Editorial

Bernadette Tobin
Director, Plunkett Centre for Ethics in Healthcare, St Vincent's Hospital, Darlinghurst NSW

PP: 209 - 212

Article Text

Megan-Jane Johnstone argues in this issue (Vol. 12/3, pp. 213-224) that healthcare ethics needs to be revisited, revisioned and revitalized[1]. Its practitioners have systematically failed to recognize and respond appropriately to the processes that have contributed to, created and/or compounded the vulnerability and suffering of whole groups of disadvantaged people (indigenous people, people with mental health problems, people who are disabled, people who are very old, children, amongst others). And they have failed to motivate both individuals and systems to engage personally in activities that will genuinely promote and protect the significant moral interests, welfare and wellbeing of the people belonging to these disadvantaged groups. Johnstone identifies five aspects of healthcare ethics which require sustained attention if the field of enquiry is to overcome these current failures: its nature, its goals, its purposes, its modus operandi and its significance.

I agree with Johnstone that our healthcare arrangements systematically fail whole groups of people, in particular the very young, the very old, the very poor, and those with mental illness. And, though I question whether even the very best healthcare practitioners (and healthcare professions) can, in isolation from other social institutions, overcome those failures, I agree that a re-examination of various aspects of the ethics of healthcare is a necessary preliminary to ensuring that everyone receives his or her entitlement to healthcare. In my view three contested topics in the ethics of healthcare require renewed attention:

the idea that health itself is the goal of healthcare;
the idea that the prerequisites for health ought to be distributed justly; and
the idea that every human being counts as someone to whom we owe at least basic healthcare.

Health itself is the goal of healthcare

The idea that health is the goal of healthcare is a controversial claim. For one thing, other end points are said to be the purpose of healthcare. For another thing, there is plenty of disagreement about what counts as health. Oddly enough, the World Health Organization has (de facto) rejected the idea that healthcare is aimed at health. It has done so by making 'health' and 'happiness' equivalent, by (re)defining health as a 'state of complete physical, mental and social wellbeing'. But this cannot be right. There are many ways in which people who enjoy good health can be unhappy. And people who suffer from chronic illness often live lives of genuine fulfilment. So we need to recognize that human happiness and wellbeing depend on things (earning a sufficient income, having a challenging career, enjoying the companionship of good friends, etc.) about which healthcare practitioners, qua doctors, nurses, social workers, physiotherapists, administrators, etc., can do little for the people for whom they care.

Another putative goal of healthcare is life-prolongation or the prevention of death. Sometimes, of course, saving life or avoiding premature death is just what a good healthcare practitioner will do: the immediate point of much emergency and post-operative care is the avoidance of accidental or premature death. However that immediate purpose needs to be seen in the light of healthcare's deeper purposes. A nurse of any experience will be familiar with cases in which life has been prolonged well beyond the time at which there was hope of returning the person concerned to a reasonably tolerable, or 'healthy', state. So we need to insist that it is health, its maintenance and restoration, together with the relief of suffering associated with ill-health, which is the goal of healthcare.

But clarifying that point raises another: in what does 'health' consist? The English word 'health' comes from an older English word that denotes 'wholeness', and from two Greek words that mean 'living well' and 'having good bodily habits'. While the English word emphasizes a condition of the whole body, the Greek words emphasize proper functioning and activity. Putting them together we can say that health is the well-working of the human organism as a whole. It is health in this sense, which is the business of healthcare. But, as Johnstone points out, you often have to go beyond healthcare, or at least beyond medicine and beyond hospitals, to find the best means for attaining health: good diet, sufficient rest and exercise, clean water, sufficient income, etc. are all necessary for good health[2]. So, though health is the true business of doctors and nurses and other healthcare practitioners, it is not the business only of them.

Prerequisites for health (in particular, healthcare) ought to be distributed justly

In considering what constitutes a just distribution of health care resources, we are, once again, dealing with a contested notion. At least four competing views of distributive justice are found in political and social philosophy (and thus in the derivative field of healthcare ethics).

A utilitarian will tell us to work out all the predictable benefits and all the predictable losses of some proposed change or state of affairs, calculate the net sum (or utility) of these proposed changes and then choose that state of affairs which will maximise utility, that is, bring about the greatest good for the greatest number. In healthcare, contemporary utilitarians use two principal criteria for working out utility: quality of life measures and social contribution measures. They thus tend to favour the following broad principles:

prevention is to be preferred to cure, and cheaper therapies are to be preferred to more expensive ones;
expensive or scarce therapies are to be available only to the young and those who are likely to lead long productive lives;
preference should be given to those likely to receive the greatest benefit in terms of improved length and quality of life and to those likely to make the greatest future social contribution;
short-term services are to be preferred to longer-term care, and institutional care eliminated as far as possible;
healthcare for the terminally ill, dying, elderly, chronically sick or incapacitated, severely handicapped and permanently unconscious, is to be given the lowest priority.

