Universal health coverage (UHC) is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services. This document is the final report of the WHO Consultative Group on Equity and Universal Health Coverage. The report addresses the key issues of fairness and equity that arise on the path to UHC. As such, the report is relevant for every actor that affects that path and governments in (...) particular, as they are in charge of overseeing and guiding the progress toward UHC. (shrink)

This paper argues that societal duties of health promotion are underwritten (at least in large part) by a principle of beneficence. Further, this principle generates duties of justice that correlate with rights, not merely “imperfect” duties of charity or generosity. To support this argument, I draw on a useful distinction from bioethics and on a somewhat neglected approach to social obligation from political philosophy. The distinction is that between general and specific beneficence; and the approach from political philosophy (...) has at times been called equality of concern. After clarifying the distinction and setting out the basis of the equality of concern view, I argue that the result is a justice-based principle of “specific” beneficence that should be reflected in a society’s health policy. I then draw on this account to criticize, refine, and extend some prominent health care policy proposals from the bioethics literature. (shrink)

The objective of the paper is to explore the issue that despite the absence of adequate formal and systematic ways for the poor and disadvantaged people to get access to health benefit like in a rich liberal society, there are active social customs, feelings and individual and collective responsibilities among the people that help the disadvantaged and poor people to have access to the minimum health care facility in both liberal and non-liberal poor countries. In order to (...) explain the importance and functional contribution of the social norms in this respect, some examples will be illustrated from Bangladesh which is a poor liberal country. There will be two sections of the paper. In the first section, it will be exhibited how the naturally and socially disadvantaged people in a liberal society get benefit following Rawls‟ theory of distributive justice. In the second section, it will be showed that in a poor country where there are less resources of the government to provide enough services to the poor and disadvantaged people, the communal feelings and the informal social institutions play a vital role that helps the disadvantaged and poor people to get access to the health benefit. The traditional social norms impose indirect sanction on its people to come forward to help the worse off people of the country. It is depicted that Rawlsian theory of distribution does not work properly in these countries, rather the communitarian feelings is more welcomed for the benefit of the overall welfare of the society and this will be shown in the conclusion of the paper. (shrink)

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, (...) where theorizing about just principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that (...) threaten to drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

Background: Transgender health care is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion of ethical considerations in providing care. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in the ethical aspects (...) of clinical support for gender diverse and transgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on general ethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter in transgender health care, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the four ethical principles as applied to transgender health care. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access to care. Some of the ethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, for transgender and nonbinary people, particularly youth, seeking medical care. Discussion: We highlight the interplay between ethical principles and clinical practice, underscoring the need for ethical guidance in addressing the diverse challenges faced by healthcare providers and patients in transgender health care. We advocate for continuous refinement of ethical thinking to ensure that transgender health care is not only medically effective but also ethically sound. (shrink)

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical question is whether (...) efficiency is the correct criterion, in terms of social justice and individual needs. (shrink)

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) “Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails (...) a commitment to both distributive and recognitive justice. The disability rights movement's demand “Nothing about us, without us” requires substantive inclusion of disabled people in decision‐making related to their interests, including in crisis planning before, during, and after a pandemic like Covid‐19. (shrink)

For a long time, discussion about scarce health care resource allocation was limited to allocation of medical resources, with the paradigmatic case being kidney transplants. This narrow focus on medical resource prevents us from seeing that there are many cases-- perhaps even the majority--in which time is the real scarce resource, particularly nurse time. What ethical principles should apply to nurse time as a scarce health care resource?

