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Defining the Medical Sphere

Published online by Cambridge University Press:  29 July 2009

Margo J. Trappenburg
is Assistant Professor of Political Science at Leyden University, The Netherlands.


Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls' A Theory of Justice in 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls' A Theory of Justice has been remodeled for healthcare philosophy by Norman Daniels. Nozick's libertarian manifesto Anarchy, State, and Utopia has been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare.

Special Section: Expanding the Boundaries of Bioethics
Copyright © Cambridge University Press 1997

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1. Rawls, J. A Theory of Justice, Cambridge (MA): Harvard University Press, 1971.Google Scholar

2. Nozick, R. Anarchy, State, and Utopia. New York: Basic Books, 1974.Google Scholar

3. Walzer, M. Spheres of Justice: A Defence of Pluralism and Equality. New York: Basic Books, 1983.Google Scholar

4. Cf. Dworkin, R. To each his own, The New York Review of Books 1983;14 Apr:4–6 and Barry B. Liberty and Justice: Essays in Political Theory 2. Oxford: Clarendon Press, 1991:9–22.Google Scholar

5. See for example: Miller, D. Complex equality. In: Miller, D, Walzer, M, eds. Pluralism, Justice, and Equality. Oxford: Oxford University Press, 1995:197225;CrossRefGoogle ScholarAndre, J. Blocked exchanges: a taxonomy. In: Miller, D, Walzer, M, eds. Pluralism, Justice, and Equality. Oxford: Oxford University Press, 1995:171–96;CrossRefGoogle ScholarCarens, J. Complex justice, cultural differences, and political community. In: Miller, D, Walzer, M, eds. Pluralism, Justice, and Equality. Oxford: Oxford University Press, 1995:4566;CrossRefGoogle ScholarVeen, RJ van der. Sociale zekerheid: een omstreden verdelingsdomein. In: van den Berg, P, Trappenburg, MJ, eds. Lokale Rechtvaardigheid [Local Justice]. Zwolle: Tjeenk Willink, 1994:1540.Google Scholar

6. Bovens, MAP. Tussen Kant en conventie. De rechtvaardiging van beginselen van rechtvaardigheid [Between Kant and convention. Justifying principles of justice], Acta Politica 1988;23:333–57.Google ScholarOther members of the family of universalist thinkers include Bruce Ackerman (Ackerman BA. Social Justice in the Liberal State. New Haven: Yale University Press, 1981),Google ScholarPubMedDworkin, Ronald (Dworkin, RAMatter of Principle. Cambridge: Harvard University Press, 1985),Google Scholar and Rothbard, Murray (Rothbard, M. For a New Liberty: The Libertarian Manifesto. New York: Herz, , ed. Collier Books, 1978).Google Scholar In his later work Rawls has rewritten his theory in order to make it less universalist (Rawls, J. Political Liberalism. New York: Columbia University Press, 1993).Google Scholar

7. Maclntyre, A. After Virtue. London: Duckworth, 1981.Google Scholar

8. Barber, B. Strong Democracy: Participatory Politics for a New Age. Berkeley: University of California Press, 1984.Google Scholar

9. Bellah, RN. Habits of the Heart: Individualism and Commitment in American Life. Berkeley: University of California Press, 1985.Google Scholar

10. See note 6, Bovens 1988.

11. Walzer, M. Liberalism and the art of separation. Political Theory 1984;12:315–30.CrossRefGoogle Scholar

12. See note 3, Walzer 1983:318.

13. Cf. Cohen, J. Review of Spheres of Justice. Journal of Philosophy 1986;83:457–68.Google Scholar

14. Daniels, N. Just Health Care. Cambridge: Cambridge University Press, 1985;CrossRefGoogle ScholarPubMedDaniels, N. Am I My Parents' Keeper? An Essay on Justice between the Young and the Old. Oxford: Oxford University Press, 1988.Google Scholar

15. Elster, J. Solomonic Judgements. Studies in the Limitations of Rationality. Cambridge: Cambridge University Press, 1989:210.Google Scholar

16. Daniels, N. Am I My Parents' Keeper? An Essay on Justice between the Young and the Old. Oxford: Oxford University Press, 1988.Google Scholar Similar conclusions are reached by Dworkin in his ‘prudent insurance’ scheme, which may be characterized as a quasi-Rawlsian approach. See Dworkin, R. Will Clinton's plan be fair? The New York Review of Books 1994;13: 01:20–5.Google Scholar Cf., however, Keasberry, H. Reddingssloep-ethiek [Lifeboat ethics]. In: Jacobs, FCLM, van der Wal, GA, eds. Medische Schaarste en het Menselijk Tekort [Medical Scarcity and Human Imperfection]. Baarn: Ambo, 1988:143–69 for a Rawlsian approach reaching different conclusions.Google Scholar

