rw2

not everyone can receive everything medi­

cal science has to off er. A just and fair allocation of health care

poses conceptual and practical difficulties.

Hence, a theory of justice is necessary to

resolve the problem of health care allo­

cation (Jansen et al., 2015). Even though

various ethical principles can be used

to guide decisions pertaining to just and fair allocation of health care in individual circumstances, the concern about provid­ ing equitable access to health services on

a population level is addressed by two contrasting theories, referred to as market justice and social justice.

Market Justice The principle of market justice leaves the fair distribution of health care up to the market forces in a free economy. In consequence, medical care and its ben­ efits are distributed based on people's willingness and ability to pay (Santerre and Neun, 2010). In other words, people are entitled to purchase a share of the available goods and services that they .value; they purchase these valued goods and services by means of wealth acquired through their own efforts. This is how most goods and services are distributed in a free market. The free market implies that giving people something they have not earned would be morally and eco­ nomically wrong.

The An Overview of U.S. Health Care Delivery chapter discussed several char­ acteristics of a free market; these market characteristics are a precondition to the distribution of health care services accord­ ing to market justice principles. As previ­ ously mentioned, health care in the United States is not delivered in a free market, but

Anthro-Cultural Beliefs and Values 87

rather in a quasi-market. Hence, market justice principles are only partially appli­ cable to the U.S. health care delivery sys­ tem. Distribution of health care according to market justice is based on the following key assumptions:

• Health care is like any other economic good or service, and its distribution and consumption are determined by the free market forces of supply and demand.

• Individuals are responsible for their own achievements. With the rewards of their achievements, people are free to obtain various economic goods and services, including health care. When individuals pursue their own best interests, the interests of society as a whole are best served (Ferguson and Maurice, 1970).

• People make rational choices in their decisions to purchase health care products and services. Gross­ man ( 1972) proposed that health is also an investment commodity-in other words, people consider the purchase of health services to be an investment. For example, the invest­ ment has a monetary payoff when it reduces the number of sick days, making extra time available for pro­ ductive activities, such as earning a living. Alternatively, it can have a ·

utility payoff-a payoff in terms of satisfaction-when it makes life more enjoyable and fulfilling.

• People, in consultation with their phy­ sicians, know what is best for them. This assumption implies that people place a certain degree of trust in their physicians and that the physician­ patient relationship is ongoing.

88 Chapter 2 Beliefs, Values, and Health

• The marketplace works best with minimum interference from the gov­ ernment. In other words, the market, rather than the government, can allo­ cate health care resources in the most efficient and equitable manner.

Under market justice conditions, the production of health care is determined by how much consumers are willing and able to purchase health care at the prevail­ ing market prices. Thus, prices and abil­ ity to pay ration the quantity and type of health care services that people consume. The uninsured and individuals who lack sufficient income to pay for private health care services face barriers to obtaining health care. Such limitations to obtaining health care are referred to as demand-side rationing, or "rationing by ability to pay" (Feldstein, 1994). To some extent, the unin­ sured may be able to overcome some of these barriers through charitable services.

TABLE 2-S summarizes key charac­ teristics of the market justice system and their implications. Market justice empha­ sizes individual-rather than collec­ tive-responsibility for health. It proposes private-rather than government-solu­ tions to social problems of health.

Social Justice The idea of social justice is at odds with the principles of capitalism and mar­ ket justice. The term "social justice" was invented in the 19th century by the crit­ ics of capitalism to describe the "good society" (Kristal, 1978). According to the principle of social justice, the equitable distribution of health care is a societal responsibility, which is best achieved by letting the government take over the

production and distribution of health care. Social justice regards health care as a social good rather than as an eco­ nomic good and suggests that it should be collectively financed and available to all citizens regardless of the individual recipient's ability to pay. The main char­ acteristics and implications of social jus­ tice are summarized in Table 2-5.

Canadians and Europeans long ago reached a broad consensus that health care is a social good (Reinhardt, 1994). Public health also has a social justice orientation (Turnock, 1997). Under the social justice system, inability to obtain medical services because of a lack of financial resources is considered inequitable. Accordingly, a just distribution of health care must be based on need, not simply on the individual's ability to purchase such care in the mar­ ketplace (demand). The need for health care is determined either by the patient or by a health professional.

The principle of social justice is also based on certain assumptions:

• Health care is different from most other goods and services. Health-seeking behavior is governed primarily by need rather than by ability to pay.

