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.

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Health Inequalities or Health Care Inequalities?

Much of the health care literature attempts to distinguish between health care and health. In my estimation, most of the literature (at least as I have read thus far) fails to properly distinguish between the two concepts and as a result, comes out with muddled or confusing takes on distributive justice and the health care problem. In this brief section, I will argue that if we take the call to properly distinguish health from health care, we find that health care remains as important as ever. In fact, the theorist who wants to take health seriously will find that in order to do so, she must not lose sight of the health care problem, and in particular, she must recognize that the health care problem is primarily about economic inequality.

The distinction between health and health care is quite difficult to make. Hoedemekers and Dekkers identify these difficulties in their paper “Key Concepts in Health Priority Setting”. They illustrate how much the definitions of health care and how these variations can affect the way health care planners and resource allocators make their decisions. In discussing the WHO definition of health (“health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”), the authors show that health is holistic in such a way that individual demand for any health care services based upon it cannot be realistically restricted. On the other hand, many, especially health practitioners, restrict health to the bodily dimension only. The focus is not found in total well being but rather in whether or not the biological functioning of the organism is in working order. The dichotomy between the two views can also be seen in the way the patient and the physician view the term ‘abnormality’. The patient will often associate normality with health and abnormality with disease, based solely on personal standards of reference. For example, the fact that the smoker is hacking up a lung may be normal, while the contraction of lung cancer is not. For the physician, however, the definitions are much more precise with the definition of ‘normality’ determined by empirical data used to establish an objective standard of biological function in an organism. Comparisons of diagnostic data with these statistical standards reveal abnormalities and thus, for the physician, that same smoker who thought he was normal, is abnormal.

We’ve all heard stories about hardened older men who refuse to go visit the doctor because they’ve always been healthy and think that the doctor is just out to cause them trouble. These people have one concept of what health means, while the annoying mother who takes her children in for every ache and sniffle has a different concept of what health is. So how do we navigate these waters, especially as we try to discover the best way to distribute scarce health care resources?

In a very interesting paper, Dan Brock argues that one of the biggest failures of bio-ethicists is that they have focused too much on the problems related to health care and not enough on the problems related to health. He argues that the application of distributive justice to health care neglects very important issues brought up by the very concept of health. One of the most important things, Brock argues, is that those concerned with distributive justice and health care ought to take seriously the need for prioritization of health care services and the inevitable health care rationing that does and will occur. By focusing on health care rather than health, bio-ethicists only handicap themselves by attaching themselves to a project with no end. Justice (implied to be some kind of equity among the distribution of resources) is just not possible; theorists would be better off focusing on the prioritization of health needs rather than health care needs.

In one important paragraph, Brock attacks the idea of a right to health care, arguing that it cannot properly account for the reality of rationing.

Moreover, specifying in detail what services the right encompassed, and in particular what services it did not encompass, smacked of and was easily attacked as rationing. Although most bio-ethicists recognized the unavoidability and even the desirability of rationing, few politicians did, at least openly, and in public and health policy debates one’s views were often an easy target for discrediting if they could be tarred with the label of rationing. The general public, irresponsibly encouraged by many politicians and physicians, preferred to believe that in a rich country like ours with such an important good as health care, rationing was not necessary and did not in fact occur. Of course, this perspective overlooked the rationing imposed on the uninsured, as well as on others, but somehow this cognitive dissonance survived widely. And, given the pervasive belief that rationing did not occur, was not necessary, was politically dangerous, and would be morally wrong if it did occur, serious public discussion of it and of the limits to the right to health care was unlikely, and in fact rarely occurred. All this was quite remarkable during a period, which continues to this day, in which cost containment was the dominant issue of health policy, since the most obvious means of controlling health care costs is to deny some people some care, that is to ration care. But the preference was to believe that, by such means as cutting the “waste, fraud, and abuse” out of the health care system, costs could be adequately controlled without rationing.

By ignoring prioritization and rationing, argues Brock, those bio-ethicists who have influence in the realm of public policy are contributing to this “cognitive dissonance” within the American population (note that Brock admits that many bio-ethicists recognize the unavoidability of rationing. They just have a tendency to ignore it). Indeed even Brock agrees that the greatest inequity in the health care system is the fact that 44 million Americans have no health insurance whatsoever. To Brock’s credit, he exposes the lie that cost-effectiveness and utilitarian calculi will be able to address the issues of prioritization properly. By focusing on a population as a whole, utilitarian calculations have a cold and cruel way of neglecting the needs of those who are worst off. Others argue that utilitarianism actually focuses more on those that are worse off because it sees the utility gains from those in the poorest health as contributing more to the over all utility of the population (Gandjour, Lauterbach, 2003). While compelling, this argument fails to take into account the fact that the worst off are also those who cannot afford to pay for any services rendered, and thus in order to focus on the improvement of those who are worst off, utility would decrease as resources are a key function of aggregate utility.

That said, Brock wants to question the focus on those who are worst off. It’s not that he doesn’t think those who are worst off deserve our care. They do. But, argues Brock, there are often situations in which providing care for someone who is dying of AIDS provide less benefit than expanding inadequate funding for nonfatal conditions like substance abuse or mental health disorders.

