theories of justice and right to health care john j estrada, md associate professor of pediatrics...

Theories of Justice and Right to Health Care

John J Estrada, MDAssociate Professor of Pediatrics

LSU Health Sciences Center

Access and Equity in Health Care:Two Strangers at the Door

New Orleans, March 15, 2008

OBJECTIVES

• Understand theories of “rights” and how they apply to health care.

• Discuss theories of “justice” and how they apply to health care.

• Introduce principles that should guide health care reform.

RIGHTS

“Self determination”

“education”

“Health care”

“Life”

“Death with dignity”

“Fetus’ right to life”

RIGHTS

MORAL SOCIETY

INDIVIDUAL

LEGAL

CONSTITUTIONAL LAW

SOCIETY

INDIVIDUAL

& RIGHTS

1. Correlative duties2. Arbitration

3. Penalty for interfering

Are legal “rights” the only “rights”?

“Legal rights” are not the “only rights”

CONSTITUTIONAL LAW

SOCIETY

INDIVIDUAL

RIGHTS

MORAL LEGAL

RIGHTS

Legal or Moral entitlement to:

•Obtain or refrain from obtaining a thing.

•Obtain or refrain from obtaining an action.

•Do or refrain from doing something.

Wikepedia’s definition

“Inalienable Rights”

US Constitution:

• Life

• Liberty

• Pursue of happiness

Another Look!

Social Justice

Elements of “Social Justice”

• Human rights

• Fair treatment

• Impartiality

• Equitable share of society’sbenefits

Achieving Social Justice

Left RightProportional

taxation

Incomeredistribution

Propertyredistribution

Freemarkets

“Right to Health”

Affirmed by the Universal Declaration of Human Rights, 1948:

“Everyone has the right to a standard of living adequate for the health and

wellbeing of himself and his family”

Article 25

Universal Health Care

Germany 1883

Switzerland 1911

New Zealand 1938

Belgium 1945

United Kingdom 1946

Sweden 1947

Greece 1961

Japan 1961

Canada 1966

Denmark 1973

Australia 1974

France 1978

Italy 1978

Portugal 1979

Spain 1986

South Africa 1999

Right to Medical Care

Meaning:

“Equal access to equivalent care services”

Right to Medical Care

How do you exercise your right?

The right to health should guarantee :

• Access to medical, preventive and mental health?

• Nutrition, sanitation, and clean environment?

• Occupational health?

If health care is declared a right:

• What is the content of services?

• Who provides the funding?

• On what bases is this right granted?

On what bases is the right granted?

• Need?

• Age?

• Degree of sickness?

• Citizenship?

• Tax paying capacity?

• Merit?

Access Based on Need

• Demand for health care would have no limit

• Is likely to bankrupt the system

• Make individuals less responsible for their own health

Access Based on Markets

Premise:

Goods can be bought and sold freely in the market… the laws of supply and demand…

Reality:

•Medical inflation. $2.1 trill, 16% of US GNP.•Tendency of supply (physicians, hospitals, tests, Rx, devices, technologies) to generate its own demand.•Tax-favored insurance.

NEJM, Feb 7, 2008

Volume 358:549-551

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Market-Based Failure — A Second Opinion on U.S. Health Care CostsRobert Kuttner

Volume 358:549-551 February 7, 2008 Number 6

Access based on Equality

Equality:

Same provision for all regardless of other criteria such as age, health status, gender, income…

Criteria:

What would be the criteria to determine Equality?

Adapted from Durand-Zaleski

Access Based on Merit

Obtain health care if you are

worthy of it:

Smoker = higher premiums

Participate in yearly screening =free dental care

Problems:

Discrimination?

From Durand-Zaleski

Access Based on Degree of Sickness

Principle:Persons who are similarly ill are

treated similarly… regardless of

other socio economic factor such

as wealth, race, geographical

Location, etc

Caveats:• Doesn’t mean all illnesses will be

treated…

• There should be rationing of access

Medical Care

Health Disparities

Access & Allocation Justice & Health Policy

Over-treatment

Under-treatment

Social Determinants of Well-Being

• Health

• Personal security

• Reasoning

• Respect

• Attachment

• Self-Determination

Social Justiceby Powers and Faden

Oxford Univ Press, 2006

Health Care Reform Questions

• Treat health as a consumer product, privilege, charity, entitlement?

• Financial incentives to limit delivery of care?• Goal of universal access to care, with attention to

those who are most vulnerable?• Offer steps towards more accessible quality of

care?• Does it set minimum standards of comprehensive

quality of care for all?

NESRI & NHeLP, 2008

Over-treatment

Under-treatment

Expandfederal Programs

Regulation of Health care industry