Friday, September 28, 2007

On the 'Specialness' of Health Care

Shlomi Segall, in an article published in the September 2007 edition of the Journal of Political Philosophy, takes aim at Norman Daniels account of the specialness of health care. He gives a run down of what he takes to be Daniels’ view, and then proceeds to make some criticisms of the view from within Daniels’ own framework. In what follows I will show that while Segall succeeds on some accounts, he fails on others in such a way that the conclusion he reaches is deeply flawed.Segall challenges the equal opportunity account best elucidated in Daniels’ book “Just Health Care” and expanded upon in other books and articles. Segall is not interested in challenging the equal opportunity account per se, but is rather more interested in showing that the account doesn’t give us a good reason to think that health care is special (by ‘health care is special’ it is meant that “health care resources should be allocated in isolation from the distribution of other social goods”). The view that health care is special is what does most of the work for those who claim that health care should be allocated to people across the board, regardless of financial ability to pay for it. The ‘specialness’ claim allows for a loose lexical ordering of health care resources in front of resources spent on other social goods. It is distinct, however, from a view that considers health care to be the most important social good, which would commit us to the maximization of the allocation of all resources to health care, essentially prohibiting any allocation whatsoever from other social goods like food, housing, education, etc.

Daniels’ equal opportunity account, roughly outlined, is that health care is a necessary social good for human beings to be able to live out and pursue their life plans. Since the only way someone could have the ability to pursue their life plans is if they are found within a certain ‘normal opportunity range’ (the range of normal opportunities one has within a particular society, relative to ones talents) and a reasonable level of health is required for the normal opportunity range to mean something, we have an obligation to ensure a reasonable level of equal health care that would allow for an appropriate restoration of health to that normal opportunity range. Segall first takes aim at the idea that health is necessary to pursue ones life’s plans. This is one area where I think Segall’s criticism of Daniels stands. In brief, Segall argues that it is not worth spending significant health care resources on the life plans of senior citizens, all things considered. Yet it is consistently the case that health care for senior citizens in the twilight of their lives is placed at par with or even over and above that of people early in their lives, the time in which they are still in the process of determining what their life plans even are. In fact, the health care of seniors accounts for significant portions of health care expenditures in most advanced industrialized nations. The often-cited figure for the US is that 30% of health care expenditures are spent in the last six months of life, and of course, much of those monies are spent on seniors. While Daniels makes allowances for a dropping of health care expenditures for patients over the age of 75, the strength of Segall’s criticism is found in the fact that the specialness account of health care means that health care is special across the board, not just for those who still have life plans. Segall notes in a footnote that this criticism can be leveled against Daniels with regards to anyone who has completed (forcibly or not) their life plans but is still alive, such as a convicted serial murderer on death row. It seems then that is Segall is right (and I think he is), that health care expenditures are not justified for seniors if what justifies health care expenditures in the specialness account is the fact that normal opportunity range is required to carry out ones’ life plans. Senior citizens, most of us would agree, while important parts of society, are certainly not in the process of creating their life plans – most are, in fact, finishing up their life plans. Yet this doesn’t capture current health care spending practices nor does it capture our deep seeded intuitions about care for the elderly, nor can it properly account for why seniors are entitled to a share of health care resources despite their inability to pay.

Segall suggests a way around this problem, a way I intend to explore in more depth in my thesis itself. He suggests that rather than trying to justify his appeal to the specialness of health care by way of Rawls’ Fair Equality of Opportunity Principle, he ought to try to go through Rawls’ Difference Principle instead. For now I’d like to skip past this suggestion and move on to where I think Segall went wrong.

Using Dan Brock as ammunition (I have previously argued in a similar vein against Brock, though there are revisions on that argument to come, thanks to Colin Farrelly), Segall argues correctly that “differences in health are determined primarily by factors other than health care and most significantly by socio-economic factors… To be clear: by ‘socio-economic factors’ it is meant socio-economic factors that affect health directly, independently and apart from socio-economic factors that affect access to health care.” He continues, saying that “there is strong indication that health care is not nearly as significant in determining our health as was once thought.” In short, socio-economic factors have the most effect on health prior to health care. Daniels would agree with this assessment, though there is an underlying assumption that I think Daniels (and certainly I) would not agree with.

