Ability to Pay and
Access to Transplantation
Ability to pay now is and probably will remain a factor determining access to transplantation, as Evans shows. 1 In this article, I address the following moral issues: (1) Is ability to pay a morally acceptable criterion for rationing health care services in general? (2) Is it either more or less acceptable to ration transplantation by ability to pay than other health care services?
I agree with Evans that, in general, distributing health care by ability to pay is unjust. As I argue elsewhere, 2,3 health care (I include nonmedical health services) is of special moral importance. Its function is to maintain, restore, and compensate for losses of normal species functioning, and departures from normal functioning have a significant impact on the range of opportunities open to an individual. Since a society is just only if it assures fair equality of opportunity, health care systems should be designed so that they optimally protect opportunity, given the limits of resources and technology. This fair equality of opportunity account implies that there should be no discriminatory barriers to whatever system of services optimally protects opportunity. Still, individuals have rights or entitlements only to those services that are part of the design of such a system. They do not have rights to any or every technology that can in some way provide them with a benefit. Rather, technologies must be assessed before being incorporated in a system so that we include only these services that optimally protect opportunity, given fixed or reasonable limits on resources.
When ability to pay determines access to effective medical treatments, the distribution of opportunity depends in an unacceptable way on inequalities in wealth and income. We should not, then, ration health care in general by ability____________________