Thursday, May 17, 2007

Is Healthcare Special?

The distributive principles of justice we invoke should be "good-specific". In other words, the principles that might be appropriate for the distribution of X (e.g. wealth, punishment, education, healthcare, etc.) are not necessarily the appropriate principles for the distribution of Y.

What principles should govern the distribution of healthcare? I believe this is one of the most challenging and important questions we need to tackle. Ezekiel Emanuel has an excellent commentary piece in the latest issue of JAMA entitled "What Cannot Be Said on Television About Health Care". His focus is on the need for healthcare reform in the United States but I think some of his insights also apply to Canada. Here is a sample:

For decades it was accepted that health care was special. Indeed, it was so special it could not be considered a usual good or service to be traded on the market for other goods. As Daniels, a leading bioethicist, once argued, “A theory of health care needs should . . . illuminate the sense in which many of us think health care is special and should be treated differently from other social goods.”

To many, the specialness of health care meant that cost should not be a consideration in care. Ethical physicians could and should not consider money in deciding what they should do for sick patients. Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing. Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold costs down.

The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food. Health care actually was being traded off against other goods both at the individual and social level. The implication was that for Americans, health care did not necessarily seem so special; other essential needs—food, housing, or heating—could be just as special. The same phenomenon began to play out in state budgets. Increasing costs of Medicaid and health insurance premiums for state workers meant cuts in Medicaid’s discretionary services or, more commonly, in other state services, especially primary and secondary education and support for state colleges and universities.

Americans began to realize that, as the economists would say, spending on health care has opportunity costs. Too much money spent on health care reduced the ability to obtain other essentials of human life as well as some goods and services not essential to life but still of great value, such as education, vacations, and the arts. Indeed, experts in the social determinants of health emphasized that many of these other factors, from income to education, were integral and perhaps even more integral than health care services for improving health outcomes. When health care began compromising access to other important goods—food, heating, and education—it ceased to be so special it was beyond cost.

The Canadian healthcare system is of course different from the American system in important ways. Many Canadians like to beat the patriotic drum and claim the superiority of our universal publicly funded system, but I myself am not inclined to do so. In part because I think it is very difficult to compare the virtues and vices of the two different systems. And I believe this stems from the larger problem that the question "How should healthcare be distributed?" has not been given enough serious consideration and debate.

Defenders of the status quo in Canada might feel that answer is obvious- that the universal publicly funded system is just because it coheres with a principle of equal opportunity. But such a stance really fails to address the central dilemma that Emanuel highlights- the need for tradeoffs. Invoking equal opportunity, in the context of healthcare, does not tell us how much we should spend on healthcare versus other important social programmes (e.g. education). So if we spend too much on healthcare we run the risk of ignoring the importance social determinants play in promoting our health (and social justice more generally). When equal opportunity for healthcare is combined with a "spare no expense" attitude it unjustly privileges mitigating one particular type of disadvantage over other laudable aims.

The other horn of the dilemma is that if we do not invest enough in the pubic healthcare system we end up with a situation of everyone having equal opportunity for inadequate provisions. In this kind of scenario should we prevent those who can afford to pay for better healthcare from doing so? Consider, for example, the case of Chaoulli v. Quebec (2005) (decision here, helpful summary here). The Supreme Court of Canada ruled that a prohibition on private health insurance is not constitutional when the public system fails to deliver reasonable services. Now one might of course argue that that the Supreme Court should not be the judge on what constitutes "reasonable and unreasonable" healthcare services- that responsibility should fall to Canadian citizens and their elected representatives. But if the Court is correct in its judgement about the state of these provisions, then either more should be done to better fund the public system or we should not prevent individuals from privately purchasing better healthcare. The danger with the former course of action is it could unfairly privilege the priority of healthcare over other social programmes because healthcare is a bottomless pit. And the cost of the second option is greater inequality.

I don't know what the just course of action is in this kind of scenario. But I think it is imperative that we make explicit the pros and cons of the options available rather than simply invoke the rhetoric of abstract ideals. If pushed, I guess I am inclined to take the view that healthcare is not so special that we should take the "spare no expense" attitude, nor is equality of opportunity so special we should prevent people from spending their money on improving their own health (rather than spending it on something else). But I am still of mixed minds on this. In part because the interplay between the different stakes involved in the debate are so complex and interconnected.

These various problems are not of course unique to the distribution of healthcare. Rights-based theories of justice, which dominate philosophical debates, maintain that all rights are special- that they should be serially ordered (to borrow Rawls's terminology) and thus are immune from these kinds of tradeoffs. This stance has impoverished our theories of justice and wedged an almost irreconcilable gap between theory and practice.