Everyone agrees that justice is of paramount importance, and that it should be a core value and a leading principle when decisions affecting health and well-being are made. However, theoretically, justice lends itself to dozens of different meanings. This special section brings together nine scholarly contributions that study the notion of justice in relation to healthcare and well-being. The contributions start from the predominantly theoretical and gradually the emphasis shifts toward the practical.
The collection opens with Matti Häyry’s extensive study of the different theories of justice. In his article, Häyry provides a systematic review of the theories, and shows their relative positions on a conceptual map. Häyry uses a distinction between “American” and “European” notions of justice as a heuristic tool to further understand the many facets of justice. Häyry’s article is an important reminder of the numerous connotations of “justice,” and a prompt that for any meaningful discussion on justice—and healthcare and well-being—we need to remain cognizant of the competing, and often incommensurable, definitions. Footnote 1
Niall Scott adds anarchism to the discussions. Anarchism does not have a theory of justice per se, although, as Scott demonstrates, some of the justice-related considerations within anarchism come close to communitarian ideals, but also share credos of liberalism. What anarchism brings to the discussion is, in search of a better term, the idea of “organic justice” (not a term that Scott uses) that grows from the grassroots level. Possibly more importantly, perhaps more than any other approach, anarchism is concerned with the plight of the marginalized, and is interested in exposing power relations that can have an adverse effect on people’s health and well-being. Footnote 2
Rosamond Rhodes’s article continues with the complexity and many-sidedness of justice. Rhodes argues that it is a mistake to assume that there would be one monolithic concept of justice that would be appropriate in all fields of healthcare. Rather, we should realize that the context will tell us which notion of justice is applicable and when. She analyses several real-life cases and shows how the notion of justice varies from one setting to another. There is no simple rule for knowing which notion of justice to invoke and when; however, according to Rhodes, centuries of consensus decisions by physicians give us some guideposts. For example, the principles of justice at play in nonacute care cases are different from those in acute care, and when it comes to allocation of critically scarce resources, yet another set of principles are relevant. Footnote 3
Similarly to Rhodes, Darryl Gunson suggests that different theories of justice ought to be invoked in different settings. His position is influenced by Michael Walzer’s idea “spheres of justice,” and further inspired by John Rawls’s “reflective equilibrium” and its inbuilt idea of balancing intuitions against theoretical considerations. Gunson studies the notion of justice in relation to genetics. He postulates scenarios that seem to evoke different intuitions about what would be the relevant notion of justice in each case. For example, the justice considerations behind decisions on who should have access to treatment, on the one hand, and to enhancements, on the other, would appear to be dissimilar. Gunson hopes that by foregoing the assumption of one-justice-theory-fits-all-contexts, a more nuanced appreciation of justice in bioethics will arise. Footnote 4
In her studies of humanitarian efforts and theories of global justice, Kadri Simm echoes the plurality view endorsed by Rhodes and Gunson. The reasons she explicates are more practical than those of the two previous contributors. She is asking how the theories of justice could help humanitarian efforts. Issues of justice, on a global scale, are so complicated that it is unlikely that any one theory could adequately address them all. However, that does not mean that theories of global justice could not contribute to fighting global suffering. From a pragmatic point of view, theories of justice offer important insights into global problems, and provide a number of solutions to the more defined problems. Footnote 5
Leonard M. Fleck analyses cost effectiveness and quality-adjusted life years (QALYs) from the viewpoint of justice. In the reality of increasingly scarce resources, hardly anyone denies the need to control healthcare costs, and a cost-effective way of doing that would surely be better than a wasteful one. However, not all cost-effective measures are just. By using expensive targeted cancer treatments as examples, Fleck shows how certain cost-effective courses of action turn out to be unjust or simply not adequately just to be defensible. He proposes that cost-effective measures should be constrained by considerations of healthcare justice. Footnote 6
Steve J. Firth continues on the theme of QALYs. Firth studies the limitations of QALYs as a truly utilitarian tool. He questions the very narrow definition of utility used in calculating QALYs, and suggests an expansion to the metric. According to Firth, instead of “quality adjusted life years” we should acknowledge the social aspects affecting our well-being, and the well-being of those around us, and be more concerned with “inclusion adjusted life years” (IALYs), as those would provide a more comprehensive tool for assessing overall utility. Footnote 7
Iain Brassington’s contribution studies the 24 hour society we live in. His concern is the lack of adequate sleep and disturbed sleep patterns that modern life imposes on some people, the ways in which pharmacopeia (now and in the future) can be used to “mediate” the problem, and the various justice concerns that this gives rise to. Lack of sleep is linked to a myriad health problems, and in this sense, the 24 hour society can be seen as a public health issue. Brassington asks the reader to consider various professions and in which cases the use of “wake enhancers” could be justified and why. Footnote 8
Marianne Virtanen and Marko Elovainio’s article reviews decades of research into organization justice. On reading the article, it will be made apparent that especially recently, there is an increasing amount of literature making the connection between feelings of injustice at the workplace and ill health, and there are studies suggesting that feelings of injustice among healthcare workers lead to worse health outcomes for patients. When we talk about justice, healthcare, and well-being, it is not only about just healthcare delivery, but it also works the other way around: The justice of organizations and institutions has an impact on health, and this should also be acknowledged. Footnote 9
