Published online by Cambridge University Press: 29 July 2009
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.
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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.
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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.
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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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