The application of Artificial Intelligence (AI) in healthcare and epidemiology undoubtedly has many benefits for the population. However, due to its environmental impact, the use of AI can produce social inequalities and long-term environmental damages that may not be thoroughly contemplated. In this paper, we propose to consider the impacts of AI applications in medical care from the One Health paradigm and long-term global health. From health and environmental justice, rather than settling for a short (...) and fleeting green honeymoon between health and sustainability caused by AI, it should aim for a lasting marriage. To this end, we conclude by proposing that, in the upcoming years, it could be valuable and necessary to promote more interconnected health, call for environmental cost transparency, and increase green responsibility. (shrink)

The proposition that digital innovations can put people in charge of their health has been accompanied by prolific talk of empowerment. In this paper we consider ethical challenges and opportunities of trying to achieve justice and empowerment using digital health initiatives. The language of empowerment can misleadingly suggest that by using technology, people can control their health and take responsibility for health outcomes to a greater degree than is realistic or fair. Also, digital health (...) empowerment often primarily reaches people who already have high technological and health literacy, leaving others behind. We critically investigate whether the concept of health empowerment could be re-engineered to mean something different, namely the process of improving the health literacy and access of those who least possess it, in line with recent proposals for conceptual engineering in the service of justice. We settle on the weaker conclusion that underlying ethical values including justice should be used to interpret the existing concept of empowerment. To conclude, we take a high-level view of various strategies for achieving the ethical value associated with digital health empowerment. (shrink)

The problem of standard of care in clinical research concerns the level of treatment that investigators must provide to subjects in clinical trials. Commentators often formulate answers to this problem by appealing to two distinct types of obligations: professional obligations and natural duties. In this article, I investigate whether investigators also possess institutional obligations that are directly relevant to the problem of standard of care, that is, those obligations a person has because she occupies a particular institutional role. (...) I examine two types of institutional contexts: (1) public research agencies – agencies or departments of states that fund or conduct clinical research in the public interest; and (2) private-for-profit corporations. I argue that investigators who are employed or have their research sponsored by the former have a distinctive institutional obligation to conduct their research in a way that is consistent with the state's duty of distributive justice to provide its citizens with access to basic health care, and its duty to aid citizens of lower income countries. By contrast, I argue that investigators who are employed or have their research sponsored by private-for-profit corporations do not possess this obligation nor any other institutional obligation that is directly relevant to the ethics of RCTs. My account of the institutional obligations of investigators aims to contribute to the development of a reasonable, distributive justice-based account of standard of care. (shrink)

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is (...) because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that (...) a complete theory of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

I outline and defend two egalitarian theories, which yield distinctive and, I argue, complementary answers to why health-related inequalities matter: a brute luck egalitarian view, according to which inequalities due to unchosen, differential luck are bad because unfair, and a social egalitarian view, according to which inequalities are bad when and because they undermine people’s status as equal citizens. These views identify different objects of egalitarian concern: the brute luck egalitarian view directs attention to health-related well-being, while social (...) egalitarianism focuses on health-related capabilities that are central to a person’s status as a citizen. I argue that both views are correct and should jointly guide priority-setting in health. (shrink)

In our recent article, together with more than 60 of our colleagues, we outlined a proposal for drug policy reform consisting of four specific yet interrelated strategies: (1) de jure decriminalization of all psychoactive substances currently deemed illicit for personal use or possession (so-called “recreational” drugs), accompanied by harm reduction policies and initiatives akin to the Portugal model; (2) expunging criminal convictions for nonviolent offenses pertaining to the use or possession of small quantities of such drugs (and releasing those serving (...) time for these offenses), while delivering retroactive ameliorative relief; (3) the ultimate legalization and careful regulation of currently illicit drugs; and (4) the delivery of a new “Marshall Plan” focused on community-building initiatives, expanded harm reduction programs, and social and health care support efforts (Earp et al. 2021). We were gratified to see so many thoughtful commentaries on our proposal, and we respond to them in part in this reply. (shrink)

I critically examine a common liberal egalitarian view about the justification for, and proper content of, mandatory health insurance. This view holds that a mandate is justified because it is the best way to ensure that those in poor health gain health insurance on equitable terms. It also holds that a government should mandate what a representative prudent individual would purchase for themselves if they were placed in fair conditions of choice. I argue that this common justification (...) for a mandate is incomplete. A further reason for mandated insurance is that it helps secure social egalitarian public goods that would be underprovided if insurance were optional. I also argue that rather than mandating what a representative individual would choose for themselves, we should design the mandatory package by appealing to a pluralistic egalitarian view, which cares about improving people’s well-being, reducing unfair inequality, and maintaining egalitarian social relations. (shrink)

