorally outrageous aboutthe very idea that health care should be simply boughtand sold like other consumer goods. The sense thatthere are moral considerations to be taken accountof in health care delivery is expressed, for example,in the claim that an injustice is done when healthcare resources are allocated unequally, between differ-ent income groups or between different geographicalareas.

Not everyone, of course, would think that suchinequalities in the allocation of health care resourcesconstituted an injustice. Engelhardt, for instance,argues that ‘inequalities in the distribution of healthcare resources that are the result of differences injustly acquired privileges’ are ‘unfortunate’, ratherthan ‘unfair’.2 Such a view equates health-care withcommodities which no one would doubt could legiti-mately be allocated in accordance with market mech-anisms, such as chocolate cake. No one would think itunjust if the amount of chocolate cake which could beconsumed by poor people or by those living in remoteareas of the country were less than was eaten by therich or the inhabitants of the metropolis. If you can’tafford to pay for such goods, we would say, you can’texpect to have them, and if the costs of transportingthem to remote areas are so high as to make it unprof-itable to do so, then people in those areas simply haveto do without.

Considerations of moral entitlement in the relevantsense simply do not apply to the workings of the mar-ket, at least in respect of the supply of goods. It isin the nature of markets that they allocate goods inaccordance with consumer preferences, as expressedin the price which they are willing to pay. Since abilityto pay is likely to be unequal, the preferences of someconsumers will necessarily carry more weight in themarket than those of others. Where all that determinesthe ‘goodness’ of something is individual preferences,there can be nothing wrong with this from a moralpoint of view. If chocolate cake is good in my eyesonly in the sense that I like to eat it – if there is nomore objective reason for calling it good – then thereis no moral reason why my personal tastes ought to besatisfied. I only have a moral claim to chocolate cake ifI can (and do) pay for it, and if my payment is acceptedby the vendor.

There are some (including Engelhardt) who wouldsay, on these grounds, that the market is actuallymorally superiorin a certain respect to other methodsof allocation. For in a market system, each individ-ual chooses for him- or herself which goods he or

she will have (provided he or she has the money topay for them), so that the market economy is morallysuperior in that it respects the freedom of choice of theindividual. This argument is used by some to justifya market system of health care allocation. In a freehealth care market, for example, no one who wantedrenal dialysis would be denied access to it as a resultof decisions taken by others, as such sufferers arein the non-market allocation practiced in the BritishNational Health Service. However, a market systemdenies access to medical treatment to those who areunable to pay for it (or who do not qualify for chari-table provision). Under the market system, freedom ofchoice only really exists for those who have the abilityto pay. This sort of objection on the part of writers suchas Engelhardt does not really, therefore, establish themoral superiority of market provision of health care.

The distinction between ‘wants’ and ‘needs’

In this paper I shall try to show how the question aboutnon-market and market systems can be resolved bydetermining whether there is a viable distinction tobe made between ‘wants’ and ‘needs’. We can makesome sort of rough and ready, provisional, distinctionbetween the two concepts in the following way. Theobject of both wants and needs is the same, namely,some good or other: but in the case of a ‘want’, whatmakes that thing good is simply that someone happensto prefer it. It follows that what may be good in thissensefor me is not necessarily goodfor you: it is a‘subjective’ good. Since it is only ‘good’ in the senseof being subjectively preferred, it is not good in anymoral sense, and I do not therefore have any moralclaim or entitlement to it. The only sense in which Icould claim any moral entitlement would be if I hadpaid the price required for it: a supplier of such agood who took my money and then refused to provideme with what I had paid for would be cheating me,denying me my legitimately acquired property, andso would be doing me an injustice. But if I have notpaid for what I want, I have no entitlement to havethat want satisfied. For wants in this sense, therefore(of which chocolate cake would be as good an ex-ample as any) the market is a perfectly appropriatemechanism.

