Several prominent writers including Norman Daniels, James Sabin, Amy Gutmann, Dennis Thompson and Leonard Fleck advance a view of legitimacy according to which, roughly, policies are legitimate if and only if they result from democratic deliberation, which employs only public reasons that are publicised to stakeholders. Yet, the process described by this view contrasts with the actual processes involved in creating the Affordable Care Act and in attempting to pass the Health Securities Act. Since the ACA seems to be legitimate, (...) as the HSA would have been had it passed, there seem to be counterexamples to this view. In this essay, I clarify the concept of legitimacy as employed in bioethics discourse. I then use that clarification to develop these examples into a criticism of the orthodox view–that it implies that legitimacy requires counterintuitively large sacrifices of justice in cases where important advancement of healthcare rights depends on violations of publicity. Finally, I reply to three responses to this challenge: that some revision to the orthodox view salvages its core commitments, that its views of publicity and substantive considerations do not have the implications that I claim and that arguments for it are strong enough to support even counterintuitive results. My arguments suggest a greater role for substantive considerations than the orthodox view allows. (shrink)

Temkin asks how we should distribute resources between the social determinants of health and health care; Sreenivasan argues that if our goal is fair opportunity, funding universal health coverage is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly than he claims: it applies to any argument for UHC based on health (...) equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given what Sen calls the multidimensional nature of health equity and the role of UHC in cost containment, UHC may not be a threat to health equity. I also argue against Sreenivasan's claim that the data he discusses should not trouble sufficientists and prioritarians. The worst-off are not simply lagging in improvement; rather, their health status is stagnating or worsening. (shrink)

Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health care justice, and outlines a new approach that can (...) justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)