• Responsibility for health is shared. Individuals are not held completely responsible for their condition because factors outside their control may have brought on the condition. Society is held responsible because individuals cannot control certain environmental factors, such as economic inequali­ ties, unemployment, or unsanitary conditions.

• Society has an obligation to the col­ lective good. The well-being of the community is superior to that of the

Characteristics

• Views health care as an economic good

• Assumes free-market conditions for health

services delivery

• Assumes that markets are more efficient in

allocating health resources equitably

• Production and distribution of health care

determined by market-based demand

• Medical care distribution based on people's

ability to pay

• Access to medical care viewed as an economic

reward of personal effort and achievement

Implications

• Individual responsibility for health

• Benefits based on individual purchasing power

• Limited obligation to the collective good

• Emphasis on individual well-being

• Private solutions to social problems

• Rationing based on ability to pay

individual. An unhealthy individual is a burden on society. A person carrying a deadly infection, for example, poses a threat to society. Society, therefore,

Anthro-Cultural Beliefs and Values 89

• Views health care as a social resource

• Requires active government involvement in health services delivery

• Assumes that the government is more

efficient in allocating health resources

equitably

• Medical resource allocation determined

by central planning

• Ability to pay is inconsequential for

receiving medical care

• Equal access to medical services viewed as a basic right

• Collective responsibility for health

• Everyone is entitled to a basic package of

benefits

• Strong obligation to the collective good

• Community well-being supersedes that of

the individual

• Public solutions to social problems

• Planned rationing of health care

is obligated to cure the problem by providing health care to the indi­ vidual. By doing so, the whole society will benefit.

90 Chapter 2 Beliefs, Values, and Health

• The government, not the market, can better decide through central plan - ning how much health care to produce and how to distribute it to all citizens.

Just as true market justice does not exist in health care, so true social justice also does not exist. In the real world, no society can afford to provide unlimited amounts of health care to all its citizens (Feldstein, 1994). The government may offer insurance coverage to all, but must also find ways to limit the availability of certain health care services. For example, under the social justice principle, the gov­ ernment decides how technology will be dispersed and who will be allowed access to certain types of costly high-tech ser­ vices, even though basic services may be available to all. The government engages in supply-side rationing, which is also referred to as planned rationing or non­ price rationing. In social justice systems, the government uses "health planning" to limit the supply of health care services, although the limited resources are often more equally dispersed throughout the country than is generally the case under a market justice system. The necessity of rationing health care explains why citizens of a country can be given universal cover­ age but not universal access. Even when a covered individual has a medical need, depending on the nature of health services required, he or she may have to wait until services become available.

Justice in the U.S. Health Delivery System In a quasi-perfect or imperfect market, such as the market for health care deliv­ ery in the United States, elements of both

market and social justice principles exist. In some areas, the principles of market and social justice complement each other. In other areas, the two present conflicts.

The two contrasting principles com­ plement each other in the employer-based health insurance available to most middle­ class working Americans (market jus­ tice) and the publicly financed Medicare, Medicaid, and CHIP coverage for certain disadvantaged groups (social justice). Insured populations access health care services delivered mainly by private prac­ titioners and private institutions (market justice). Tax-supported county and city hospitals, public health clinics, and com­ munity health centers can be accessed by the uninsured in areas where such services are available (social justice).

Market and social· justice principles create conflicts when health care resources are not uniformly distributed throughout the United States, and when there is a gen­ eral shortage of primary care physicians (an issue discussed in the Health Services Professionals chapter). Consequently, in spite of having public insurance, many Medicaid-covered patients have difficulty obtaining timely access, particularly in rural and inner-city areas. This conflict is partly created by artificially low reim­ bursement from public programs; in comparison, reimbursement from private ·payers is more generous.

Limitations of Market Justice The principles of market justice work well for allocating economic goods when their unequal distribution does not affect the larger society. For example, based on individual success, people live in dif­ ferent sizes and styles of homes, drive

different types of automobiles, and spend their money on a variety of things. In other cases, the allocation of resources has wider repercussions for society. In these areas, market justice has severe

limitations:

• Market justice principles fail to rec­ tify critical human concerns. Perva­ sive social problems, such as crime, illiteracy, and homelessness, can sig­ nificantly weaken the cohesion of a society. Indeed, the United States has recognized such issues and instituted programs based on the social justice principle to combat such problems. These programs have added police protection, publicly supported educa­ tion, and subsidized housing for many poor and elderly populations. Health care is an important social issue because it not only affects human pro­ ductivity and achievement but also provides basic human dignity.