Contrast this with what I want to call ‘needs’.‘Needs’ is a term which is used in more than one way,and it is important, if confusion is to be avoided, thatwe are clear about which sense is intended. Often,the term is used in a value-neutral sense, to refer forexample to the empirically determinable requirementsfor maintaining life and normal functioning. But then,just because statements about needs are value-neutral,

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it follows, if one accepts Hume’s distinction between‘is’ and ‘ought’, that no evaluative conclusions can bedrawn from them. Hence no such concept of a ‘need’can have any bearing on the moral acceptability ofparticular systems of provision.3

What is required, therefore, for our purposes is aconcept of ‘need’ which isnot value-neutral. To saythat someone has a ‘need’ forx, in this sense, would beto say thatx is a good to which that person is morallyentitled. The good in question may be either somethingto which someone is morally entitledin itself or elsesomething which is a necessary condition for the exis-tence of such an intrinsic good, and so to which one ismorally entitled in a derivative way. If health care, orcertain kinds of health care, is a need, it will be one inthis latter, ‘derivative’, sense.

But is this rough and ready distinction between‘wants’ and ‘needs’ sustainable? Many suspicions ofthe distinction have been voiced on the grounds thattalk of ‘needs’ is simply a means of imposing one’sown subjective value judgements on others, or of giv-ing a spurious dignity to one’s own wants. If that kindof objection is to be met, it will be necessary to showthat the determination of ‘needs’ is a matter for rationalargument, rather than political rhetoric. But how couldone do this? It would have to be shown that there werecertain goods to which human beings as such weremorally entitled, that is, that a life without these goodswould not be worthy of human beings. And then, forany claimant to the status of being a ‘need’, it wouldhave to be shown that it was either such a good, orelse a necessary condition for the existence of sucha good.

But is not the concept of ‘a life worthy of humanbeings’ hopelessly subjective? Do not different cul-tures, and even different groups within the sameculture, have widely varying conceptions of what con-stitutes human worth? To take an obviously relevantexample, one group might consider the only worthylife for a human being to be one of risk, adventureand enterprise, whereas another might consider a lifelacking basic comforts and amenities of civilized exis-tence to be unworthy of human dignity. For the lattergroup, these civilized amenities would be ‘needs’, inmy sense; for the former, mere ‘wants’, to which peo-ple were entitled only if, by virtue of their own hardwork and enterprise, they were able to pay for them.How can we say that one group is right, the othermistaken? What common ground can we find betweenthem which might make some sort of rational argumentbetween their opposing positions possible?

I want to argue, however, that we need not despairof finding such common ground. To do this requiresus to distinguish, first, between what I shall call ‘first-order’ and ‘second-order’ conceptions of the value of

a human life. A ‘first-order’ conception consists of alist of specificgoods which are considered to be neces-sary components of a human life if it is to be regardedas worthwhile. The details of the list may well varyfrom one society or culture to another. The variationsreferred to in the preceding paragraph would be anillustration of this. A ‘second-order’ conception, bycontrast, would not be subject to this sort of variation.There are certain goods which must be secured to ahuman being if he or she is to have anything whichmight be called a life of human worth at all, whateverdifferences at first-order level there might be in con-ceptions of that worth. It is goods of this kind whichwould be included in a second-order conception.

What sort of ‘second-order’ goods do I have inmind? Chief among them, obviously, is having a life atall (being alive), and a life of sufficient length for oneto be able to develop and realise conceptions of whata worthy life for a human being might be. Anothercandidate for such a good would be having the great-est possible use of one’s human faculties, mental andphysical, for the development and realisation of one’sconception of a worthy human life. A third mightbe freedom from excessive pain, where ‘excessive’pain means pain which is not an inevitable part of thepursuit of one’s first-order goods, and which is suchindeed as to distract one from that pursuit. Howevermuch different groups might disagree in their first-order conceptions of human dignity, if they have aconception of human dignity at all, they must agreethat all human beings are morally entitled to the goodsjust mentioned. These things are good in a way whichdoes not merely imply that they are subjectively pre-ferred (though no doubt most people would also preferto have them rather than not have them): they areobjectively good, in the sense that any rational personwho recognizes the concept of a human good at allmust regard them as good.

Health and health care as needs

These goods could be taken, between them, as con-stituting a single good, namely ‘health’. The famous(or notorious) WHO definition described health as ‘astate of complete physical, mental and social well-being’.4 It would generally, and rightly, be agreed,however, that whether or not this defines an ideal tobe aspired to, it is utterly inappropriate as a workingdefinition of the concept of health as it is actually used.To be ‘healthy’, as we actually use this term (whichis admittedly rather vague), is to be functioning, espe-cially physically, in such a way as to be able to performthose human activities which are required if we are toachieve a life worthy of a human being, as conceived

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in our society, both in terms of its length and in termsof the goods achieved in it.

