Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-26T22:55:50.422Z Has data issue: false hasContentIssue false
  • English
  • Français

Medicine and Contextual Justice

Published online by Cambridge University Press:  06 March 2018

ROSAMOND RHODES
Get access Rights & Permissions [Opens in a new window]

Abstract:

This article provides a critique of the monolithic accounts that define justice in terms of a single and often inappropriate goal. By providing an array of real examples, I argue that there is no simple definition of justice, because allocations that express justice are governed by a variety of reasons that reasonable people endorse for their saliency. In making difficult choices about ranking priorities, different considerations have different importance in different kinds of situations. In this sense, justice is a conclusion about whether an allocation reflects the human interests and priorities that are at stake. The article describes how several principles of justice have a legitimate place in medical allocations. To achieve justice within medical practice, professionals should focus on the human interests and compelling reasons for prioritizing specific principles within their specific medical domain.

Keywords

justicemedical allocationsmedical practicehuman interestsprioritizing principles
Type
Special Section: Justice, Healthcare, and Wellness
Information
Cambridge Quarterly of Healthcare Ethics , Volume 27 , Issue 2 , April 2018 , pp. 228 - 249
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Notes

1. Margalit, A. The Ethics of Memory. Cambridge: Harvard University Press; 2002.Google Scholar

2. Aristotle (trans. Ross WD) The Nichomachean Ethics of Aristotle,. London: Oxford University Press; 1971, Book 1, chap. 4.

3. English: Oxford Dictionaries. Oxford: Oxford University Press, 2017; available at https://en.oxforddictionaries.com/definition/principle (last accessed 23 July 2017).

4. Aristotle enumerates three types of justice: distributive, retributive, and equity. The discussion of justice in this section is primarily concerned with distributive justice; that is, how the limited supply of medical resources should be distributed. Retributive justice is principally concerned with punishments, a topic that is beyond the scope of this project. Taking seriously Aristotle’s claim that justice is virtue entire (Aristotle: See note 2, original pagination 1130a9), the rest of this article can be seen as a discussion of what equity requires from medical professionals.

5. I count contractarian constructivists, such as Scanlon, in this camp. Scanlon, TM, What We Owe to Each Other. Cambridge, MA: The Belknap Press of Harvard University Press; 1998.Google Scholar

6. Bentham, J (ed. Burns, JH, Hart, HLA). An Introduction to the Principles of Morals and Legislation. London and New York: Methuen; 1982 (originally published 1789).Google Scholar

7. Mill JS (ed. Sher G). Utilitarianism. Indianapolis and Cambridge: Hacket Publishing; 1979 (originally published 1861).

8. Rawls, J. A Theory of Justice. Cambridge, MA: Harvard University Press; 1971.Google Scholar

9. Rawls, J. Political Liberalism. New York: Columbia University Press; 1993.Google Scholar

10. See note 9, Rawls 1993, at 228–9.

11. See note 9, Rawls 1993, at 326.

12. See note 9, Rawls 1993, at 6.

13. Daniels, N. Justice, health, and health care. In: Rhodes, R, Battin, M, Silvers, A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2012:17–33.CrossRefGoogle Scholar Daniels, N, Sabin, JE. Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philosophy and Public Affairs 1997;26:303–50.CrossRefGoogle ScholarPubMed

14. See note 13, Daniels 2012, at 19.

15. See note 13, Daniels 2012, at 20.

16. See note 13, Daniels 2012, at 19.

17. Brock, DW. Priority to the worse off in health-care resource prioritization. In: Rhodes, R, Battin, M, Silvers, A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2002:362–72.Google Scholar Brock, DW. Aggregating costs and benefits. Philosophy and Phenomenological Research 1998;58:963–8.CrossRefGoogle Scholar

18. Kamm FM. Whether to discontinue nonfutile use of a scarce resource. In Rhodes et al. 2002, at 373–89; Kamm, FM. Morality, Mortality Vol. I: Death and Who to Save From It. New York: Oxford University Press; 1993.Google Scholar

19. Wasserman D. Aggregation and the moral relevance of context in health-care decision making. In: Rhodes et al 2002, at 65–77.