Before you have a heart attack, remember how I began this discussion. It is important to see that Brock is drawing a line in the sand between health care priorities and health priorities. Perhaps the AIDS patient is in need of a bone marrow transplant or some other treatment for a disease that will lead to his eventual death, a definite health care priority. But perhaps a drug addict is seeking help in a facility, looking to get off the street. If one looks at health in a holistic sense, a dilemma becomes quite clear. Where do limited resources go? What justifies their allocation? Or, alternatively, suggests Brock, what reasons do we have to give priority to the worst off? Who are the worst off? How much priority should they receive in health care prioritization?

As Hoedemekers and Dekker suggest and Brock agrees with, the more expansive your definition of health, the more resources will be necessary. And unfortunately, the more resources needed, the more justification will be needed for prioritizing those who are worst off.

This brings us to a second issue for Brock. This concerns the socioeconomic factors laden in the health care issue. The question is really one of chicken and egg, as far as I can tell. It’s well documented that socioeconomic factors have an influence on the ability to obtain health care and more dangerously, poor socioeconomic status has a negative effect on the health of an individual. What’s more difficult to show is that poor health has an effect on socioeconomic status (Hausman, Asada, Hedemann, 2002; Brock 2000). The key thing to note is this: by focusing on health care rather than on health, bio-ethicists have neglected the links and ties of health to socio-economic factors that surround health. Brock writes, rather forcibly,

More important, inequalities in health among individuals and groups that are within human and social control are not primarily the result of inequalities in access to or use of health care. This is not to deny, of course, that medical care is often of great importance for the life and well-being of individual patients. But differences in access to and use of health care have only a negligible effect on health inequalities among social groups, in particular individuals of different socioeconomic classes. The crucial point is that differences in the incidence of illness and injury from social causes swamp the effects on health of differences in access to and use of medical care to treat that illness and injury (Wilkinson 1996). So if inequalities in access to health care are of moral concern because they result in inequalities in health, then focusing on health care will miss most of the action on the real matter of concern—health and health inequalities.

Now this may cause the reader to question the focus on the health care system, thinking that those concerned with distributive justice and health care must instead focus on the inequalities found in health rather than on health care. However, I don’t think this shift should happen that fast. In another section, Brock unwittingly gives us a clue as to why. He writes,

Higher societal income inequality adversely affects citizens’ health and life expectancy; for example, infant mortality and death rates of the lowest social classes in Sweden, which has low inequality in income, are lower than those of the highest social classes in England and Wales, which have much less egalitarian income distributions (Wilkinson 1996). So there are at least two important social determinants of health at work, where one stands in the socioeconomic hierarchy affects one’s health, and the degree of income inequality in a society affects the society’s overall level of health and health inequality. If the effects of poverty and inequality are combined, even in a rich country like the United States, the size of the impact is striking. In the U.S. the difference in age-adjusted mortality between metropolitan areas with the combination of high inequality and low per capita income and those with low inequality and high per capita income is greater than the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide, and homicide (Lynch et al. 1998).

So it turns out that economically unequal societies have greater incidences of health inequality, and more importantly, the negative effects from economic inequality are greater than the negative effects of negative health. Not only does one’s place on the socioeconomic ladder determine health, but so does the overall degree of income inequality in that society.

If we remember back to a post I wrote a few days ago and something I alluded to at the beginning of this post, health care is primarily an economic problem. Unlike normal products, it involves an individuals well being, the commodification of knowledge and an undesired state of being that needs to be rectified. It is precisely the commodification of health inequality that makes health care an economic issue. Brock is right – a greater focus on health inequalities will broaden the agenda of the bio-ethicist and show her that not only does the definition of health matter, but so do the economic inequalities found in the social system as a whole. I think that Brock answers his own questions though he fails to see the answer supplied by his own arguments. Focusing on health, coming to the recognition that prioritization and health care rationing in inevitable, and understanding that economic inequalities in the system itself contribute to poor health is precisely why theorists should pay attention to the health care system and not simply health as a general idea. Not only is the concept of health contentious, broad and open to interpretation, but it doesn’t deal with the currency of care – money. When a theorist interested in justice, and in particular justice for the worse off, finds herself interested in the health question, she ought to turn her attention primarily to health care inequalities over health inequalities. The maximization of resources in a way that takes rationing into account and pays attention to the worse off, while recognizing all the external socioeconomic factors involved will go a lot further towards achieving economic equality than will theorizing about an ill-defined and subjectively interpreted category of human existence.

References:

Brock, Dan. (2000) Broadening The Bioethics Agenda. Kennedy Institute of Ethics Journal. 10: 21-38.

Gandjour, Afschin; Lauterbach, Karl. (2003) Utilitarian Theories Reconsidered: Common Misconceptions, More Recent Developments and Health Policy Implications Health Care Analysis 11: 229-244.

Hausman, Daniel M et al. (2002) Health Inequalities and Why They Matter. Health Cara Analysis 10: 177-191.

Hoedemaekers, Rogeer; Dekkers, Wim. (2003) Key Concepts in Health Care Priority Setting. Health Care Analysis 11: 309-323.

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