If so, then ‘health’ could be said to be a pri-mary human ‘need’ in my sense – something to whichhuman beings are morally entitled. But what followsfrom this about healthcare? Health care, in gen-eral, means any activity likely to, and intended to,promote someone’s health. This may include bothactivities engaged in by the person him- or herself-exercise, maintenance of a proper diet, etc., and thingsdone by others. The latter includes public health mea-sures – provision of supplies of clean water, goodsewage-disposal, unpolluted air, vaccination againstdisease, safe working conditions and so on, all ofwhich have a beneficial effect on the health of therecipients; (public health measures may of course beheld to include provision of assistance to individualsin caring for their own health – provision of sport-ing facilities, health education programmes, and thelike). But what springs first to most people’s mindswhen we think of things done by others to promotesomeone’s health ismedicalcare, activities, usuallycarried out by trained professionals, to treat illnessand injury with a view to alleviating pain, restoringnormal levels of activity and preserving an accept-able lifespan. For most of us (though wrongly) ‘healthcare’ is effectively identified with ‘medical care’ in thissense.

To the extent that health care depends on our ownefforts, it would seem absurd to speak of it as a ‘need’,as something to which we are morally entitled: thevery term ‘entitlement’ seems to imply an obligationon someone else’s part to provide the good in ques-tion. Our discussion, therefore, must concentrate onthe sorts of health care which are provided by others(including those aspects of public health mentionedabove which can be regarded as preconditions for per-sonal health care – provision of sporting facilities,etc.). Health care in this sense is clearly one neces-sary condition for the existence of health, but it isnot the only necessary condition. To be healthy alsorequires being free of those conditions, whether consti-tutionally or environmentally engendered, which tendto shorten life or incapacitate their bearer and whichare irremediable by the current state of medical sci-ence and technique. But no one could say that anyonewas ‘morally entitled’ to be free of such conditions,since there is no one, except perhaps God, who couldbe regarded as morally obliged to make one free ofthem. ‘Health care’ consists, for our purposes, in thosehumanactivities by which we endeavour, as far as ourknowledge and skill allow, to put right the results ofthese contingencies of constitution and environmentin order to achieve a healthy life for other humanbeings.

If, as I have argued, health, in the sense defined, isan intrinsic feature of a life worthy of human beings,and if health care is a necessary condition for the exis-tence of health, it follows that health care is a ’need’ inmy sense. We are therefore morally entitled to expectthe provision of health care, that is, of such measuresas will, as far as the current state of knowledge andskill at the time in question allows, make it possible toachieve a healthy life as defined earlier. This entitle-ment includes public health measures to provide thefundamental conditions for living a life of an appro-priate length and of a satisfactory level of activity,including provision of facilities to enable people tolook after their own health; and medical care, intendedmainly to correct the harmful consequences of injuryand disease for the length of life and the level of activ-ity. If we are morally entitled to expect such provision,it follows that the provision cannot depend on suchmorally irrelevant features of our situation as our abil-ity to pay. Hence, it is morally inappropriate to requirethat health care in this sense should be provided bymarket mechanisms, which essentially depend on theconsumer’s willingness and ability to pay.

Comparison with Daniels and Buchanan

In this section, I want to compare the argument justoutlined with some other contributions to the discus-sion. No account of this field could leave out the workof Norman Daniels, who argues that it is a require-ment of fairness that the life-opportunities of everyoneshould be as far as is humanly possible equalized.5

Basing his argument on David Braybrooke’s conceptof a ‘course-of-life need’,6 as a requirement such that,in Braybrooke’s words, a deficiency with respect to it‘endangers the normal functioning of the subject ofneed considered as a member of a natural species’,Daniels contends that health care is a need (in thatsense) to the extent that it is necessary ‘in orderto maintain, restore, or provide functional equiva-lents (where possible) to normal species functioning’.7

The moral entitlement to health care (which makesit a ‘need’ in my sense) would then come from theRawlsian account of justice, according to which so-ciety must guarantee equality of opportunity to allits members. To the extent that disease or injury re-duce a person’s opportunity-range in comparison withthat of others, by interfering with normal species-functioning, and that health-care seeks to restore thatnormal functioning and so to equalize the opportunity-ranges of different members of society, people havean entitlement to such health-care. What seems to bemeant by ‘opportunity’ here is something very gen-eral, and certainly much wider than is intended by

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most advocates of equality of opportunity. It seems toinclude, not just chances to follow the career of one’schoice, but chances to realise one’s preferences moregenerally.

