Medical Ethics: Justice

Respect for autonomy, as well as the principles of justice, are important concepts in current medical ethics debates.

Justice is the most recent addition to the principles of core medical ethics, and an explicit commitment to justice has been added to the latest draft of the World Medical Association’s International Code of Medical Ethics.

Three principles for justice in health care are currently proposed in the academic literature: need principles, maximising principles and egalitarian principles.

Many people, however, argue that these principles are based on rationing healthcare, and the meaning of ‘justice’ is not always easy to discern.

Justice in healthcare can be considered on many levels and in many different ways. One current area of discussion, for example, concerns the importance of having strategies to decrease inefficiencies in healthcare systems. On a much broader level, another area of justice being debated is the delivery of health care on a global scale in order to reduce health poverty. It is said by many that every society must ration resources, while also attempting to close gaps in health care delivery.

Examples of questions involving justice in medicine?

• Is it right that the world spends more on treating heart disease than malaria, when heart disease is often regarded as a self-inflicted illness, but when malaria causes mortality and morbidity to millions of people across the world each year who have no ready access to treatment?
• Should more money be spent on deprived areas to tackle health inequality, even when drug abuse, smoking and alcohol abuse all are self-inflicted causes of many underlying health problems in these areas?
• Should people have a right to euthanasia?
• Is it fair that abortion is not legal in all states of America? Is abortion the universal right of a woman?
• Should cannabis be legalised? Is it right that its use might be limited solely for medicinal purposes?
• How should identified inequalities suffered by black and Asian minority ethnic communities in health care be addressed?

‘Principles’ in justice are important current concepts in healthcare rationing:

Need principle:
‘Distributed healthcare’ is based on the need of a patient and their capacity to benefit. If one patient needs a hip replacement costing £4,000 and another patient needs cancer treatment costing £20,000, but both would benefit from treatment, then the principle of distributed healthcare would allocate funds to both patients.

Egalitarian principle:
This is a principle determining that healthcare resources should be allocated with the primary intention of reducing inequality. This is based on the premise that everyone, regardless of their circumstances, is entitled to a healthy life.

For many, however, this can be a really difficult concept to realise, as a very large part of good health is often dependent on each individual being prepared to take an active lead in their own well-being. Compare, for example, the patient with an unhealthy lifestyle, who smokes throughout their life and doesn’t take exercise, then has significant health care needs in later life, compared with the patient who has taken care of him or herself all their life, but then has an accident while out training on their bike, requiring the same cost to the NHS to treat as the unhealthy patient. Should one person be treated above the other? If so, why?

Combination principle:
This is where a combination of structured principles come together to deliver best healthcare. Combining the needs principle with the need to maximise healthcare cost-effectiveness in order to deliver the best possible healthcare is an example.

In the combination principle, however, along with all other ethical principles, with conflicting demands, and limited resources, the theory is often much easier to articulate, and the end goal all the more difficult to reach.

In the UK, the NHS appears to be under ever-increasing demand: the population is ageing, yet the resources seem increasingly limited. In preparation for university interviews, you might like to think about how you think healthcare in the 21st-century should be delivered.