Luck egalitarianism provides a reason to object to conditionality in health incentive programmes in some cases when conditionality undermines political values such as solidarity or inclusiveness. This is the case with incentive programmes that aim to restrict access to essential healthcare services. Such programmes undermine solidarity. Yet, most people's lives are objectively worse, in one respect, in non-solidary societies, because solidarity contributes both instrumentally and directly to individuals' well-being. Because solidarity is non-excludable, undermining it will deprive both the prudent (...) and the imprudent citizens of its goods. Thereby, undermining solidarity can make prudent citizens worse off than they would have otherwise been, out of no fault or choice of their own, but rather as a result of somebody else's imprudent choice. This goes against the spirit of luck egalitarianism. Therefore (luck egalitarian) justice can require us to save the imprudent and avoid conditionality in access to essential healthcare services. (shrink)

In response to Ruud ter Meulen’s contribution, it is argued that, although the relationship between these concepts is both tight and complex, solidarity should be carefully distinguished from justice. Although ter Meulen wants to defend a normative conception of solidarity, the relation to its descriptive component is not always very clear. As a normative concept it should not collapse into that of justice; and as a descriptive notion it is obviously defective. In order to successfully navigate between these (...) unhappy alternatives, ter Meulen rightfully turns to critical theory. But then it is still not entirely clear how the normative considerations that ter Meulen wants to defend follow from this promising framework. (shrink)

This paper considers the obligation higher income countries have to lower and middle income countries during a global pandemic. Further considers which reforms are needed to the global supply-chain of medical resources. The short-comings in distribution and medical infrastructure have exacerbated the health crisis in developing countries. Global justice demands radical redistribution of medical resources in order to prevent mass casualties. This is argued first by highlighting that the COVID-19 pandemic should be acknowledged as an issue of global (...) justice, secondly, higher income countries ought to account for distribution inequity as a matter of rectifying past injustices, and thirdly argue for reform in distribution while considering the vaccine rollout as a prime example. We aim to show how the differences from country to country in response capabilities are a result of the economic foundation colonialism established and a direct result of cyclical poverty, which wealthy countries perpetuate to this day. (shrink)

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with (...) ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D. (shrink)

The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. (...) Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

In a recent article, Marilyn Baffoe-Bonnie offers three arguments for conducting CRISPR/Cas9 biotechnology research to cure sickle-cell disease (SCD) based on addressing historical and current injustices in SCD research and care. I show that her second and third arguments suffer from roughly the same defect, which is that they really argue for something else rather than for conducting CRISPR/Cas9 research in particular. For instance, the second argument argues that conducting this gene therapy research would improve the relationship between SCD (...) sufferers (who are mostly of African descent) and health care providers. But really what is essential in improving this relationship is for those providers to genuinely care and be concerned, and this could be lacking even with the CRISPR research being done. Indeed, this relationship could be improved even without that research being done, as long as there is genuine concern. Thus, this argument actually argues for the need for genuine concern. As for the third argument, one (of two) problems arises because it claims that CRISPR research for SCD should be pursued because the benefits would be shared by even non-research-participants, as non-participants would be encouraged. However, this argues for any research for SCD, not for CRISPR research in particular. I conclude that a better justice-based argument will use only Baffoe-Bonnie’s first argument, which is based on historic neglect of an actual cure for SCD (going beyond merely management or transplant therapies). (shrink)

Analysing the demands of global justice for the distribution of resources is a complex task and requires consideration of a broad range of issues. Of particular relevance is the effect that different distributions will have on global population growth and individual welfare. Since changes in the consumption and distribution of resources can have major effects on the welfare of the global population, and the rate at which it increases, it is important to establish meaningful principles to ensure a just (...) distribution of resources. In order to establish such principles we must consider the scope of any reproductive rights, and rights to other goods, such as food and health care, as well as examine the extent of duties correlating to those rights. In addition to the impact that distributions of global goods have on the welfare of current generations, it is also important to consider what duties we have, if any, to future generations. -/- The final version of this paper is available to download here: http://dx.doi.org/10.1002/9780470015902.a0024140. (shrink)

