Where Can We Find Justice?

Jecker makes three major points in her article, “A Broader View of Justice” (2008). First, she argues that justice in healthcare relates to justice in the broader social conditions of society as these conditions influence how, when, and how often people develop health problems. Second, she argues that the bioethics literature has, with few exceptions, ignored the implications of broader institutional and social issues, instead using a medical paradigm of justice that focuses predominately on clinical and research questions. Finally, she recommends that bioethics ought to be pursued from a broader (social) paradigm of justice that examines and normatively engages these broader conditions. She uses the example of access to healthcare as a case in which society helps or hinders individuals’ health.

The first point, that social conditions such as education, poverty, availability of preventative care, exposure to crime, income inequalities, and poor nutrition play an important role in people’s subsequent health conditions has been demonstrated by numerous studies in various fields. Jecker (2008) argues that we ought to examine the environmental and social factors in people’s lives, as well as their direct interactions with the healthcare system, in order to fully address health problems in society. Although not a new argument, it loses little in the repetition.

Jecker (2008) next argues that these issues are not the focus of bioethics literature, and should be. Jecker is not the first to complain that bioethics, and bioethicists, pay too little attention to justice, or that there is a disproportionate emphasis on clinical issues related to justice, when she states that “concerns related to just access to healthcare, organizational ethics, healthcare systems, and the social determinants of health have not been a dominant focus” (2). In a country with gross inequalities in access to care and well-documented health disparities, one wouldn’t be surprised if, like other academics, bioethicists contribute to the status quo by overemphasizing new technologies, break-throughs in science, allocation of organs for transplant, end–of-life decision-making, and other headline-making issues.

Criticizing the field of bioethics, however, is an iffy business. What counts as work in bioethics, or a bioethicist? To claim that a scholarly field pays insufficient attention to a topic implies that one has looked everywhere (or almost everywhere) that work is found. If one turns only to peer-reviewed journals in Medline or PubMed, one’s hypothesis of an overemphasis on the medical paradigm in bioethics will be self-fulfilling, since these search engines are dominated by biomedical literature. The public health, public policy, political philosophy, social science and environmental literature yield counter-examples to Jecker’s medical paradigm.¹ Does work in these fields not count as “bioethics?” Had Jecker (2008) conducted a systematic, well-described, keyword-based review, readers would have a better idea of the range of work she included. In a non-systematic search, we found numerous examples of bioethicists engaging issues of social justice. As far back as 1973, the Hastings Center Report published David Mechanic’s, “Health and Illness in Technological Societies” which drew connections between the social conditions in these societies and the statistics of health and illness that emerge (Mechanic 1973). Even more on point, The Hastings Center Studies published Peter Sedgwick’s article, “Medical Individualism” in 1974 critiquing the individual contractual model of disease:

whole persons facing acute problems of life-management; [the individualist-contractual model] tends further to encourage the parceling of the sick community into unrelated sets of individual patients… finally, of course, it disbars an incalculable number of such persons from entering the paradigm at all since they lack the requisite fee with which to fulfill their part of the bargain (Sedgwick 1974, 73).

In the 35 years since these early articles, numerous articles and books explore the contextual and institutional issues that Jecker believes to have been overlooked. Although we would agree that more attention to issues of justice in health and healthcare is deserved, perhaps Jecker’s (2008)— and others’—complaints that bioethics pays insufficient attention to social conditions and social justice, or too much attention to certain questions of justice (e.g., allocating organs) stems from too restricted a view of where to look. Perhaps such a complaint stems merely from a sense that not enough has been done.

In the latter third of her article, Jecker proposes a supplemental framework that she calls a “social paradigm” (2) of justice. She argues that just healthcare (or, more accurately, just health policy) must consider the distribution of the social conditions that contribute to ill health, and therefore opportunity:

… debates about just healthcare are incomplete if they ask only how health systems should allocate their scarce resources. Such debates must also consider non-health system questions, such as how do governments distribute risk for disease in the population, either directly by distributing access to the healthcare system or indirectly by distributing the social and material conditions that affect the health of populations. (Jecker 2008, 2).

