Reading the current US debate on health care from the outside is pretty dispiriting. It is an example of what happens to rational debate in circumstances of inequality where vested interests and partisan pundits can distort discussion by throwing loads of noise, fear and disinformation into the conversation. Still, that’s no reason not to try to have a conversation about which principles ought to obtain, and I think for that it is hard to beat Ronald Dworkin’s paper “Justice in the Distribution of Heath Care”, McGill Law Journal, 38 (1993), pp. 883-98 (though I’m looking at the reprint in Clayton and Williams eds The Ideal of Equality ).
Dworkin’s “central idea”:
… we should aim to make collective, social decisions about the quantity and distribution of health care so as to match, as closely as possible, the decisions that people in the community would make for themselves, one by one, in the appropriate circumstances, if they were looking from youth down the course of their lives and trying to decide what risks were worth running in return for not running other kinds of risks. (C&W, 209)
Dworkin invites us to imagine a thought experiment involving three changes to existing society:
(1) Society changes so as to implement whichever economic structures the reader thinks implement equal concern and respect. (Obviously, Dworkin thinks his own “equality of resources” conception does that best, but he doesn’t require us to buy into that ideal for the purposes of the present exercise.
(2) Assume everyone knows all the relevant technical information about the costs, prognoses, risks associated with the full range of medical procedures.
(3) Imagine that no-one knows anyone’s antecedent probability of contracting a particular illness, dying from a particular cause, and so forth.
Now imagine (against the background of 1, 2 and 3) a free-market in health care, and ask what people would choose, both individually and in the aggregate, and what the distribution of medical treatment would look like. Dworkin’s claim is that whatever such as society would choose in such (hypothetical) circumstances is just for that society.
So what would people choose?
Dworkin argues that they would band together in big insurance schemes (possible a single scheme) to realize economies of scale in the provision of some agreed basic package, but that this would be supplemented by a secondary market enabling people to purchase some additional medical services (cosmetic surgery etc.).
So what wouldn’t get covered in the basic package? In other worlds, what conditions would rational individuals not choose to buy insurance to secure treatment of? Here are Dworkin’s answers: (1) “almost no-one would purchase insurance that would provide life-sustaining equipment once he had fallen into a persistent vegetative state …. (212). (2) nor would anyone buy insurance to provide expensive treatment for themselves in late-stage Alzheimer’s (it would be better to spend the money in the here and now whilst you’re fit and healthy). (3) people would also prefer to spend their money on their vigorous and healthy younger selves rather than on keeping themselves alive, at enormous expense, for a few additional months of low-quality life. So people wouldn’t choose to spend thousands of dollars (or pounds) on insurance to buy expensive treatements to prolong the life of terminal cancer sufferers, or severe heart failure cases: people would rather spend the money on other things. And we can extend the thought to cover a lot of R&D too. It may be all very nice (stimulating, good for careers etc) for scientists and/or drug companies to devote billions to speculative research that might or might not issue in treatments extending the life of the terminally ill by a few month, but almost nobody faced with a choice between that investment of resources or spending the money on other stuff (education, culture, vacations, their kids) would squander their resources on such research.
So it turns out that the McMegans of this world are right about one thing: in a just society (not that they’d call it that) there would be less spent on expensive medical/drug research and development than a country like the US spends now. But that’s a good thing : against a background of fairness and equality, rational and fully informed people would look at the opportunity cost of such activity and say “no thanks!”