• Market justice does not always protect a society. Individual health issues can have negative consequences for soci­ ety because ill health is not always confined to the individual. The AIDS epidemic is an example of how a society can be put at serious risk by illness originally affecting just a few subpopulations. The initial spread of the SARS epidemic in Beijing, China, was largely due to patients with SARS symptoms being turned away by hospitals because they were not able to pay in advance for the cost of the treatment. Similar to clean air and water, health care is a social concern that, in the long run, protects against the burden of preventable disease and disability-a burden that is ultimately borne by society at large.

Anthro-Cu/tural Beliefs and Values 9 1

• Market justice does not work well in health care delivery. On the one hand, growing national economy and pros­ perity in the past did not materially reduce the number of uninsured Amer­ icans. On the other hand, the number of m�insured people increases during eco­ nomic downturns. For example, dur­ ing the 2007 -2009 recession, 5 million Americans lost employment-based health insurance (Holahan, 2011 ).

Integration of Individual and Population Health It has been recognized that the typical emphasis on the treatment of acute ill­ ness in hospitals, biomedical research, and high technology has not significantly improved the U.S. population's health. Instead, the medical model should be integrated with a disease-prevention, health-promotion, primary care-based model to produce significant gains in health. Society will always need the ben­ efits of modern science and technology for the treatment of disease, but health promotion and primary care can prevent and delay the onset of many diseases, disability, and premature death. An inte­ grated approach will improve the overall health of the population, enhance peo­ ple's quality of life, and conserve health care resources.

The real challenge for the health care delivery system is incorporating medical and wellness models within the holistic context of health. For instance, the Ottawa Charter for Health Pro­ motion mentions caring, holism, and ecology as essential issues in develop­ ing strategies for health promotion (de Leeuw, 1989). "Holism" and "ecology"

not everyone can receive everything medi­

cal science has to off er. A just and fair allocation of health care

poses conceptual and practical difficulties.

Hence, a theory of justice is necessary to

resolve the problem of health care allo­

cation (Jansen et al., 2015). Even though

various ethical principles can be used

to guide decisions pertaining to just and fair allocation of health care in individual circumstances, the concern about provid­ ing equitable access to health services on

a population level is addressed by two contrasting theories, referred to as market justice and social justice.

Market Justice The principle of market justice leaves the fair distribution of health care up to the market forces in a free economy. In consequence, medical care and its ben­ efits are distributed based on people's willingness and ability to pay (Santerre and Neun, 2010). In other words, people are entitled to purchase a share of the available goods and services that they .value; they purchase these valued goods and services by means of wealth acquired through their own efforts. This is how most goods and services are distributed in a free market. The free market implies that giving people something they have not earned would be morally and eco­ nomically wrong.

The An Overview of U.S. Health Care Delivery chapter discussed several char­ acteristics of a free market; these market characteristics are a precondition to the distribution of health care services accord­ ing to market justice principles. As previ­ ously mentioned, health care in the United States is not delivered in a free market, but

Anthro-Cultural Beliefs and Values 87

rather in a quasi-market. Hence, market justice principles are only partially appli­ cable to the U.S. health care delivery sys­ tem. Distribution of health care according to market justice is based on the following key assumptions:

• Health care is like any other economic good or service, and its distribution and consumption are determined by the free market forces of supply and demand.

• Individuals are responsible for their own achievements. With the rewards of their achievements, people are free to obtain various economic goods and services, including health care. When individuals pursue their own best interests, the interests of society as a whole are best served (Ferguson and Maurice, 1970).

• People make rational choices in their decisions to purchase health care products and services. Gross­ man ( 1972) proposed that health is also an investment commodity-in other words, people consider the purchase of health services to be an investment. For example, the invest­ ment has a monetary payoff when it reduces the number of sick days, making extra time available for pro­ ductive activities, such as earning a living. Alternatively, it can have a ·

utility payoff-a payoff in terms of satisfaction-when it makes life more enjoyable and fulfilling.

• People, in consultation with their phy­ sicians, know what is best for them. This assumption implies that people place a certain degree of trust in their physicians and that the physician­ patient relationship is ongoing.

88 Chapter 2 Beliefs, Values, and Health

• The marketplace works best with minimum interference from the gov­ ernment. In other words, the market, rather than the government, can allo­ cate health care resources in the most efficient and equitable manner.