20. Green, RM. Access to healthcare: Going beyond fair equality of opportunity. American Journal of Bioethics 2001;1(2):22–3.CrossRefGoogle ScholarPubMed

21. Gray, J. Two Faces of Liberalism. New York: The New Press; 2000, at 66.Google Scholar

22. I am using the word “context” in its colloquial sense to indicate the multiple kinds of parameters that are likely to be relevant to moral judgements. My use of the term should not be taken to imply any connection to current discussions of “contextualism” in contemporary epistemology and recent related discussions of morality.

23. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed. New York: Oxford University Press; 2009, at 280.

24. Contextualist approaches to ethics have been discussed by several authors. See, for example, Price AW. Contextuality in Practical Reason. New York: Oxford University Press; 2008; Thomas A. Values and Context: The Nature of Moral and Political Knowledge. New York: Oxford University Press; 2006; Timmons M. Morality without Foundations: A Defense of Ethical Contextualism. New York: Oxford University Press; 1999.

25. In making this claim, I am echoing a point made by John Gray about human rights. Gray writes, “Rights are not theorems that fall out of theories of law or ethics. They are judgements about human interests.” See note 21, Gray 2000, at 113.

26. In this article, I am focusing narrowly on the allocation issues that arise for medical professionals and medical institutions within the practice of medicine. I am pointedly avoiding the allocation issues that arise for health insurance companies and government policies that involve related but different issues.

27. I do not claim that this list is a full elaboration of the relevant considerations for justice in medicine. I am only arguing that the list enumerates principles of justice that should be prioritized within the three domains that I have considered in this article. Here, I have not provided an account of justice in public health and biomedical research, and the relevant factors and priorities in those domains are likely to be significantly different than for the domains that I have discussed. Furthermore, I have not discussed health policy or insurance decisions on the national level. Justice in the context of those decisions is likely to involve additional considerations.

28. See note 13, Daniels 2012, at 26–8. Daniels’s “relevance condition,” which appeals to reasonableness, appears to capture this aspect of policy setting.

29. Here, I have in mind a genuine Rawlsian “overlapping consensus” in contrast to what Rawls would term a “modus vivendi” coincidental agreement. Discussion of this issue is important, but too tangential to address in this article.

30. See note 9, Rawls 1993. In Political Liberalism, John Rawls uses the term “overlapping consensus” to describe the agreement of “reasonable and rational” people.

31. Here, I am using the term “reasonable” in the specific Rawlsian sense of reasonableness being bounded by the “burdens of judgment” and constrained by the limits of “what can be reasonably justified to others.” See note 9, Rawls 1993, at 58–66.

32. There are at least two additional domains of medical activity, namely, public health and biomedical research. A great deal can be said about justice in both areas. I am setting those issues aside for another day.

33. Wolf J. Health risk and health security. In: Rhodes et al. 2012, at 70–8.

34. Smith P. Justice, health, and the price of poverty. In: Rhodes et al. 2012, at 255–63.

35. Silvers A. Health care justice for the chronically ill and disabled: A deficiency in justice theory and how to cure it. In: Rhodes et al. 2012, at 299–312.

36. Ozar D, Oral SJ. Mental health services. In: Rhodes et al. 2012, at 401–11.

37. Francis LP. Age rationing under conditions of injustice. In: Rhodes et al. 2012, at 355–62.

38. McGary H. Racial groups, distrust, in the distribution of health care. In: Rhodes et al. 2012, at 265–77.

39. Berridge, V. The Black Report: Reinterpreting history. In: Cook, HJ, Bhattacharya, S, Hardy, A, eds. The History of the Social Determinants of Health. Andhra Pradesh: Orient Blackswan; 2010.Google Scholar

40. Rhodes, R. Perspectives: Incentives for healthy behavior. Hastings Center Report 2015;45(3): Inside back cover.Google Scholar

41. Rhodes, R. The professional responsibilities of medicine. In: Rhodes, R, Francis, L, Silvers, A, eds. The Blackwell Guide to Medical Ethics. Malden, MA: Blackwell; 2007:71–87.CrossRefGoogle Scholar

42. Boorse, C. Health as a theoretical concept. Philosophy of Science 1977; 44(Dec):542–73.CrossRefGoogle Scholar

43. Szasz, TS. What counts as disease? Canadian Medical Association Journal 1986;135(8):859–60.Google ScholarPubMed

44. Emson, HE. Health, disease and illness: Matters for definition. Canadian Medical Association Journal 1987;136(Apr 15):811–3.Google ScholarPubMed

45. See note 13, Daniels 2012.

46. See note 38, McGary 2012.