A society is said to age when its number of older members increases in relation to its number of younger members. The societies in most of the world’s industrialized nations have been aging since at least 1800. In 1800 the demographic makeup of developed countries was similar to that of many Third World countries in the early 1990s with roughly half the population under the age of 16 and very few people living beyond age of 60. Since that time, increases (...) in life expectancy, combined with declines in fertility rates, have dramatically increased the proportion of older persons in developed nations. The rapid increase in the number of older persons relative to younger ones carries important societal implications. In the domain of healthcare, societal aging will increase costs and exert greater pressure to ration services. It will, thus, bring to the fore questions, regarding a just distribution of healthcare between young and old age groups. This paper considers some of the most influential arguments to date for age-based rationing of health care. I show that these arguments fall short, and that the theoretical assumptions underlying them do not withstand careful scrutiny. (shrink)

This thesis under the title “Public Health Policy in Resource Allocation: the Role of Ubuntu Ethics in Redressing Resource Disparity between Public and Private Healthcare in South Africa” explores health care disparities pertaining to resource allocation between public and private sector. It is of relevance and importance in South Africa where 54% of the population live on less than US$3 per day. Although the government has instituted certain changes aimed at transforming the public health care (...) system, the resource allocation gap between the two persists and remains wide. The research gives special attention to the role that Ubuntu ethics can play in redressing the resource allocation disparities between public and private health care sectors in South Africa, pointing out the existing gap in financing, as well as human resource between public and private health care sectors, which leads to poor health outcomes in public sector. Therefore, the problem is the prevalent inequality of resource allocation between private and public health care sectors. The analysis of policy gaps, as well as evaluating the cause of disparities in the health system is the goal of this research. The study endeavours to redress the disparities within the context of Ubuntu ethical principles and proposes a change in public policy so as to enhance healthcare for the benefit of the people. The study is philosophical and ethical, so the methodology used is discursive in nature, majorly focusing on critically reviewing existing literature, that is, the philosophical resources on Ubuntu ethics and justice theories as well as a range of government resources inclusive of public health policy documents. Social determinants of health and their impact in a South African context are discussed with the implication that health is not merely freedom from disease and or incapacity, but rather being well mentally, physically and socially. The attainment of a healthy status goes beyond ability to access healthcare services, and incorporates social determinants including but not limited to conditions in which people have been born into, stay, establish career and grow old in. It also includes the arrangements put in place to deal with illness and determine health. Issues of revenue, literacy, communal safety networks, vocation and conditions under-which vocation is undertaken, lack of work and vocation insecurity, early stages of human development, gender, cultural group, dietary insecurity, housing communal exclusion and disability all come into the picture as factors that determine health. But there is also discussion of the socio-economic status as contributors to health inequity wherein alcohol abuse, sugar intake, and smoking are identified as behavioural factors that complicate public health. One outstanding feature of this research is that it establishes a link between Ubuntu and public health policy. The researcher establishes that Ubuntu ethics is appropriate for not only discussing public morality, but also for formulating public policy that is morally tenable for South Africa, especially for the public health sector. This thesis calls for an application of Ubuntu in a proper context in order to enhance societal well-being for the benefit of many, if not all. The research proposes the fundamental principle of Ubuntu ethics in which the good of the community is as important as the good of every member of the community. Since Ubuntu ethics does not merely seek to fulfil what benefits the majority, as would be the case in a utilitarian society, the researcher advocates for the building of consensus on the common good, which should be understood to imply not just what is good for everyone in the community, but also what is good for the continued well-being of the community as a single unit. In this regard, the research finds it important that deliberate effort be made to integrate Ubuntu ethics into policies, citing the example of the National Health Insurance (NHI). The good health of all the members of a community is an assurance of the well-being and continuity of the whole national community. The research concludes that public health policy should integrate Ubuntu ethical values such as community, sharing, care, solidarity, identity, harmony, respect, and dignity into policy documents and legislation. (shrink)

