Another brief paper submitted as part of my first health care ethics class at Creighton University:
Robert C. Baker
MH 601
September 18, 2009A mother hands each of her two children a cookie.
One cookie is larger than the other.
Silly mother!
Unequal distribution of valuable and scarce resources occurs all across the globe. It has been repeated an infinite number of times by a limitless number of mothers and fathers who, despite their their careful cutting (and nibbling), have committed the child’s cardinal sin of being “unfair.” Only the most crass relativist (and hardcore cookie hoarder) would deny that we know almost by nature, even at an early age, when we have been a recipient of injustice.
Although the concept of justice is simple to a child–you get exactly half, I get exactly half–in the cooking cutting world of an adult justice can be quite complicated–if not elusive. This has particular import when the topic is the fair distribution of medication or treatment or health services. Consider the asthmatic African-American infant, the diabetic senior citizen, or the young Hispanic construction worker permanently disabled at her work site. How do we redress the injustices faced by vulnerable populations such as these especially when “unfairnesses” tends to multiply, like so many cookie crumbs, so that individuals and groups experience not just one, but many?
Providing some assistance in answering these questions is the work of Madison Powers and Ruth Faden. Although known for their pivotal Social Justice: The Moral Foundations of Public Health and Health Policy (Powers and Faden 2006), I would like to focus my attention on some of their earlier work to provide context and elucidation for their views on justice expressed in Social Justice. To that end, I will look at two articles by Powers and Faden from the Kennedy Institute of Ethics Journal: “Forget About Equality” (1996), and “Inequalities in Health, Inequalities in Health Care: Four Generations of Discussion about Justice and Cost-Effectiveness Analysis” (2000). In the end, I hope to bring forward further insights about key elements of justice as applied to vulnerable populations.
In “Forget about Equality,” Powers offers six arguments against the ideal of equality traditionally rendered. Chiefly, Powers finds that the commitment to equality as an ideal suffers from “the need to maximize” (130), which inhibits one’s ability to reason about the practical distribution of scarce goods, and of which both utilitarians and egalitarians are guilty. He also notes the anti-egalitarian arguments of Lucas, Raz, and Goodwin who, each in his own way, note the deficiencies of equality as an ideal, including both “leveling down” and “leveling up.” Ultimately, Powers opts for an abstract form of equality and distributive justice more in line with a revised principle of sufficiency.
Teaming up with Ruth Faden, In “Equalities in Health,” Powers offers an account of “four generations” of bioethical discourse concerning justice in health policy. Apart from egalitarian arguments, bioethics literature from ultilitarian and libertarian voices during the first generation scarcely addressed health care as rights. The second generation of literature focused more on practical matters such as the CEA, or cost-effective analysis, along with other empirical measures including QALYs. The third generation was characterized by “deep doubt” (114) about resolving justice issues with efficiency goals. The fourth generation, they maintain, is beginning to focus more on health care rather than health, and “promises to make inequalities in health, not inequalities in health care, the central moral concern” (123). Powers and Faden express hope that, although traditional philosophical arguments on equality will persist, by abandoning the “magic” bullet of a single distributive theory divorced from the practical health care context in favor of a more robust theory and application of justice, overall improvements in health and health care can be achieved.
Against this backdrop, I would suggest that Powers and Faden’s six, morally-urgent, “irreducible dimensions” (2006, 15) of well-being–health, personal security, reasoning, respect, attachment, and self-determination–deserve further exploration. Although there may be prioritization of these dimensions given specific contexts and needs, their work makes a good start toward providing commonsensical solutions to global and cumulative health care problems that affect vulnerable populations. True, their work may need assistance getting to the ground. Nevertheless, they have successfully reinforced this concept: Any suggestion that dividing valuable and scare health care resources “in two” and distributing them “equally” is an impoverished appreciation of justice. We need a more robust view that can account for greater contingencies.
Because, what does a mother do with one cookie and two children,
when one of them has eaten
the rest of the box?
———————-
Sources:
Powers, Madison. “Forget About Equality.” Kennedy Institute of Ethics Journal 6.2 (1996) 129-144.
Powers, Madison, and Faden, Ruth. “Inequalities in Health, Inequalities in Health Care:
Four Generations of Discussion about Justice and Cost-Effectiveness Analysis.” Kennedy Institute of Ethics Journal 10.2 (2000) 109-127.Powers, Madison, and Faden, Ruth. Social Justice: The Moral Foundations of Public Health and Health Policy. (New York: Oxford University Press, 2006).
