Academic journal article The Hastings Center Report

Is Justice Enough? Ends and Means in Bioethics

Academic journal article The Hastings Center Report

Is Justice Enough? Ends and Means in Bioethics

Article excerpt

There call be little doubt that the dominant social issue of the 1960s and 1970s was that of justice and equality. It inspired the development of many fresh welfare policies and was a potent motivating force in the advent of Medicare and Medicaid, both thought (mistakenly as it turned out) to be the forerunners of universal health care. John Rawls' 1972 study A Theory of justice was not only a powerful work in its own right but perfectly in step with the times. Given that context, it was hardly surprising that the field of bioethics saw a great surge of writing and debate on issues of justice and health care. That was, and still is, a central topic.

Far less important for many years was any serious discussion of the ends of medicine. To be sure, there was and is a field known as the philosophy of medicine that has given considerable attention to the nature of medicine. But the discussion in that field - which was often technical and historical in any case, self-consciously academic and scholarly - proceeded independently of the interest in health care equality. And vice-versa.

In retrospect, that seems an odd bifurcation. How is it possible to have a full examination of a field as dynamic and fast-changing as health care without - simultaneous - asking some basic questions about what health care is supposed to give us and do for us? Norman Daniels, in his fine work on justice and health care, has come as close as anyone to attempting to find the specific link between the ends of health care and fair access to it. By his use of the concept of species-typical functioning as the goal of medicine he has sought to bring ends and means together. That is surely a traditional and conventionally valid concept, and in his hands has proved exceedingly useful.

But it is in the end too thin and formal a concept to give us the kind of help we need. Its main shortcoming is that it does not well take account of two dominant realities of modern medicine. One of them is the constant introduction into the health care system of new technologies, most of them expensive and of greater benefit to individual than to population health. Advances in organ transplantation would be a good example of this kind of development. The pursuit of species-typical functioning for some classes of patients can be enormously costly - and probably achieved only at the cost of limiting resources for other classes of patients. Daniels has, I would note, been working on this problem in recent years - but doing so with the language and concepts of equality rather than those of the ends of medicine and health care.

The other reality seems to me even more important. The impact of modern medical progress is often to force us to go beyond, and thus to redefine, what constitutes "species-typical" functioning. This is happening most notably in the field of aging, where one of the aims of the medical branch of the anti-ageism movement is to distinguish sharply between getting sick and getting old. In the ambitions of medical research, and now and then in its actual results, the ancient species-typical pattern of increasing illness, dementia, and frailty in old age can someday be vanquished@ the curve of morbidity can be squared. Medical progress has served to redefine the statistical notion of normality, and it is no less markedly beginning to dangle before our eyes the optimization or even enhancement of species functioning. Some now argue, moreover, that there is no real difference between normalizing and optimizing anyway.

The relationship between medical research and fairness in health care is particularly important in this context, and also little explored. What are fair and reasonable research priorities? When can it be said that no further progress is socially necessary? What kinds of research exacerbate an unfair distribution of resources, or enhance a fair one?

For both of the reasons I have cited - the cost of medical progress, on the one hand, and its power to redefine normality, on the other - there can be no full discussion of equality in health care without an equally full discussion of the substantive goods and goals that medicine and health care should pursue. …

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