An egalitarian will say that each person, irrespective of wealth or position, should be provided with equal access to an adequate (though not maximal) level of healthcare (contingent on social resources), enough to ensure 'equality of opportunity'. Distribution should be on the basis of need (which is understood as what is necessary for equality of opportunity). Better services should be available for purchase at personal expense by those who are able to and wish to do so. But everyone's basic health needs should be met at an adequate level. On this approach, there is a right to a decent minimum of healthcare, enough to ensure equality of opportunity, and an obligation for society to provide that decent minimum to all its citizens.

A libertarian will insist that people have a range of rights (to life, liberty, property) which they are entitled to enjoy and exercise free from external interference as long as they do not thereby interfere with the similar rights of others. They will say that the only just system of allocation of healthcare is the operation of the free market. It is up to people individually to choose what health cover or services (and from whom) for which they wish to spend their own resources. It is up to health professionals to decide how, when, for whom, with whom and for how much they wish to work. It is simply unfortunate, not unjust, if someone cannot afford to pay for healthcare or healthcare insurance. Any attempt to distribute healthcare in any other way constitutes an infringement of the rights of individual healthcare workers. Nor does anyone have a responsibility to provide it for others. Social intervention, to secure healthcare for all, perverts justice by placing unwarranted constraints on individual liberty.

Finally, a natural law theorist, motivated by Aristotle's thought that when human beings are friends they have no need of justice[3], will say that justice consists in favouring and fostering the common good of one's communities[4]. The common good is the good of individuals, an aspect of whose good is friendship, understood as a readiness to promote the well being of other members of one's community. The failure of the rich to redistribute that portion of their wealth, which could be better used by others for the realisation of basic goods in their lives, is unjust. One natural law theorist applies this idea to the distribution of healthcare in the following way: healthcare ought to be distributed according to a 'Golden Rule' as revealed by the application of the following two-part test:

'Would I think that a healthcare budget and principles of allocation were fair if I (or someone I loved) were in healthcare need, especially if I were one of those excluded from provision or were among the weakest in the community (ie sick with a chronic, disabling and expensive ailment, poor, illiterate, etc)?
Would I think them fair were I (or someone I loved) a healthworker, healthplanner, taxpayer and/or insurer?'[5]

Every human being counts as someone to whom we owe at least basic healthcare

Who counts as 'the other' to whom we owe the prerequisites of good health? Interestingly enough, utilitarians, egalitarians and libertarians tend to converge on the same answer: some human beings do not count as 'others' whose health ought to matter to us, and to whom we owe healthcare. In practice the most influential utilitarians tend to combine their utilitarianism with a view which excludes certain categories of human beings from counting as persons and thus as our 'others' to whom we have obligations in justice. For instance:

Peter Singer argues that newborn infants, the permanently comatose and the demented are not persons (and that gorillas, chimpanzees and the higher apes might turn out to be persons!).[6]
The work of the most influential egalitarian, John Rawls, at least invites the introduction of a 'consciousness criterion' in the allocation of healthcare and so his work has been used in support of the idea that healthcare should be distributed with a preference for those who are or will be capable of exercising moral agency.
And a consciousness criterion seems to be assumed in much of the writing on the allocation of resources by libertarians (who add that those who bring their ill health on themselves do not deserve to be rescued by the state!)

Of the four approaches to justice in the distribution of resource outlined above, only (some versions of) a natural law approach insist that every human being is to be treated as one's neighbour, and that very young, the very old, the disabled, the sick, the frail, the demented, the permanently unconscious, and indeed those who may be thought to have contributed to their own illness, all deserve our 'preferential' care.

If healthcare ethics is in need of revitalization, then clear thinking about the goal of healthcare, its just distribution and to whom it is owed will be central to that enterprise. But it has to be recognized that there is no knock down answer to any of these questions, and that each is properly the subject of philosophical debate.

[1] Megan-Jane Johnstone, The changing focus of healthcare ethics: implications for healthcare professionals, Contemporary Nurse, Volume 12, No 3, June 2002 pp. 213-224.

[2] And only health: we would have greatly increased resources to devote to healthcare if so many of them were not squandered on trivial cosmetic surgery!

[3] Nicomachean Ethics, 1155a25.

[4] Stephen Buckle's short history of a 'natural law' ethics shows how disparate are many of the elements of the natural law tradition. See his 'Natural Law' in A Companion to Ethics edited by Peter Singer, Blackwell, 1991.

[5] Anthony Fisher, The Principles of Justice considered with reference to the allocation of resources (unpublished DPhil thesis) 135.

[6] Peter Singer, Rethinking Life and Death, Text Publishing Company, Melbourne, 1994.