Social Justice v. Market Incentive
Allocating Finite Health Care Resources
This article surveys two of the most widely discussed models for dealing with issues of distributive justice in health care: market based approaches or social justice.
A central question that all democratic societies currently face is how do we allocate our finite health care resources in ways that are socially just?
Two answers to this question have been widely proposed and debated within the political arena. According to libertarians, the inexorable logic of supply and demand operating within the economic marketplace are key to determining the optimal outcomes of health care resources (with minimal or no intervention by government); this laissez-faire view has been associated with the Nobel Prize winning economist Milton Friedman who died earlier this week at the age of 94.
In contrast to this view is what the philosopher Daniel Beachamp has called the "social justice" model, which is the view that, in a just society, minimal levels of basic needs like income, housing, education, and health should be provided to all citizens as fundamental rights. These basic needs are usually provided through various forms of social insurance, which were introduced in many of the industrializing democracies in the late 19th century and early 20th centuries; the one notable exception to this generalization is the United States of America, which has yet to adopt some form universal health insurance.
In contrasting these two models, it is important to remember that, in a democratic society, we face the constant potential tension between two prima facie goods-namely, the right of the individual to self-determination (usually referred to as the principle of autonomy) and the central role of the state in preserving the health of its citizens (sometimes referred to as the principle of beneficence).
For libertarians, the personal automony principle (or personal liberty to be more etymologically precise) is clearly primary; on this view the provision of health care services is no different in kind than any other goods and/or services provided by a market economy-widgets, thumbtacks, etc.
For advocates of the social justice model, by contrast, the role of the state in preserving and promoting health is clearly primary. In other words, the difference between these two models is primarily one of emphasis; each model emphasizes a different half of a perennial dichotomy.
One leading advocate of the social justice model is the philosopher Michael Walzer. Walzer argues that market transactions are legitimate as long as they are confined to their appropriate "sphere." The problem arises when the logic of the marketplace starts to dominate or encroach on other "spheres" where the distributional logic of the marketplace is inappropriate-most notably, in the sphere of the provision of health care goods and services.
In the sphere of the market, personal wealth is the criteria that is used to allocate finite resources (which is the reason that Bill Gates can own a yacht and most of the rest of humanity can't); ability to pay is the primary "rationing" criteria.
By contrast, in the sphere of health care provision, the primary criteria for allocating finite health care resources should be medical need-that is, Bill Gates should not be allowed to receive a necessary organ transplant before someone else if that other person is in greater medical need of the procedure.
