• The philosophy of health care reform

    A couple of years ago, I was reading a biography of Albert Einstein.  I was struck by how much he, and scientists like him, we versed in philosophy.  I realized it was one of the areas in which my education was deficient.

    This seemed like a big hole, especially given the rhetoric being flung around about health care reform.  People cited the values of our founders, those of America, and how they would feel about reform.  I realized I knew shockingly little about this.  I did what I usually do in that situation – I took a whole pile of books and spent many summer evenings reading in my backyard with a glass of scotch.  My wife is still making fun of me.

    I read Hobbes.  I read Locke.  I read Rousseau.  I learned a lot, and even wrote a paper on how we could reframe reform as a reopening of the social contract that I’ll get published someday.  But it wasn’t until I got to John Rawls that things took off for me.  There was distributive justice.  There was the veil of ignorance.  And – most importantly – fair equality of opportunity:

    Equality of fair opportunity (EFO) is satisfied in a society just in case any individuals who have the same native talent and the same ambition will have the same prospects of success in competitions that determine who gets positions that generate superior benefits for their occupants. In other words, if Smith and Jones have the same native talent, and Smith is born of wealthy, educated parents of a socially favored ethnicity and Jones is born of poor, uneducated parents of a socially disfavored ethnicity, then if they develop the same ambition to become scientists or Wall Street lawyers, they will have the same prospects of becoming scientists or Wall Street lawyers if EFO prevails. (It should be noted that the specification of EFO just given departs from the specification in Rawls 2001. There Rawls defines EFO so it requires only that the socio-economic status into which one is born has no impact on one’s competitive prospects.)

    Is there any better description of America? We don’t declare that everything will be the same for everyone.  We don’t say that outcomes for everyone will be exactly equal.  But we believe in the equality of opportunity – that each of us should have the same chance of succeeding given equal innate ability and drive.  It’s the American dream.

    I was wishing that someone would take Rawls and apply him specifically to health care, when someone pointed me to Norman Daniels.  He did just that.  I can’t do his work justice, but I will say that he goes where others won’t.  He tries to answer questions like what is the special moral importance of health? When are health inequalities unjust? And, most importantly, how can we meet health needs fairly when we cannot meet them all?

    I bring this up because I was lucky enough to have lunch with Norman Daniels today.  He even signed my copy of his book.  He didn’t disappoint.

    I’m willing to bet most of you haven’t heard of him.  Or John Rawls.  You can fix that:

    Update: If you’ve read these before, there is no need to take offense. Many people haven’t. I hadn’t until relatively recently.

    • I have learned a ton from Norman Daniels. But I question the tack he takes when extending Rawls to address issues in health care access/provision. Consider one of Rawls’s statements about what Fair Equality of Opportunity entails:

      “Offhand it is not clear precisely what the desired equality [of opportunity] entails, but assuming that the analogy with games is relevant, we might say that those with similar abilities and skills should have similar life chances.”

      This is from a 1968 paper, most of which eventually made it into A Theory of Justice. Except for the clause about games. Nevertheless, the stress on negating only the influence of distinctly *social*–as opposed to natural–causes of unequal opportunity is preserved by Rawls in A Theory of Justice.

      If we follow Rawls and think of equality of opportunity in terms of what we think is required to ensure that games or competitive sporting events are fair, we do *not* think that health or innate talent needs to be evened out in order for the contest to be fair. True, we do say things like, “That game last night was unfair,” when five players for the Red Sox are on the “disabled list.” But we don’t mean that there was something *wrong* with playing the game or with letting the winner go on to the World Series while the loser unfairly goes home. We don’t think the loser needs compensation, or deserves some time to “catch up” to the health that the winning team had.

      The point is that there are many interpretations of equality of opportunity. Rawls’s was one. And Daniels’s is quite another–despite the fact that Daniels claims to “borrow” the theoretical justification that Rawls generated for his own version in his very long book. Once we own up to the fact that there are other interpretations that may be defensible, one wonders what is left of Daniels’s view, and whether we might not be better off looking for a basis of justice in health care somewhere else. My own view is that Allan Buchanan was on the right track in the latter part of his own critique of Daniels from 1984 (“A Right to a Decent Minimum of Health Care.”) But Buchanan’s argument is quite incomplete. I’m working on completing it. 🙂

    • No offense, but Rawls is actually mentioned fairly commonly in my experience.

    • You might want to also take a look at some of the writings of Ronald Dworkin, especially “Justice in the Distribution of Heath Care”, McGill Law Journal, 38 (1993),

    • Also relevant here is the following remarks by Nancy Pelosi made on the House floor just before the vote that mattered:

      “Education and health care reform—health care reform and education: equal opportunity for the American people…And this legislation tonight, if I had one word to describe it would be “opportunity.”

      I have no doubt that Normal Daniels’s work is the actual intellectual foundation for this statement.

    • Rawls yes, Daniels no. Thanks for the reference.

      I was thinking along similar lines while on call the other night. How can health care ever come close to being equitable, when we pay vastly different amounts of money for the same care based upon the kind of insurance people have, or dont have? The large differences in pay lead, IMHO, to playing off one group of insured against another for political purposes.