This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and James Wilson argues that healthcare is not of special importance if social determinants of health have a major causal impact on population health. Annette Rid is concerned that the (...) relevance condition in accountability for reasonableness is unclear and does little work. Harald Schmidt aims to flesh out where an account of responsibility for health should go since one is under-developed in Just health. Michael Schefczyk and Susanne Brauer challenge aspects of the prudential lifespan account. Samia Hurst asks what impact a population view should have on clinician obligations. (shrink)

In the literature on the subject there is a trend towards understanding the idea of rationing in healthcare very broadly, to include any form of restriction in supply. It is suggested in this paper that there are good reasons to resist this move, since it would both render the concept redundant through being trivially true and displace an earlier, egalitarian one that retains great moral significance for the supply of healthcare. The nature and significance of the narrower, egalitarian conception is (...) set out, drawing particular attention to the fact that it marks a contrast with the idea of prioritising certain people or groups over others and to the fact that it is a form of rationing that is plausibly regarded as a morally desirable response to severe shortages. It is contrasted with the broad conception and arguments in favour of this latter are considered and rejected. (shrink)

In this paper, I examine the conflicts between autonomy and justice. The problem of justice in healthcare concerns both micro-allocation and macro-allocation. The latter has to do with distributive justice: who should get what healthcare resources at whose expense. The current debate about healthcare reform brings up two competing models of distributive justice from political philosophy. The libertarian theory holds to the ideal of individual responsibility and choice, viewing taxation for the purpose of providing goods to those who cannot afford (...) them as a form of unjustified coercion. The liberal theory holds that society should ensure that all members are provided with basic goods that correct for inequalities that deprive them of human dignity. Even though both theories value individual choice, these theories provide opposing answers to the question of whether taxes should be collected and used for the purpose of ensuring universal access to healthcare. In my paper, I show that neither theory can respect patient choice in healthcare and achieve distributive justice. Libertarians ignore the realities of the healthcare system and why a free market where patients choose and pay for what they want cannot exist. Liberals face the problem that the choices that patients make can lead to over-consumption of healthcare at the expense of other goods important to society. (shrink)

El contexto de crisis y restricciones presupuestarias sirve de pretexto para promover en la Comunidad de Madrid la implantación de un modelo dual de gestión de los centros y servicios sanitarios, ampliamente contestado en la calle por profesionales sanitarios, asociaciones, pacientes y usuarios. Este proceso se inicia sin evidencia científico-técnica que avale las presuntas ventajas del modelo de concesión y carece de una evaluación solvente de impacto sanitario, conforme a estándares de transparencia, rendición de cuentas y calidad democrática. Entre los (...) aspectos éticos y jurídicos involucrados en este debate analizo los relacionados con el conflicto de intereses y las evidencias recientes que desaconsejan adoptar en España modelos similares. Tras analizar el desafío que supone el nuevo marco institucional para el ejercicio de la responsabilidad profesional conforme a criterios de equidad y buenas prácticas, se concluye aportando elementos para generar un marco más equilibrado de reformas. (shrink)