Daniels himself recognises some possible criti-cisms which might be made of his argument. Health-care, he accepts, achieves certain goods which do notseem to fit naturally under the heading of ‘improvedopportunities’, even in Daniels’ wide sense – the reliefof pain, for instance, or counselling for psychologicaldistress (one might add the obvious use of health-carefor prolonging life, which may be a condition for hav-ing any opportunities at all, but which it seems odd todescribe as itself a life-opportunity). What this indi-cates, as will be argued later, is an underlying lack ofclarity in Daniels’ argument.

There are, however, other, more fundamental,objections to Daniels’ position. First, (to repeat a pointalready made in another connection), statements about‘normal species functioning’ are statements of empir-ical scientific fact, and so cannot, if one accepts the‘is-ought’ distinction, license any judgements aboutwhether the requirements for such functioning oughtto be provided for anyone. Secondly, the argumentthat justice requires us to secure equality of opportu-nity to everyone surely only implies that we ought notto do anything ourselves which might prevent some-one’s exercising those opportunities which he or shenaturally has. Someone who is blind from birth or asa result of disease, for instance, does not have theopportunity to become a great portrait painter, butdoes have opportunities for all sorts of other formsof artistic expression (in music, for instance). Equal-ity of opportunity surely requires that her blindnessshould not prevent her from following any artistic bentwhich she has: but equally surely, it does not requireanyone to seek a cure for her blindness. It cannot bea requirement of humanjustice that we should cor-rect the natural limitations to which human beings aresubject.

Perhaps, anyway, the realm of justice and of rightsis the wrong place to look for a moral basis for provid-ing health-care irrespective of an individual’s ability topay. Allen Buchanan has suggested that a basis inchar-ity rather than justice is more plausible.8 Buchananargues that ‘the concept of a right to a decent minimumof health care is inadequate as a moral basis for a co-ercively backed decent minimum policy in the absenceof a coherent and defensible theory of justice’.9 Thework that is supposed to be done by such an allegeduniversal right can be done at least as well, and withoutraising the problem of a defensible theory of justice,by the notion of ‘effective charity’. If we start from thereasonable assumption that we all have a basic moralobligation of beneficence to those in need, Buchanan

goes on to argue, and if we also assume (equally rea-sonably) that beneficence requires the provision of ‘atleast certain forms of health care’, then we can con-clude that those in need of it are morally entitled tobe so provided. The element of compulsion (compul-sory payment of taxes to provide such health-care)can be justified, Buchanan considers, even from a lib-ertarian point of view, by the need to overcome theindividual’s tendency to withhold his or her contribu-tion by imposing penalties and by assuring everyonethat everyone else is also contributing; and by the needto coordinateindividual acts of beneficence in the mosteffective way. Expensive health-care cannot be effec-tively provided by individuals, however beneficent,acting in isolation. ‘What is needed is a coordinatedjoint effort’.10

This is an attractive argument in many ways, whichseems to avoid the difficulties in, for instance, Daniels’position. Nevertheless, it fails to give an adequateanswer to the question posed in the present paper. Forone thing, the notion of an obligation to beneficenceseems much too weak to provide a moral basis for theprovision of free health-care. It may be plausible to saythat we have a moral obligation, where we can, to helpthose in need: but this is an extremely vague obligation– it carries no specific implications aboutwhichsortsof human situations constitute the sort of ‘need’ whichcreates the obligation to help. If we are confronted bytwo people, both distressed, the one because his sex-ual potency is declining with age, the other becauseshe has post-menopausal osteoporosis, do we have anobligation to help both, or neither, or one but not theother? A principle of being charitable goes no way toanswering this question. Again, it gives us no guid-ance as to how far our charity should extend. Shouldwe, for instance, help strangers in our own communitywho happen to want medical treatment, rather than thestarving in the Third World? It might be suggested thatwe all have a duty to helpanyonewhatsoever who is inneed in any way, but that sounds more like a descrip-tion of saintly or supererogatory virtue than of ordinarymoral obligations.