We consider an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the (...) worst off. (shrink)

This paper seeks to provide an overview of some of the main areas of debate that have emerged in recent years at the interface between theories of justice and health care. First, the paper consi- ders various positions as to what the index of justice with respect to health ought to be. It warns on practical and principled grounds against conceptual inflation of the notion of "health" as it appears in theories of distributive (...) class='Hi'>justice. Second, it considers how various standards according to which goods ought to be distributed in a just society apply to debates within health care. (shrink)

The increased complexity of health information management sows the seeds of inequalities between health care stakeholders involved in the production and use of health information. Patients may thus be more vulnerable to use of their data without their consent and breaches in confidentiality. Health care providers can also be the victims of a health information system that they do not fully master. Yet, despite its possible drawbacks, the management of health information is (...) indispensable for advancing science, medical care and public health. Therefore, the central question addressed by this paper is how to manage health information ethically? This article argues that Paul Ricœur’s ‘‘little ethics’’, based on his work on hermeneutics and narrative identity, provides a suitable ethical framework to this end. This ethical theory has the merit of helping to harmonise self-esteem and solicitude amongst patients and healthcare providers, and at the same time provides an ethics of justice in public health. A matrix, derived from Ricœur’s ethics, has been developed as a solution to overcoming possible conflicts between privacy interests and the common good in the management of health information. (shrink)

This article challenges the use of social deprivation as a punishment, and offers a preliminary examination of the human rights implications of exile and solitary confinement. The article considers whether a human right against coercive social deprivation is conceptually redundant, as there are recognised rights against torture, extremely cruel, inhumane, or degrading treatment as well as rights to basic health care, education, and security, which might encompass what this right protects. The article argues that the right is not (...) conceptually redundant, but that, even if it were, there would be significant reasons to articulate it. (shrink)

The term “environmental justice” carries with it a sort of ambiguity. On the one hand, it refers to a movement of social activism in which those involved fight and argue for fairer, more equitable distribution of environmental goods and equal treatment of environmental duties. This movement is related to, and ideally informed by, the second use of the term, which refers to the academic discipline associated with legal regulations and theories of justice and ethics with regard to sustainability, (...) the environment, and ecology. It is this latter, more academic—though vast and interdisciplinary—use of the term that is the subject of this essay. However, activists who pay careful attention to the arguments offered with regard to the political, legal, social, and philosophical treatments of these issues are potentially in a stronger position with regard to their own social movement. In that way, the two uses of the term may progress hand in hand. More broadly, however, the foundational claim about which both grassroots activists and legal, ethical, and policy advocates can agree is that environmental burdens—climate change, pollution, and their associated health risks—are borne disproportionately by the poorest and most vulnerable populations, and tend to have the greatest impact on racial and ethnic minorities, no matter where they are in the world. This is what makes the empirical questions about the environment a normative question about justice. (shrink)

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I (...) also argue against an overly strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort. (shrink)

Recent epidemiological research on the social determinants of health has been used to attack an important framework, associated with Norman Daniels, that depicts healthcare as special. My aim is to rescue the idea that healthcare has special importance in society, although specialness will turn out to be mainly limited to clinical care. I build upon the link between Daniels's theory and the work of John Rawls to develop a conception of public justification liberalism that is suitable to the (...) field of justice and health. I argue that, from the perspective of public justification liberalism, (clinical) healthcare deserves special status. (shrink)

Some bioethicists and political philosophers argue that rich states should restrict the immigration of health workers from poor countries in order to prevent harm to people in these countries. In this essay, I argue that restrictions on the immigration of health workers are unjust, even if this immigration results in bad health outcomes for people in poor countries. I contend that negative duties to refrain from interfering with the occupational liberties of health workers outweighs rich states' (...) positive duties to prevent harm to people in sending countries. Furthermore, I defend this claim against the objection that health workers in poor countries acquire special duties to their compatriots that render them liable to coercive interference. (shrink)

