Rational self-interest and the inverse care law: how Rawls and Nozick might have reflected on Julian Tudor Hart’s problem

THE INVERSE CARE LAW

The NHS was introduced in Britain in 1948 to provide equal access to health care to everyone in the UK. It has offered ‘ a comprehensive national service, available to all, free at the time of use, non-contributory, and financed from taxation.’ ¹ However, Julian Tudor Hart (1927–2018), who was a GP working in Wales, observed that the healthcare availability and the population that needs it have an inverse correlation relationship.¹ As factors that contribute to the inverse care law, Tudor Hart suggested that market forces working on primary-care services led to an inequality of health care between the wealthy and the poor.¹

Tudor Hart argued that the inverse care law is expressed in the lack of availability of healthcare services. Wyszewianski and McLaughlin define availability as, ‘The extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client’.²

According to Tudor Hart, doctors didn’t prefer to work in poorer or more working- class areas unless they had social and familial ties.¹ People living in such areas at the time, such as miners, tended to work in dangerous and dirty environments and end up with major diseases. Doctors in such areas were supposed to care for patients with less money (funding) even though doctors in more affluent areas could earn more money looking after patients who were less sick and fewer in number. Tudor Hart further observed that the working environment of doctors in deprived areas was poor, but doctors in middle-class areas enjoyed better equipment and resources.¹

Availability of health care is meaningless unless people can access it. Wyszewianski and McLaughlin define accessibility as, ‘how easily the client can physically reach the provider’s location’.² Tudor Hart found there were expanding list sizes for GPs in industrial areas. These large list sizes could mean that patients did not receive good quality care or would have to wait longer before being tended to.¹

In recent times, however, other factors could limit access to health care such as language barriers, the inability to take time off work, stigma associated with illness, and a struggle to get an appointment with a GP.

Tudor Hart asserted that ‘the function of the state is, in general, to do those things which the individual cannot do and to assist him to do things better’.¹ As the NHS is a state intervention in communion with a market economy I reference here two moral, legal, and political philosophers from a quintessential market economy (the US): John Rawls (1921–2002) and Robert Nozick (1938–2002). Rawls would argue that the state ought to provide need-based support for the population because we have a rational interest in a government that protects us from misfortune, and therefore gives aid to those worst off. In contrast, Nozick would claim that the state should not provide further support (beyond a minimum level) because the government should only provide limited protections to protect people’s natural rights, essentially limited to property and security rights. Taking money away from people to help those in need is therefore an unacceptable affront to liberty.

RAWLS AND THE VEIL OF IGNORANCE

In ‘A Theory of Justice’, Rawls did a thought experiment on the just role of the state and explained how society’s resources can be distributed fairly. He believed that ‘no one should be advantaged or disadvantaged by natural fortune or social circumstances in the choice of principles’.³ On fairness, he provided an idea of a ‘veil of ignorance’, in which people have no idea of their own social position.³ In the state called ‘original position’, a hypothetical situation in which we are unaware what social position we occupy, he believed that people can, however, conceive of equal distribution. In other words, injustice happens when there are inequalities that are not to the benefit of everyone and are perceived as such. Based on this concept, he suggested two principles for social justice. The first is ‘justice as fairness’, which states that ‘each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all’.³ This suggests that everyone has basic liberties and they should not be taken away, as in the United States Constitution.

The second principle is that social and economic inequalities are to be arranged when people consider both the Difference Principle and fair equality of opportunity. The Difference Principle means inequalities should be arranged to ‘the greatest benefit of the least advantaged, consistent with the just savings principle’ . Fair equality of opportunity means that inequalities should be arranged so that they are ‘attached to offices and positions open to all under conditions of fair equality of opportunity’.³

Tudor Hart believed that people should have equal access to an environment in which primary-care doctors interact with individuals within a community since need-based treatments are most likely to satisfy patients.⁴ Rawls would argue that the outcome after distribution of resources should be just, and that inequality in society should be accepted when the least advantaged group of people receive the greatest benefit.⁵ Health and other outcomes differ due to the differences in individual ability and status even if people receive an equal amount of resources.³ A market solution such as a US insurance- based healthcare system wouldn’t work without state intervention in maintaining help to the neediest. Health insurance companies, for example, assess whether clients have pre- existing illness or rare diseases. If they do, the insurance fees increase and people are less able to afford them.

NOZICK AND THE MINIMALIST STATE

Rawls argued that people should not be given any advantage or disadvantage due to their ‘natural fortune’.³ However, Nozick advocated entitlement theory that argues ‘everyone has some entitlement or claim on the totality of natural assets’. He defined this distribution of natural abilities as a collective asset. He argued that the government should treat people ‘as persons having individual rights’.⁶ He defined this kind of government as a ‘minimalist state’, which ‘treats us as inviolate individuals, who may not be used in certain ways by others as means or tools or instruments or resources’.⁶ So, the government should provide limited protection and focus on respecting people’s rights.

Nozick promoted the notion that liberty should not be limited except for serious reasons. His entitlement theory has two main aspects: the principle of justice in acquisition of holdings and the principle of justice in transfer of holdings. The former said that ‘a person who acquires a holding in accordance with the principle of justice in acquisition is entitled to that holding’, and the latter said that ‘a person who acquires a holding in accordance with the principle of justice in transfer, from someone else entitled to the holding, is entitled to the holding’.⁶ In essence, you are entitled to what you own and what you earn.

Regarding the inverse care law, Nozick would say the government does not need to provide further support in health care. He argued that ‘the right to health care should be strictly limited to lifesaving, basic necessities’.⁶ When Nozick mentions health, he refuted Bernard Williams’ argument that social resources should be redistributed to those in poor health who cannot afford necessary medical care.⁶ He insisted that Williams ‘ignores the question of where the things or actions to be allocated and distributed come from’.⁶ In other words, someone other than the poor people in need of care must pay for the care, and this is what Nozick found unacceptable.

The UK Government provides equal access to health care that is financed by taxation. Pardi insists that Nozick would argue that ‘universal access to health care only can come about as a result of the government redistributing wealth through means such as progressive taxation and penalties’.⁷

In Nozick’s viewpoint, mandatory taxation imposed by the state to provide services or benefits to others is unjust. The government infringes on individual liberty by absorbing wealth from citizens in the form of taxes, before redistributing it in the form of health care. In a free market, by contrast, people can use their money at their own discretion. This position would support the availability of a private insurance-based healthcare system because people can themselves decide whether and how they spend their money in order to access the best medical care. Therefore, although the inverse care law describes the inverse correlation between healthcare availability and the populations that require it, Nozick would assert that the disadvantaged group of people need to accept their ‘natural positions’ as long as they can access the minimum resources to stay alive.

CONCLUSION

To conclude, Rawls and Nozick would have markedly different perspectives on the inverse care law. Rawls would argue the state should provide need-based medical support for the population because rational self- interest dictates that we must look after those who are most in need (one day that could be us). In contrast, Nozick would claim that the state should promote people to accept their ‘natural status’ rather than providing further support because he concludes that the government should be a minimalist state providing minimal protections to protect people’s natural rights.

Weighing these arguments up in relation to the inverse care law is a first step to assessing whether either are credible in a civilised society.