Distributive Justice in Medicine

D. John Doyle MD PhD

April 2004

djdoyle@hotmail.com

Jeffrey Crippin MD, Baylor University once said, "In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have approximately the same opportunity of receiving a donor liver."  This note discusses this issue.

Beauchamp and Childress (Principles of Biomedical Ethics, 4th Edition, page 228) discuss various standards of fairness in the context of distributive justice. These are:

1.To each person an equal share

2.To each person according to need

3.To each person according to effort

4.To each person according to contribution

5.To each person according to merit

6.To each person according to free-market exchanges

These standards of fairness may be explored in the context of three commonly described models of distributive justice:

• Egalitarian model -  where individuals have equal access to goods and services

• Utilitarian model -  where goods and services are provided to those who are likely to benefit the most

•  Libertarian model -  where individuals rights and resources govern access to goods and services

Which model one agrees with most will depend to some extent on whether one views health care as a right (implying a right to universal access to health care),  views health care as a need  (where people with the greatest need have highest priority and  people with similar needs treated similarly), or  views health care as a market commodity.

Let us now consider the words of Dr. Crippin: "In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have approximately the same opportunity of receiving a donor liver." While a single sentence of this kind is usually inadequate to express a complex philosophical position, my view is that Crippin’s statement is primarily an expression of the Egalitarian model. In this model of social justice, one gives equal consideration to all interests while treating everyone as equals. As a result, individuals in need have equal access to goods and services. Note also that when Beauchamp and Childress write “To each person an equal share” they are invoking an Egalitarian model of medical services.

Notice that Crippin does not explicitly emphasize the degree of need in his statement. He does not say: "In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have those individuals in greatest need to be given priority over those patients with a lesser need." Such an approach would reflect a Utilitarian model, in which medical resources are provided on the basis of maximal medical benefit. 

 

In the Libertarian model medical services are merely a market commodity subject to free-market conditions, and a fair distribution of medical resources occurs as long as they are distributed without force or fraud in a free-market economy. When Beauchamp and Childress write “To each person according to free-market exchanges” they are invoking a Libertarian model of medical services.

My view is that any ethically appropriate model for organ allocation must take into account issues related to benefit and need. I believe that those patients who both have a strong need for a transplant and will strongly benefit from a transplant should get priority over patients with either less of a need or who would be expected to obtain less of a benefit. This is a Utilitarian viewpoint based primarily on clinical factors. And, in fact, this is more or less how things are done in the real clinical world. For instance, according to the American Medical Association [1] criteria for organ allocation include:

(1) The likelihood of benefit to the patient;

(2) The impact of treatment in improving the quality of the patient’s life;

(3) The duration of benefits;

(4) The urgency of the patient’s condition; and

(5) In some cases, the amount of resources required for successful     treatment

This particular set of criteria for organ allocation appears to me to be a particularly well thought out set of Utilitarian principles that is superior to the simpler Egalitarian model advocated by Crippin in that if takes into factors like benefit, quality of life and urgency that are not explicitly addressed by the Egalitarian model. I would cast my vote for this approach.

Reference

[1] http://www.ama-assn.org/ama/pub/article/2036-2387.html