The work of the philosopher, John Rawls (b. 1921) on the theory of justice has provided the fundamental underpinnings for the concepts of equity and resource allocation for health. According to his moral viewpoint, inequalities of birth, natural endowment, and historical circumstances are undeserved. Rawls argues that all vital economic goods and services should be distributed equally, unless an unequal distribution would work to everyone's advantage, including the worst off.
Consistent with this view is the concept of equity, which means "fair shares" and "fair opportunities" in the distribution of and access to resources and services. Equity is different from equal shares or equal opportunities, however. Equity means that greater resources and more services should be made available to the most vulnerable and needy groups. In the context of health care, equity means care according to need. (A subtlety not to be missed is that the pursuit of equity in health care requires a capacity for identifying differential need, so that care can be supplied according to such needs.)
The fair opportunity rule says that properties distributed by the lottery of social and biological life are not grounds for morally acceptable discrimination between persons if they are not the sorts of properties that people have a fair chance to acquire or overcome. This argument provides a justification for a corrective redistribution of shares to many classes of disadvantaged persons, as well as a basis for numerous health policies.
THE RIGHT TO HEALTH CARE
The fair opportunity rule suggests that the justice of social institutions is gauged by their capacity to counteract lack of opportunity caused by unpredictable bad luck and misfortune over which a person has no meaningful control. When those misfortunes are expressed in terms of threats to health, the call for corrective action becomes the right to health care.
The most intractable problem has been how to specify the exact commitments of a right to health care. Two major contemporary views hold that there is a right to equal access to medical care and a right to a decent minimum of medical care. The "right to equal access" to health care takes on several meanings. One would be an equal right to certain goods and services. A more elaborate view of equal access requires that everyone should have equal access to any treatment that is available to anyone.
Given the considerable uncertainty carried by the call for equal access to health care, it may be easier to consider the less expansive expression of the right to health care, namely, the right to a decent minimum of health care. This suggests a government obligation to meet certain basic health needs of all citizens. This approach accepts a two-tiered system of health care: social coverage for basic and catastrophic health needs (tier 1), together with private coverage for other health needs and desires (tier 2).
On the first tier, distribution is based on needs, and needs are met by equal access to health services that are responsive to differential needs. This approach would generally be considered as primary health care, supported by secondary and tertiary services as determined by needs. Further services might be available for purchase at personal expense (tier 2), but everyone's basic health needs would be met at the first tier. This approach avoids the straight jacket of a one-tiered, equal access for all, health care delivery system.
Despite its attractions, this proposal of a decent minimum has proved difficult to explicate and implement. It raises problems of whether a society can fairly, consistently, and unambiguously structure a public policy that recognizes a right to care for primary needs without creating a right to exotic and expensive forms of treatment, such as liver transplants.
FORFEITURE OF THE RIGHT TO HEALTH CARE
Can an individual forfeit the right to health care, or at least to certain forms of health care, as a result of one's personal neglect or misdeeds, such as personal lifestyles or individual actions? Examples would be patients who acquired AIDS as a result of risky sexual activities or intravenous drug use, patients with lung disease as a result of smoking, and patients with liver disease as a result of heavy consumption of alcohol. Does society have the same obligation to provide health care to these groups as it does to patients who are "victims" of the natural social and environmental lotteries?
A person may forfeit his or her right to liberty by criminal action that violates basic social responsibilities, and some argue that a person may forfeit his or her right to health care by failing to act responsibly. However, several principles set limits on policies of exclusion of individual risk takers from societal funds for health care. First, it must be possible to identify and differentiate various causal factors in morbidity—such as the natural lottery, the social environment, and personal activities— and to confirm that a pertinent disease or illness is the result of personal activities. Second, it must be possible to show that the personal activities in question were autonomous, in the sense that the actors were aware of the risks and voluntarily accepted them.
Regarding the first condition, it is virtually impossible to isolate causal factors for many of the most crucial examples of ill health because of the complexity of causal links and the limitations of knowledge. It would not be unfair to require individuals who engage in certain risky actions that result in costly medical needs to pay higher premiums or taxes. Risk takers might be required to contribute more to particular pools, such as insurance schemes, or to pay a tax on their risky conduct, such as increased taxes on cigarettes. These requirements may fairly redistribute the burdens of the costs of health care, and they may deter risky conduct without unduly compromising the principle of respect for autonomy.
PRIORITIES IN THE ALLOCATION OF HEALTH CARE RESOURCES
Macro-allocation decisions determine how much should be expended and what kinds of goods will be made available in society, as well as how they are to be distributed. Such decisions determine: (1) what kinds of health care services will exist in a society, (2) who will get them and on what basis, (3) who will deliver them, (4) how the burdens of financing them will be distributed, and (5) how the power and control of those services will be distributed.
The most general question for a society committed to providing a decent minimum of health care to all citizens is how much of its budget should be allocated for health care and how much for other social goods, such as housing, education, culture, and recreation. Once a society has determined its budget for health care, it still has to allocate funds within health care. A vital question is whether priority should go to prevention or to critical care. It is reasonable for a society to turn to fair, democratic political procedures to make a choice among just alternatives. Given the great imprecision in the notion of adequate health care, however, it is especially important that the procedures used to define that level be—and be perceived to be—fair. Overall, in considering equity and resource allocation, it is fair to say that the field of ethics has brought considerable concern and helpful moral reasoning to the field of health care and related policies, including resource allocation.