17. Walzer, M. Interpretation and Social Criticism. Cambridge (MA): Harvard University Press, 1987.Google Scholar

18. Engelhardt, HT Jr. The Foundations of Bioethics. Oxford: Oxford University Press, 1986:341.Google ScholarPubMed

19. Lyons, D. The new Indian claims and original rights to land. In: Paul, J, ed. Reading Nozick. Totowa: Rowman & Allanheld, 1981:355–79.Google Scholar

20. Oversloot, J. Klein bezwaar tegen het libertarisme [Small objection to libertarianism]. De Vrijbrief 1995;20:13–4.Google Scholar

21. Bovens, MAP, Liberalisme als gemeenschap [Liberalism as community]. In: de Beus, JW, Lehning, PB, eds. Beleid voor de Vrije Samenleving [Policy for a Free Society]. Meppel, Amsterdam: Boom, 1990:105–29.Google Scholar

22. Callahan, D. Minimalist ethics: on the pacification of morality. In: Caplan, AL, Callahan, D, eds. Ethics in Hard Times. New York: Plenum Press, 1981:261–81, 263.CrossRefGoogle Scholar

23. Callahan, D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster, 1987:43.Google Scholar

24. See note 5, Andre 1995.

25. Cf. Walzer, M. Just and Unjust Wars. A Moral Argument with Historical Illustrations. New York: Basic Books, 1977:xi.Google Scholar I am indebted to an anonymous reviewer for noting at this point that such reevaluation itself entails some concept of justice, and that we might then be caught in a circular argument.

26. This is both a normative and a factual question. In Walzer's theory these two are inextricably linked. Normative standards are hidden in factual institutional arrangements.

27. See note 4, Dworkin, 1983.Google Scholar

28. Walzer, M. Spheres of justice: an exchange. The New York Review of Books 1983;21 07:43–6.Google Scholar

29. See note 27, Dworkin, 1983.Google Scholar

30. See note 28, Walzer, 1983.Google Scholar

31. See note 3, Walzer, 1983:8687.Google Scholar

32. Cf. Veatch, RM, ed. Medical Ethics. Boston: Jones and Bartlett Publishers, 1989.Google ScholarPubMed“The Hippocratic Oath is often acknowledged by both physicians and lay people to be the foundation of medical ethics for physicians in the West” (p. 7)Google Scholar. “[T]he Hippocratic Oath has been elevated to premier status among physicians as the summary of their sense of ethical obligation. What was once a code of a minority medical group became the dominant ethical document for all professional medicine in the West.” (p. 9).Google Scholar

33. See note 3, Walzer, 1983:156–7, italics added.Google Scholar

34. Of course, there are exceptions to this rule. Sometimes welfare workers will fulfill individual needs of their clients. However, a welfare recipient who is in desperate need for champagne, cigarettes, a large car, or a motorbike will not get what he needs, no matter how needy he feels. A patient, on the other hand, can have expensive needs (say, for a liver transplant) and his doctor will try his utmost to fulfill them.

35. Cf. Kuitert, H. Mag Alles Wat Kan? Ethiek en Medisch Handelen [May We Do Everything We Can? Ethics and Medicine]. Baarn: Ten Have, 1989.Google Scholar

36. See note 16, Dworkin, 1994:22, italics added.Google Scholar

37. Surely there will be people who insist on being treated till the very end. There are always exceptions to my general argument and in the medical sphere there is ample room for them. After all, doctors are supposed to treat individual patients in accordance with their individual needs; as I said, this does not and should not resemble the welfare distributional logic. A doctor cannot tell his patients ‘No one would want to live in your position, so I am not going to treat you’; he is supposed to be there for the patient he is treating, not for patients or people in general.

38. Does this mean there can be no external budget? There can be, insofar as it would help doctors choosing the most cost-efficient treatment for their patients. However, an external budget should never be an absolute brake on medical spending.

39. Of course this does not mean that anything that has not been defined as medical treatment should be outlawed for that reason. One can buy vacation, placebos, homeopathic medicine, and so forth in the sphere of ‘money and commodities’ through a process of free exchange.

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