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order (...) to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident. (shrink)

Common principles for resource allocation in health care can prioritize the alleviation of small health burdens over lifesaving treatment. I argue that there is some evidence that these principles are at odds with a sizable share of public opinion, which holds that saving a life should take priority over any number of cures for minor ailments. I propose two possible explanations for this opinion, one debunking and one vindicatory. I also outline how well-designed surveys and moral inquiry (...) could help decide between them. Finally, I consider how priority-setting principles could be adjusted if the view that saving a life always trumps alleviating small burdens were vindicated. (shrink)

This article makes a moral argument for universal access to health care and for the legitimate function of government to guarantee that access. Constructed as a reply to the libertarian argument against universal access, this article utilizes the moral and political theory of John Locke, favored by libertarianism, to develop a Lockean argument for a view contrary to the libertarian philosophy. In particular, the argument here shows how libertarianism’s neglect of a crucial element of the natural-law tradition, to (...) which Locke adhered, not only undercuts the libertarian objection to universal access to health care but also underwrites an alternative argument in favor of such. (shrink)

This report from the WHO Consultative Group on Equity and Universal Health Coverage offers advice on how to make progress fairly towards universal health coverage.

When, if ever, can healthcare provider's lay claim to knowing what is best for their patients? In this paper, I offer a taxonomy of clinical disagreements. The taxonomy, I argue, reveals that healthcare providers often can lay claim to knowing what is best for their patients, but that oftentimes, they cannot do so *as* healthcare providers.

This chapter argues that rather than viewing transparency as a right, we should regard it as a finite resource whose allocation involves tradeoffs. It then argues that those tradeoffs should be resolved by using a multi-principle approach to distributive justice. The relevant principles include maximizing welfare, maximizing autonomy, and giving priority to the worst off. Finally, it examines some of the implications for law of recognizing the tradeoffs presented by transparency proposals.

Considerations of autonomy and independence, properly understood, support strictly egalitarian provision of necessary medical treatment. If the financially better-off can purchase access to necessary medical treatments that the financially less well-off cannot purchase without help, then their discretionary power to give or to withhold monetary gifts indirectly gives them the power to make life-and-death or sickness-and-health decisions for others. To prevent private citizens from having this objectionable form of power, government must ensure that citizens’ finances do not affect their (...) access to medical treatments that significantly prolong life, relieve suffering, or cure or mitigate disabilities. Government should ensure this even if doing so involves leveling down and even if it is unclear whether egalitarian provision of necessary treatment would provide better care to the poor than a less egalitarian health care system would. (shrink)

The truth about health care policy lies between two exaggerated views: a market view in which individuals purchase their own health care from profit maximizing health-care firms and a control view in which costs are controlled by regulations limiting which treatments health insurance will pay for. This essay suggests a way to avoid on the one hand the suffering, unfairness, and abandonment of solidarity entailed by the market view and, on the other hand, (...) to diminish the inflexibility and inefficiency of the control view. It suggests that the way to mitigate these problems is to recognize the malleability of motivation and the range of factors, in addition to financial incentives, that may influence the behavior of patients and especially physicians. (shrink)

Health care systems can positively influence our personal decision-making and health-related behavior only if we trust them. I propose a conceptual analysis of the trust relation between the public and a healthcare system, drawing from healthcare studies and philosophical proposals. In my account, the trust relation is based on an epistemic component, epistemic authority, and on a value component, the benevolence of the healthcare system. I argue that it is also modified by the vulnerability of the public (...) on healthcare matters, and by the system’s credibility. I apply my proposed analysis of public trust in health care systems to the phenomenon of vaccine hesitancy, a tendency to question vaccine policies, and to seek alternative vaccine schedules or to refuse vaccination. Understanding the role of trust and its components can be key to understanding the phenomenon. (shrink)