Secondly, the notion of ‘compulsory charity’sounds almost like a contradiction in terms. The wholepoint of the concept of charity is surely that it is vol-untary beneficence, as distinguished from doing goodto others because one is made to. In so far as the oblig-ation of beneficence is amoral obligation, it cannotbe compelled by any external agency such as the stateand its tax-collectors. One may, of course, pay one’staxes willingly because one knows that the revenuethus generated will be used for purposes of which oneapproves: nevertheless, one is obliged to pay one’staxes anyway, no matter whether one does so willinglyor not. In this sense, doing good to others by using rev-

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enue from taxation cannot be described as an exerciseof the virtue of charity.

An example may make this point clearer. It isobviously a morally good thing for me to offer anunfortunate homeless person a room in my house tolive in, but it is only an example of charity on my part ifI do it entirely voluntarily – that is, would do it even ifI were not compelled to do so. Equally clearly, if somestate agency collects taxes in order to provide housingfor homeless people, it is likely to be more effectiveand coordinated an effort than if it is left to the charityof individuals, and so the outcome for the homelesspeople will be much better. But it will no longer betrue that the moral basis for the effort is individualcharity: rather, it will be that people who have beenmade homeless through no fault of their own are enti-tled to expect that housing will be provided for them.A similar point could be made about the provision ofhealth-care. In short, talk of an ‘obligation to char-ity’ does not explain why health-care morally ought tobe provided whether or not the better-off members ofsociety have the relevant motivation to be voluntarilycharitable.

Thirdly, and perhaps most relevantly of all,Buchanan’s talk of ‘the provision of resources for atleast certain forms of health care’, like Daniels’ talkof equalizing opportunities, is hopelessly vague. Whatwe want to know is,what forms, and what is themoral basis for selecting these forms rather than oth-ers? Should our obligation of beneficence, or thoseof justice, require us to provide resources for hi-techmedicine, or only for basic nursing care? For antibi-otics for all kinds of bacterial infection, or only forsome? For long-term psychiatric or geriatric care, oronly for treatments for acute conditions? Not only doBuchanan and Daniels not answer such questions: theyfail to provide even a basis for answering them.

Conclusion

Can the argument developed in the present paper suc-ceed where Daniels and Buchanan have failed? Letus first review that argument. A morally evaluativeconcept of ‘need’ was developed such that to say thatsomething was a ‘need’ implied that it was a humangood of a kind which people were morally entitled toenjoy. To say that it was a moral entitlement was heldto imply that its goodness was not simply a matter ofsatisfying a subjective preference, but arose from itscontribution to a life worthy of human dignity. Becauseof this, it was argued that it was morally inappropriateto make its enjoyment dependent on a person’s abilityto pay for it, and so to subject its provision to marketmechanisms.

It was then argued that ‘health’, in the sense of acondition in which one lived long enough to have arealistic chance to formulate and put into effect one’sown values, and in which one’s level of physical func-tioning and activity was sufficient to enable one todo so, was such a good. In turn, this implied thathealth care, to the extent that it was a necessary con-dition for the existence and maintenance of health inthis sense, was a ‘need’, and so that human beingsare morally entitled to be provided with such healthcare, independently of their ability to pay for it, andso without recourse to market mechanisms. It mightbe argued that this conclusion was compatible with asystem which was basically organized as a market, butin which those who were unable to pay for health carethemselves could be provided with it by charity. Butthis does not seem to be correct: if health care is amoral entitlement, then, first, market provision evenfor those able to pay is morally inappropriate, and sec-ond, provision should not even have to depend on thecharitable impulses of others. The only system whichseems morally appropriate, on this argument, is onein which provision of health care is guaranteed to allas a matter of right, and such a system can, it seemsevident, be operated only by the state. In contrast toDaniels and Buchanan, therefore, the argument pre-sented here does seem to justify the conclusion thata publicly-funded, non-market, system of health caredelivery is morally required.

