1. Social Contract Theory : from Veatch back to Hobbes John Spicer GP South London Head of Primary Care Education Health Education South London October 2014

2. What is a contract ?

3. The bare bones 1 Persons are primarily self interested. 2 Rational assessment of best strategy for maximising same impels them to act morally….. 3 [where moral norms determined by maximisation of joint interest] 4 ……and to consent to government authority

4. Veatch R A theory of medical ethics 1981 Triple contract theory 1 Social contract : basic principles for social interaction 2 Health professions and society 3 Physicians and patients

5. John Rawls 1921-2002

7. Jean-Jacques Rousseau 1712-1778

8. John Locke 1632-1704

10. Thomas Hobbes 1588-1679

12. Social contract and health care: implications Universal access Robust minimum basic care Financial equitable burdens Allocation of scarce resources respect equal value and dignity of individuals Democratic control ? Mutuality and solidarity

13. Counter arguments Nozick : compulsory redistributive taxation is forced labour Englehardt: this evil compounded by tax spend on immoral acts [cf abortion etc] Epstein: private charity can cover health care spend anyway Personal responsibility for health

14. The will of the people Democratic influence Excluded and prioritised treatments Red neck factors Obtuse decisions [ teeth capping over appendicectomies' ] Legal rights to change

15. Other issues Cost utility The ‘fair innings’ Anti- ageism Needs and wants Values

16. Some related issues Contracting in the NHS Contracting in education The swampy lowlands The business model of care

17. Contemporary social contract theory Gauthier – Critique – Feminist - Race conscious