Breast cancer treatment is being transformed by artificial intelligence (AI). Nevertheless, most scientists, engineers, and physicians aren't ready to contribute to the healthcare AI revolution. In this paper, we discuss our experiences teaching a new American student undergraduate course that seeks to train the next generation for cross-cultural design thinking, which we believe is critical for AI to realize its full potential in breast cancer treatment. The main tasks of this course are preparing, performing and translating interviews with healthcare professionals (...) from both Portugal and the USA. Since the course is offered in Portugal as a short-term faculty-led study abroad program, students can explore the effect of culture on healthcare delivery and the design of healthcare technologies. The learning tests demonstrated student growth for breast cancer treatment in many areas important for the development of AI. In respect to understanding breast cancer care, most students had undervalued the effect of cancer and its treatment on the quality of life of women before taking this course and most were unaware of the importance of multidisciplinary care teams. Regarding AI in medical, students became more mindful of data privacy issues and the need to consider the effect of AI on healthcare professionals. (shrink)

This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, and freedom–where (...) freedom is understood as independence and self-determination–justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and–although this is arguable–government action to guarantee access to health care does not itself undermine freedom. (shrink)

Citizens in wealthy liberal democracies are typically expected to see to basic needs like food, clothing, and shelter out of their own income, and those without the means to do so usually receive assistance in the form of cash transfers. Things are different with health care. Most liberal societies provide their citizens with health care or health care insurance in kind, either directly from the state or through private insurance companies that are regulated like (...) public utilities. Except perhaps for small co-pays or deductibles, citizens are not expected to see to their health needs out-of-pocket, at least for some basic level of care. Instead, when a citizen gets sick, the state or her insurance company foots the... (shrink)

Discussions concerning whether there is a natural right to health care may occur in various forms, resulting in policy recommendations for how to implement any such right in a given society. But health care policies may be judged by international standards including the UN Universal Declaration of Human Rights. The rights enumerated in the UDHR are grounded in traditions of moral theory, a philosophical analysis of which is necessary in order to adjudicate the value of specific (...) policies designed to enshrine rights such as a right to health care. We begin with an overview of the drafting of the UDHR and highlight the primary influence of natural law theory in validating the rights contained therein. We then provide an explication of natural law theory by reference to the writings of Thomas Aquinas, as well as elucidate the complementary “capabilities approach” of Martha Nussbaum. We conclude that a right to health care ought to be guaranteed by the state. (shrink)

Imagine you are the CEO of a hospital [. . .]. Decisions are constantly being made in your organization about how to spend the organization's money. The amount of money available to spend is never adequate to pay for everything you wish you could spend it on, therefore you must set spending priorities. There are two questions you need to be able to answer . . . How should we set priorities in this organization? How do we know when we (...) are doing it well? When people seek to achieve good public policy, the result will tend to be good public policy. In a collective choice process, public‐spirited individual participants produce good public policy by deliberating—talking with each other, listening to each other's arguments, and being willing to learn and change their minds based on such dialogue. –Steven Kelman (1992: 181) Public policy scholars agree that those persons (or agencies) vested with the authority to establish health care priorities should elicit public input before making rationing decisions. The two most common approaches are (i) consultation and (ii) deliberation. Though deliberation has obvious advantages over consultation, it falters in the face of the objection that ordinary citizens lack the cognitive resources for the extended, rigorous inquiry required of them in undertaking the priority‐setting task. To overcome this objection, I propose that deliberative forums for health care rationing should be designed so that they imitate the natural pattern of human experience. The experience of deliberation should encompass both prolonged periods of less‐demanding cognitive activity, in which citizens passively receive information, and briefer periods of more‐demanding cognitive activity, in which they engage in active problem‐solving. In arguing for this thesis, I rely on two theoretical sources and one practical case study, in the following order: (i) John Dewey's metaphysics of experience, (ii) cognitive science research on schemas and frames, and (iii) the Health Care Council in São Paulo, Brazil. (shrink)