It is true that socio-economic factors affect health more directly than they affect health care, however, this does not preclude socio-economic factors from having a nontrivial indirect effect on the delivery of health care. Segall alludes to this objection, though he never explicitly engages it. Instead, he engages the objection that non-clinical public health concerns indirectly affect health and proceeds to show that if they are allowed within the purview of health care they will mean we will have to expend precious resources on things that don’t look much like health care, like enforcing cleanliness requirements at supermarkets and ensuring that restaurants meet a certain level of health safety standards. These indirectly affect health, but not in a way that could rationally construed as health care, or even in a way that an effective argument could be mounted for their inclusion in spending designated specifically for health care. But this objection, (a fair one at that) doesn’t take into account the objection I raised to his exclusion of health care specifically because socio-economic factors do not have as direct an impact on health as they have on health itself. All it shows is that there are some factors that have an effect on health that we cannot classify as health care expenditures or that we cannot otherwise justify under the banner of health or health care. It doesn’t say anything about the indirect manner that socio-economic status can have on the delivery of health care itself, or more importantly, on access to health care. All Segall has established is that health is prior to health care with regards to the direct effects of socio-economic status. However, it could very well be argued that the indirect impact of socio-economic factors on health care is not displaced or rendered less important because of this fact. Just because these factors are shown to have a direct effect on health doesn’t get us off the hook for socio-economic injustices found in the health care system, even if they are produced indirectly. Moreover, health care is a response to poor health. While it is not the whole story of health (for instance, it cannot account for the issues of public health that were raised above), it is enough of the story of health that we can reasonably include it in discussions of health, and also, I contend, in discussions surrounding the manner to which socio-economic status affects health more generally.

Does Segall succeed in showing that because of the concessions Daniels has been forced to make (life plans, the impact of public health and education on health) he must abandon the specialness of health care resource allocation? Segall seems to think that yes, he does, saying, that “Daniels cannot meet the ‘social determinants’ objection by shifting focus from health care to health without thereby abandoning the allusion to specialness altogether.” But I think Segall is being too hasty when he claims that Daniels must move from health care to health because of this objection. Daniels is rightly forced to admit that health is important in the determination of health care resource allocation, a point that strikes me as somewhat trivial. But he is not forced to admit that because there is more than just health care involved in health – quite clearly, health care concerns a response to health deficiencies; when health deficiencies are the result of negative socio-economic factors, it is not especially hard to think that these factors may carry over into the treatment of health care deficiencies. The fact that a homeless person’s diet contributed to his malnutrition doesn’t mean that his poverty won’t have a noticeable effect on his ability to get treatment for his malnutrition, unless a system is in place that does not discriminate against his inability to pay for that treatment. Even if it turns out that the socio-economic factors play a more significant role in his diet than they do in his ability to pay for health care treatments, this does not mean that health care is neither important or special: To say that somehow health care is not affected by socio-economic factors because these factors are more noticeable at the level of general health seems to miss the entire point of having a health care need. While there is much to be said for preventative measures with regards to health, health care retains its specialness because when any person, disadvantaged or not, is in need of it, their quality (and quantity) of life is seriously jeopardized in such a way that they must rely entirely on the expertise of others to make it better (I’ve argued this point in particular here). Other social goods do not rely on the specific expertise of others in the same way. Showing that socio-economic factors are more influential at the higher more abstract level of health doesn’t right away imply that there are not other reasons that health care may be a special social good. Moreover, it doesn’t stop the theorist from arguing that socio-economic factors are transitive – that is, they don’t stop with direct effects, but are rather causally related in important ways with the way those direct effects are treated or dealt with (thus socio-economic factors will have both a direct and indirect effect on the distribution of health care resources). This will require empirical evidence, though I don’t think it is particularly difficult to see how ones income would determine their ability to access an expensive health care system if they were in the position of the homeless man that I described above and that health care system did not have a commitment to equality and universality of access. However, I’m not committing myself to this as it stands right now, for fear of being charged with begging the question.

ADDENDUM: Colin Farrelly, a political philosopher here at Waterloo who is on my thesis committee, has reached a different conclusion than I. To see his take on this article, see his post here.