Justice pivots partly on our understandings of goods. In the words of Michael Walzer, "all distributions are just or unjust relative to the social meanings of the goods at stake." So too with health care. Over a quarter century ago, Robert Veatch held that "any abstract argument about distribution principles in health care without pinning down precisely what is being distributed will be fruitless." (2) Nearly a decade later, in the first book-length treatise on justice and health care, Norman Daniels noted the futility of applying general theories of justice to health care without knowing "what kind of social good health care is." (3) Recent discussions of the commodification of health care--that is, of the changing nature of health care as a social good highlight its implications for just health care. (4)
Yet despite this long-standing belief and despite the health care reform efforts of the last decade, relatively little critical ethical attention has been given to the wide-ranging social meanings of health care. What does it mean to say that health care is a social good? What persons or groups are implied by social?. What roles do they play in health care? And in just health care?
The phrase "health care is a social good" is often used to mean health care as a societal or national good signifying that "society" or "nation" (often used interchangeably) is the pertinent social group for health care. But society is not the only, nor even the primary, social collectivity relevant to health and health care. Both health and health care involve a much more complex and diverse set of social relations and contexts, including those at the interpersonal, family, community, state, regional, national, continental, and global levels. A full conceptualization of health care as a social good would recognize its multilayered reality and its many intercontextual connections.
Let us say, for now, that communities are various types of social collectivities typically smaller than a society and larger than a family. Geographically defined groups may be communities. So also may racial, ethnic, religious, cultural, and professional groups. Communities, I argue, are the primary contexts for the social relations and institutions most central to health and health care, and they are critical moral resources in any effort to make health care more just. But because communities are complex and overlapping entities, any effort to make health care more just will be more complicated than most commentators have recognized.
Bioethics has been appropriately criticized for its narrow emphases on autonomy, individualism, and the dyadic relations between physicians and patients, and researchers and subjects. Says Susan Wolf, "Bioethics has strained for universals, ignoring the significance of groups and the importance of context." (5) To the extent that "community" and communities have been addressed in relation to just health care, three problems are evident: "community" has multiple, unexamined meanings; the overall importance of real communities is minimized; and specifically the moral and ethical significance of communities is neglected.
These difficulties are exemplified in the ethical framework offered by Dan Brock and.Norman Daniels for reforming the U.S. health care system. In this framework, fourteen ethical principles and values are claimed to "provide a tool for the broad moral assessment of a reformed health care system and its performance over time." (6) These principles and values, including universal access, comprehensive benefits, and fair burdens, are asserted to be "deeply anchored in the moral traditions we share as a nation, reflecting our long-standing commitment to equality, justice, liberty, and community" (p. 1189).
The first problem is this framework's use of the word "community" to refer to multiple, morally and otherwise distinct social groups. …