Theories of Justice and Right to Health Care John J Estrada, MD Associate Professor of Pediatrics LSU Health Sciences Center Access and Equity in Health Care: Two Strangers at the Door New Orleans, March 15, 2008

OBJECTIVES Understand theories of “rights” and how they apply to health care. Discuss theories of “justice” and how they apply to health care. Introduce principles that should guide health care reform.

RIGHTS “Self determination” “education” “Health care” “Life” “Death with dignity” “Fetus’ right to life”

RIGHTS MORAL SOCIETY INDIVIDUAL LEGAL

CONSTITUTIONAL LAW SOCIETY INDIVIDUAL & RIGHTS 1.Correlative duties 2.Arbitration 3.Penalty for interfering

Are legal “rights” the only “rights”? “Legal rights” are not the “only rights”

CONSTITUTIONAL LAW SOCIETY INDIVIDUAL RIGHTS MORAL LEGAL

RIGHTS Legal or Moral entitlement to: Obtain or refrain from obtaining a thing. Obtain or refrain from obtaining an action. Do or refrain from doing something. Wikepedia’s definition

“Inalienable Rights” US Constitution: Life Liberty Pursue of happiness

Another Look! Social Justice

Elements of “Social Justice” Human rights Fair treatment Impartiality Equitable share of society’s benefits

Achieving Social Justice Left Right Proportional taxation Income redistribution Property redistribution Free markets

“Right to Health” Affirmed by the Universal Declaration of Human Rights, 1948: “ Everyone has the right to a standard of living adequate for the health and wellbeing of himself and his family ” Article 25

Universal Health Care Germany1883 Switzerland1911 New Zealand1938 Belgium1945 United Kingdom1946 Sweden1947 Greece1961 Japan1961 Canada1966 Denmark1973 Australia1974 France1978 Italy1978 Portugal1979 Spain1986 South Africa1999

Right to Medical Care Meaning: “Equal access to equivalent care services”

Right to Medical Care How do you exercise your right?

The right to health should guarantee : Access to medical, preventive and mental health? Nutrition, sanitation, and clean environment? Occupational health?

If health care is declared a right: What is the content of services? Who provides the funding? On what bases is this right granted?

On what bases is the right granted? Need? Age? Degree of sickness? Citizenship? Tax paying capacity? Merit?

Access Based on Need Demand for health care would have no limit Is likely to bankrupt the system Make individuals less responsible for their own health

Access Based on Markets Premise: Goods can be bought and sold freely in the market… the laws of supply and demand… Reality: Medical inflation. $2.1 trill, 16% of US GNP. Tendency of supply (physicians, hospitals, tests, Rx, devices, technologies) to generate its own demand. Tax-favored insurance. NEJM, Feb 7, 2008 Volume 358:

FREE NEJM E-TOC HOME | SUBSCRIBE | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | Search Term Advanced Search FREE NEJM E-TOC HOME SUBSCRIBE CURRENT ISSUE PAST ISSUES COLLECTIONS Advanced Search Institution: LSU HEALTH SCIENCES CENTER LIBRARY | Sign In as Individual| Contact Subscription Administrator at Your Institution | FAQSign In as IndividualContact Subscription Administrator at Your InstitutionFAQ Market-Based Failure — A Second Opinion on U.S. Health Care Costs Robert Kuttner Next Next Volume 358: February 7, 2008 Number 6 PDF PDA Full Text Add to Personal Archive Add to Citation Manager Notify a Friend When Cited When Letters Appear PubMed Citation FREE NEJM E-TOC HOME | SUBSCRIBE | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | Search Term Advanced Search FREE NEJM E-TOC HOME SUBSCRIBE CURRENT ISSUE PAST ISSUES COLLECTIONS Advanced Search Institution: LSU HEALTH SCIENCES CENTER LIBRARY | Sign In as Individual| Contact Subscription Administrator at Your Institution | FAQSign In as IndividualContact Subscription Administrator at Your InstitutionFAQ Market-Based Failure — A Second Opinion on U.S. Health Care Costs Robert Kuttner Volume 358: February 7, 2008Number 6

Access based on Equality Equality: Same provision for all regardless of other criteria such as age, health status, gender, income… Criteria: What would be the criteria to determine Equality? Adapted from Durand-Zaleski

Access Based on Merit Obtain health care if you are worthy of it: Smoker = higher premiums Participate in yearly screening = free dental care Problems: Discrimination? From Durand-Zaleski

Access Based on Degree of Sickness Principle: Persons who are similarly ill are treated similarly… regardless of other socio economic factor such as wealth, race, geographical Location, etc Caveats: Doesn’t mean all illnesses will be treated… There should be rationing of access

Medical Care Health Disparities Access & Allocation Justice & Health Policy

Over-treatment Under-treatment

Social Determinants of Well-Being Health Personal security Reasoning Respect Attachment Self-Determination Social Justice by Powers and Faden Oxford Univ Press, 2006

Health Care Reform Questions Treat health as a consumer product, privilege, charity, entitlement? Financial incentives to limit delivery of care? Goal of universal access to care, with attention to those who are most vulnerable? Offer steps towards more accessible quality of care? Does it set minimum standards of comprehensive quality of care for all? NESRI & NHeLP, 2008

Over-treatment Under-treatment Expand federal Programs Regulation of Health care industry