Jecker’s (2008) more controversial points address which of these social conditions are not merely unfortunate, but unjust, and the proper locus to address these injustices. Unequal social conditions, by themselves, are morally neutral. They become morally relevant when they are both contingent and capable of evaluation in terms of choice and responsibility. Jecker clearly wants to focus on those social conditions that “are the result of human agency, e.g., the policies governments make, and are subject to change.” (2). Jecker often describes government as a personified entity that can choose, or not, to solve social inequities, income disparities, crime, and racism that contribute to health problems in our society. Not all contingent social conditions, however, result directly from governmental choices. Surely government has little role in and responsibility for much of the aspects of our lives described in the International Centre for Health and Society of the World Health Organization (WHO):

as social beings, we need not only good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work (Wilkinson and Marmot 2003, 9).

To illustrate the advantage of the social paradigm, Jecker uses the example of universal access to healthcare. Although lacking health insurance assuredly predisposes to poorer health outcomes, and is therefore a “social determinant of health,” many possible social policies related to employment, the environment, transportation and public safety could provide greater impact on health, and health equity, than ensuring universal health insurance. Given her emphasis on “upstream” social conditions, why choose the one that expands access to healthcare? Furthermore, while Jecker (2008) emphasizes lack of insurance, the health policy literature increasingly demonstrates that other obstacles—geographic, cultural, and non-insured costs, for instance—greatly influence access to care. Outside of government choices, institutional policies, cultural norms, genetic predispositions, historical circumstances, and individual choices all contribute to health and ill health, an area of knowledge and research that remains complex and thinly understood.

If, as Jecker (2008) argues, government should ensure equitable distribution of the social and material conditions that predispose to health or disease, considerable redistribution of wealth would be required, of which the cost of ensuring access to healthcare (via universal insurance coverage, for instance) is only a small portion. Further, universal coverage does not entail equal—or even equitable—access to healthcare, and thus the bioethical discussions of rationing and distribution that Jecker sidelines must remain at center stage to address her recommendations. Norman Daniels, whose work she cites, makes this point explicitly:

Equal access to medical services does not itself assure equity if we have made the wrong trade-offs in our health system between equity and maximizing of aggregate health benefits. Just as important, we cannot produce equity in health simply by distributing medical and even public health resources equitably. Health inequalities have more complex origins (Daniels 2006, 24).

Since differences in health can be attributed to differences in economic and social standing large and small (Pincus et al. 1998), complete equality in the distribution of risk for disease could not be achieved; not everyone can be a chief executive officer of a company. What policies for redistributing such risk would be “just enough?” (Fleck 2001).

Even if a case could be made for attributing responsibility for social disparities largely to governmental policies, there may be good reasons not to cede to the government complete responsibility to remedy them. Separating individual choices from the social conditions that affect health, and identifying social conditions that are unjust and not just unfortunate, poses enormous challenges. Numerous cases already exist of boundary disputes between the government’s right to protect individuals from risk—biking without helmets, wearing seatbelts, smoking, fluoridating water, mountain climbing—and individuals’ rights. How might individual freedoms (to choose more or less education, a risky or safe job or pastime) be compromised if we grant government responsibility for protecting us from the conditions that put health at risk? This is not to say a line should not be drawn, but rather that Jecker’s attribution of contingent health risks to government responsibility can easily obscure more nuanced dynamics between human freedoms and human protections.

Just health policy faces significant logistical, political and philosophical challenges, and certainly deserves the attention of bioethicists. Jecker rightly draws attention, as have many other scholars (for example, Daniels 2006 and others) to questions of fairness that affect the “upstream” side of health and ill-health. Unfortunately, she proposes bioethics move away from work on rationing and questions of justice for those who are already ill, and thus fails to recognize how such work contributes to the ethical operation of a just system with universal access. Any expansion of insurance coverage will likely require greater progress in curtailing healthcare spending (McCain 2008, Obama 2008). Ethical rationing benefits from a just system, and a just system needs ethical rationing. In the hopes that Jecker’s (2008) article will inspire broad, sustained, and rigorous attention to the justice agenda in bioethics, we propose that rationing, access to care, social determinants of health, the distribution of the benefits and burdens of biomedical research, and numerous important, challenging questions in bioethics would benefit from applications of justice. ■