Thursday, September 27, 2007

Is Healthcare Special? (Part 2)

This post is Part 2 of an earlier post and brings together a few of the thoughts I have been pondering lately. And the issue concerns the primacy a theory of justice ought to place on healthcare rather than health itself. So is healthcare “special”?

I just read an excellent paper in the latest issue of The Journal of Political Philosophy. It was Shlomi Segall’s “Is Health Care (Still) Special?” and he got me thinking about these issues again. Segall’s goal is to take issue with Normal Daniels’s argument that healthcare is special because it has strategic importance in facilitating the pursuit of our life plans. Segall offers two arguments against Daniels. Firstly, Daniels’s specialness account is too narrow (it cannot justify treatment to the elderly). Secondly, it is too wide (many of the opportunities the account depends upon lie beyond the reach of healthcare). I found both of Segall’s arguments persuasive.

Segall also invoked the following useful taxonomy of views:

(1) Most Important: health care resources should be allocated in line with health being the most important good.
(2) Special: health care resources should be allocated in isolation from the distribution of other social goods.
(3) Separate Sphere: health care resources should be allocated in line with the purpose of health care, which is only to promote health.

He also differentiates between two versions (weak and strong) of the Special view:

Strong version: the fact that a person possesses Y ought not affect how much of X she receives.

Weak version: the fact that a person possesses Y ought not determine how much of X is allocated to her.

And it is the weaker version of the specialness account that Segall targets.

I have always been struck by what I see as the paradoxical nature of debates about healthcare reform in Canada. Someone defending the status quo will invoke the specialness account and say something like the following: “Canadians are pretty egalitarian. We (unlike Americans) don’t believe that the rich should be able to buy better healthcare. So we should resist the move towards [more] private healthcare.”

What always puzzles me about this is that those who have such a view do not seem troubled by the fact that Canada has no inheritance tax (nor are lottery winnings taxed ) while the US does (though it is under threat). Furthermore, since the 1990's family income inequality has risen substantially in Canada (see this). I suspect the dismissal of such facts- facts which I think debunk the myth of Canada’s supposed egalitarian commitments- occurs because many Canadians believe that healthcare (unlike wealth and income) is “special”.

So how egalitarian does a commitment to (2) really make a society? And most importantly (since I’m not an egalitarian), how *just* does a commitment to (2) really make a society? Sadly this question seems, in my opinion, to be largely ignored. Canadians take it for granted that the virtues of (2) are self-evident. But I do not believe they are.

What is the problem with treating healthcare as “special”? Segall echoes the concern of Dan Brock (in his excellent KIEJ 2000 article “Broadening the Bioethics Agenda)- that it ignores the broad range of factors that have an influence, and often a greater influence, on our health prospects. These factors include our genetic endowments, stress at work, familial nurture in early life, diet, etc. These are the kinds of factors that I emphasized in my previous posts on Taking People as They Really Are (Parts 1 and 2).

So if healthcare is special to our health prospects then so is the family, education, our diet, etc… And thus singling out heathcare itself for special treatment is really not very helpful (indeed it could do more harm than good). For such a strategy impairs our ability to adopt the “big picture perspective” of these issues.

Who will help Canadians inspire a public debate that transcends the narrow limitations of the “healthcare is special” mantra? Will it come from our political leaders? (I’m not holding my breath!) Perhaps the concerns of the medical profession will help inspire this debate. Or the concerns raised by the Supreme Court.

At least the latter has had the courage to stick its neck out and tell Canadians the reality of the current situation. That is better than simply burying our heads in the sand and pretending that there are no serious problems here.

Healthcare reform is of course much more complex than simply prohibiting or permitting private insurance companies to cover core physician and hospital services (as this informative article argues). ). But by treating healthcare as special we really obstruct the likelihood that any informed, reasoned debate could gain any real steam. And that is why I do not believe that a fair and humane public ethic should treat healthcare as "special"; where "special" means treating healthcare as noted above- by no means am I suggesting that universal healthcare is not important. To continue to treat healthcare as “special” is to fail to give due attention to the other important goals we should be promoting. Goals that also greatly influence the health prospects of our citizens.

Let me conclude by just noting how the issue of healthcare illustrates another point I have been making at various stages on this blog. And this is the point that the principles appropriate for the distribution of anything cannot be determined solely by appeals to “first-best conceptualism”. And that is precisely what the Daniels position does. It takes an abstract principle (in this case Rawls’s principle of fair equality of opportunity) and applies it to one particular good (healthcare). But the problem with this tactic is that a determination of whether or not that is sage advice is not something we can establish by simply pondering what the ideals of equality require. Rather it requires us to do the difficult, complex empirical work needed to get a sense of the kinds of factors that really influence health outcomes. And so it is not surprising that an empirical examination of these issues take us in a direction very different from an idealized, abstract analysis. And this further reinforces how impoverished ideal theory actually is.