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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
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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.
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RIGHTS
“Self determination”
“education”
“Health care”
“Life”
“Death with dignity”
“Fetus’ right to life”
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RIGHTS
MORAL SOCIETY
INDIVIDUAL
LEGAL
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CONSTITUTIONAL LAW
SOCIETY
INDIVIDUAL
& RIGHTS
1. Correlative duties2. Arbitration
3. Penalty for interfering
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Are legal “rights” the only “rights”?
“Legal rights” are not the “only rights”
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CONSTITUTIONAL LAW
SOCIETY
INDIVIDUAL
RIGHTS
MORAL LEGAL
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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
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“Inalienable Rights”
US Constitution:
• Life
• Liberty
• Pursue of happiness
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Another Look!
Social Justice
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Elements of “Social Justice”
• Human rights
• Fair treatment
• Impartiality
• Equitable share of society’sbenefits
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Achieving Social Justice
Left RightProportional
taxation
Incomeredistribution
Propertyredistribution
Freemarkets
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“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
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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
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Right to Medical Care
Meaning:
“Equal access to equivalent care services”
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Right to Medical Care
How do you exercise your right?
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The right to health should guarantee :
• Access to medical, preventive and mental health?
• Nutrition, sanitation, and clean environment?
• Occupational health?
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If health care is declared a right:
• What is the content of services?
• Who provides the funding?
• On what bases is this right granted?
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On what bases is the right granted?
• Need?
• Age?
• Degree of sickness?
• Citizenship?
• Tax paying capacity?
• Merit?
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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
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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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FREE NEJM E-TOC HOME | SUBSCRIBE | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | Search Term Advanced Search
Institution: LSU HEALTH SCIENCES CENTER LIBRARY | Sign In as Individual| Contact Subscription Administrator at Your Institution | FAQ
Market-Based Failure — A Second Opinion on U.S. Health Care CostsRobert Kuttner
Volume 358:549-551 February 7, 2008 Number 6
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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
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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
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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
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Medical Care
Health Disparities
Access & Allocation Justice & Health Policy
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Over-treatment
Under-treatment
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Social Determinants of Well-Being
• Health
• Personal security
• Reasoning
• Respect
• Attachment
• Self-Determination
Social Justiceby Powers and Faden
Oxford Univ Press, 2006
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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
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Over-treatment
Under-treatment
Expandfederal Programs
Regulation of Health care industry