Recent postings here on health care expenditure made me think of Ronald Dworkin’s essay “Justice in the Distribution of Health Care” (McGill Law Journal 1993, but also in Clayton and Williams eds, The Ideal of Equality. Dworkin is concerned to ask (a) how much society should spend on health care and (b) how that spending should be distributed. To answer this question he uses an ideal market (as a model, as a thought experiment, mind, he’s not advocating a market-based health care system). Dworkin argues that we should
bq. 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.
Dworkin enters three counterfactual modifications to his hypothethical choice situtation.
1. The decisions would be taken against a fair background distribution of resources. [See Dworkin, _Sovereign Virtue_ for his view on this.]
2. The choosers would know everything about risks, costs, procedures etc that very good doctors actually know.
3. Except that the choosers are to be deprived of the knowledge of the antecedent probability of any _particular_ person going down with any particular disease or infirmity. I think Dworkin’s idea here is that they would know about the incidence of a disease such a sickle-cell in the general population, but not, crucially, that blacks are more likely to suffer from it than whites.
Dworkin argues that choosers in that position and subject to those constraints would _not_ think it a good bargain to spend money that they could otherwise spend in their fit and healthy youth on insurance to cover them against some eventualities. In particular:
* Almost no one would injure to provide themselves with equipment to keep them alive if they had lapsed into a persistent vegetative state.
* Almost no one would insure to provide themselves with expensive medical treatment (even life-saving treatment) if they had lapsed into some form of irreversible dementia.
* Almost no one would by cover to extend their lives by a few months when doing so would be very costly and they would enjoy a low quality of life.
In all those cases, and others we can imagine, the cost of the treatment is so high and the expected benefit so low that it would be a poor bargain to buy the insurance rather than spending the money on education, training, travel, fun, whatever, today.