If anything has become clear from the discussion ofDaniels and Buchanan, however, it is that the conceptof health care which is a ‘need’, in the sense of thispaper, is not coextensive with that of ‘medical care’,as it is generally used in our society. For it is clear thatnot all medical care, especially nowadays, is intendedsimply to secure to patients a reasonable lifespan anda level of activity which will enable them to realisetheir human worth. Some medical care, as in the caseof sterilization, the provision of contraceptive facilitiesand advice, and non-therapeutic abortion, is designedto prevent the consequences of normal human activi-ties rather than to make an acceptable level of activitypossible. Other sorts of care aim to enhance the lives ofpatients in ways which have little or nothing to do with‘health’ as defined earlier – cosmetic surgery, treat-ment for acne, psychotherapy, for instance; yet others,a slightly different case, seek to provide patients withpossibilities denied to them by nature –in vitro fer-tilization for those naturally infertile, gene therapy tocorrect genetic handicaps. The list might go on indef-initely, but one type of increasingly common medicalintervention which must be mentioned is that whichis designed toprolong the lifespan beyond the pointwhich might seem to be naturally indicated: someexamples of the kind of treatment I have in mind would

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be organ transplantation, coronary bypass operations,renal dialysis and the like, for patients who are alreadyadvanced in years. This is far from being an exhaustivelist, but it may suffice to illustrate the central point.That is, that the aim of medical care in these cases isnot to secure to human beings a reasonable lifespan inwhich to realise their values but to extend the lifespanbeyond what that might require. Living as long as wecan may be something which we prefer to do: but doesthat make it a ‘need’, rather than a ‘want’?

The radical conclusion to be drawn from the argu-ment of this paper is that these and similar forms ofhealth care, if they have been correctly described, donot count as ‘needs’ (do not, indeed, count ashealthcare), and so do not qualify on that ground for pro-vision as a matter of moral entitlement regardless ofability to pay. If so, then as far as that goes, the appli-cation of market mechanisms in these cases may bemorally acceptable. Of course, it may well be that Ihave wrongly described them. It may equally well beclaimed that the definition of ‘health’ as an essentialrequirement for human dignity, which I have made thebasis for my attempted justification of the non-marketprovision of health care, makes something essentiallysimple far too complicated. Could we not, for instance,simply define ‘health’ as the absence of suffering, andthen justify the use of public funds in providing healthcare in terms of the obligation to relieve suffering? Inthat case, some at least of the medical interventionsmentioned above might qualify for being provided ona non-market basis.

If an alternative definition of ‘health’ is to beoffered, however, it must be shown to give objectivesupport to a moral entitlement to health care at leastas firm as the one offered here. It is far from clearthat this is the case with the definition of ‘health’ as‘the absence of suffering’. Could we really hope toachieve universal agreement among all rational beingsto the proposition that we have a moral obligation torelieveanykind of human suffering? A certain amountof suffering, both physical and emotional, seems to bean inescapable part of the human condition, though itcould no doubt be ‘relieved’, for example by admin-istering euphoria-inducing drugs. But, however muchwe mightwishfor such relief, it is doubtful whether wecould justifiably claim to be morally entitled to it in allcases. And if we are to distinguish between differentkinds of suffering in this respect, then the mere fact ofsuffering in itself would no longer be the grounds ofour moral entitlement.

Finally, it may be that there are other justificationsfor providing certain forms of medical care indepen-dently of the market: provision of facilities for steril-

ization, contraception, abortion free of charge might,for instance, be justified on grounds of public policy(population control). There might be economic gainsfor society from extending life for certain individu-als, and so extending their economic productivity. Butthen the argument for non-market provision wouldno longer be one of moral entitlement, but of socialefficiency.

Notes

1. See, for instance, Mooney (l992), pp. 28f.2. Engelhardt, (l986), p. 343.3. This seems to me to be a central confusion in Rod Sheaff’s

book The Need for Healthcare. Sheaff tries to combine a‘scientifically-based’ concept of health care needs with aconcept which will be relevant to health policy: but such acombination is incoherent if one also accepts, as he does,Moore’s notion of a ‘naturalistic fallacy’. For instance,from the fact that human beings have a biological ‘need’for food, no policy decisions (value-judgements) can followabout any obligation to provide them with food.

4. Constitution of the World Health Organisation(1946).5. See Daniels (l985), esp. chapters 1 and 2.6. Daniels refers to Braybrooke (1968); the concept has more

recently been further elaborated in Braybrooke (l987).7. Daniels (1985), p. 32.8. Buchanan (l994).9. Buchanan (1994), p. 697.

10. Buchanan (1994), p. 699.

References

Braybrooke, D.: 1968, Let needs diminish that preferencesmay prosper,Studies in Moral Philosophy, American Philo-sophical Quarterly Monography Series No. 1. Oxford: BasilBlackwell, pp. 86–107.

Braybrooke, D.: 1987,Meeting Needs. Princeton UniversityPress, Princeton, NJ, 1987.

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