Healthcare and distributive justice

"Distributive justice" <- How goods "ought" to be distributed.

It comes up in matters of scarce resources, when we haven't got enough to give everyone everything

This can be macro allocation - distributing resources between different services and micro allocation - allocating treatments betweeb individuals

Distributive justice

There are differences between justice and equality.

Most would not argue for every single person to get the exact amount of healthcare. As some people "need more", but how do we decide who needs what or who deserves what?

"We need to determine which of the differences between people are morally relevant"

How to approach this? Consequentialist vs Non Consequentialist

Consequentialist

So a consequentialist view often looks at "cost-effectiveness", this is another "greatest good for the greatest number", or a "most bang for your buck" approach.

One way is using QALYs (Quality Adjusted Life Years). This is an economic approach

So a QALY would state a treatement that gains 1 additional year of healthy life is one QALY. A treatment that gains additional quantity of life with "less quality" (more impairment), would be less than 1 QALY. And A treatment that improves quality without quantity would do something similar.

NICE use QALYs in resource allocation

QALY Problems

1) Is a QALY any use as a measure? (Who decides what Quality is gained? The patient or society at large, It only pays attention to the QUALITY gained by the patient, and not the quality gained to the people around the patient)

2) Does QALY treat people equally? The sicker people may gain less quality per intervention, so then may get disadvantaged against

3) QALY according to Harris (1987) discriminates against older people and those with disabilities and illnesses. In "indirect discrimination"

Allocation according to need

So this is saying that peoples different needs are a "morally relevant difference". This is holding first that needs are differents to wants. Basically we should focus on the foundations of what people need when allocating resources, ignoring some of their wants (so cancer trumps pain control which in turn trumps cosmetic surgery would be an example.)

The difficulty here is we then need to work out what ther threshold is between a need and a want.

Wiggins says "in order to flourish as a human being" - but then you need to decide what flourishing as a human being means.

And then "allocation according to need" still doesn't tell you what to do when you have more needs than resources

Contractualism

The right thing to do would be what people would agree upon if they were free and equal.

This was put forward by Hobbes, Locke, and Rousseau. They used it to argue for the state, if the state didn't exist we'd have to invent it to protect us.

Rawls also puts forward a similar thing, but he talks about the "veil of ignorance". What would you decide would be fair for everyone, if you didnt know which part of society you would end up in yourself.

This might put us at the other end of majority vs minority (where utilitarian QALYs may put too heavy priority on majority interests, contractualist may put all the emphasis on minority interests)

Daniels puts forwards a contractualist, arguing healthcare allocation should be on the basis of giving a baseline level of health to allow equality of opportunities.

Dworkin gives a hypothetical "insurance model". Where society allocates treatment resources at the level that people would choose to insure against, when they had equal share of resources but had to pay insurance premiums, if they didn't know their own health. Dworkin uses this as he says people wouldn't allocate their own insurance funds on expensive less effective treatments.

Luck egalitarianism

Dworkin then argues that society should provide resources to rectify inequalities due to bad luck but not due to bad choices. So this would argue we shouldn't give as much to smoking, alcohol, etc.

But then we have to work out what is luck and what is choice. When a lot of choices have social determinants. And then what about more "wholesome" choices like sport and exercise injuries. Or someone who is injured due to a noble risk taking for the good of others, what would we do for the firefighters who went into the burning twin towers for example?

Age

Some argue treating younger patients not just for cost effectiveness (more life years saved) but also it's fairness, everyone should get a certain amount of life.

Accountability

Daniels and Sabin argue we won't agree on what principles to use to guide resource allocation. So instead we should try and agree what is a "fair process"

They call this "Accountability for Reasonableness", where even if you don't agree with the decision, you can see that it follows reasonable standards. These standards were:

1) Publicity - These decisions and their criteria must be public 2) Relevance - The criteria must be ones fair-minded people would agree are relevant in the context 3) Challenge/Revision - Must be opportunites for challenging decisions/resolving disputes 4) Regulation - There should be regulation of the process to ensure the first 3 standards

The problem with Accountablity of Reasonableness is mainly with point two. How do we decide who is fair minded, how do we decide what is relevant?

But also, if loads of different approaches can follow these standards, does that mean they're all correct? Or have we just not worked out which one is correct?