Under market justice conditions, the production of health care is determined by how much consumers are willing and able to purchase health care at the prevail­ ing market prices. Thus, prices and abil­ ity to pay ration the quantity and type of health care services that people consume. The uninsured and individuals who lack sufficient income to pay for private health care services face barriers to obtaining health care. Such limitations to obtaining health care are referred to as demand-side rationing, or "rationing by ability to pay" (Feldstein, 1994). To some extent, the unin­ sured may be able to overcome some of these barriers through charitable services.

TABLE 2-S summarizes key charac­ teristics of the market justice system and their implications. Market justice empha­ sizes individual-rather than collec­ tive-responsibility for health. It proposes private-rather than government-solu­ tions to social problems of health.

Social Justice The idea of social justice is at odds with the principles of capitalism and mar­ ket justice. The term "social justice" was invented in the 19th century by the crit­ ics of capitalism to describe the "good society" (Kristal, 1978). According to the principle of social justice, the equitable distribution of health care is a societal responsibility, which is best achieved by letting the government take over the

production and distribution of health care. Social justice regards health care as a social good rather than as an eco­ nomic good and suggests that it should be collectively financed and available to all citizens regardless of the individual recipient's ability to pay. The main char­ acteristics and implications of social jus­ tice are summarized in Table 2-5.

Canadians and Europeans long ago reached a broad consensus that health care is a social good (Reinhardt, 1994). Public health also has a social justice orientation (Turnock, 1997). Under the social justice system, inability to obtain medical services because of a lack of financial resources is considered inequitable. Accordingly, a just distribution of health care must be based on need, not simply on the individual's ability to purchase such care in the mar­ ketplace (demand). The need for health care is determined either by the patient or by a health professional.

The principle of social justice is also based on certain assumptions:

• Health care is different from most other goods and services. Health-seeking behavior is governed primarily by need rather than by ability to pay.

• Responsibility for health is shared. Individuals are not held completely responsible for their condition because factors outside their control may have brought on the condition. Society is held responsible because individuals cannot control certain environmental factors, such as economic inequali­ ties, unemployment, or unsanitary conditions.

• Society has an obligation to the col­ lective good. The well-being of the community is superior to that of the

Characteristics

• Views health care as an economic good

• Assumes free-market conditions for health

services delivery

• Assumes that markets are more efficient in

allocating health resources equitably

• Production and distribution of health care

determined by market-based demand

• Medical care distribution based on people's

ability to pay

• Access to medical care viewed as an economic

reward of personal effort and achievement

Implications

• Individual responsibility for health

• Benefits based on individual purchasing power

• Limited obligation to the collective good

• Emphasis on individual well-being

• Private solutions to social problems

• Rationing based on ability to pay

individual. An unhealthy individual is a burden on society. A person carrying a deadly infection, for example, poses a threat to society. Society, therefore,

Anthro-Cultural Beliefs and Values 89

• Views health care as a social resource

• Requires active government involvement in health services delivery

• Assumes that the government is more

efficient in allocating health resources

equitably

• Medical resource allocation determined

by central planning

• Ability to pay is inconsequential for

receiving medical care

• Equal access to medical services viewed as a basic right

• Collective responsibility for health

• Everyone is entitled to a basic package of

benefits

• Strong obligation to the collective good

• Community well-being supersedes that of

the individual

• Public solutions to social problems

• Planned rationing of health care

is obligated to cure the problem by providing health care to the indi­ vidual. By doing so, the whole society will benefit.

90 Chapter 2 Beliefs, Values, and Health

• The government, not the market, can better decide through central plan - ning how much health care to produce and how to distribute it to all citizens.

Just as true market justice does not exist in health care, so true social justice also does not exist. In the real world, no society can afford to provide unlimited amounts of health care to all its citizens (Feldstein, 1994). The government may offer insurance coverage to all, but must also find ways to limit the availability of certain health care services. For example, under the social justice principle, the gov­ ernment decides how technology will be dispersed and who will be allowed access to certain types of costly high-tech ser­ vices, even though basic services may be available to all. The government engages in supply-side rationing, which is also referred to as planned rationing or non­ price rationing. In social justice systems, the government uses "health planning" to limit the supply of health care services, although the limited resources are often more equally dispersed throughout the country than is generally the case under a market justice system. The necessity of rationing health care explains why citizens of a country can be given universal cover­ age but not universal access. Even when a covered individual has a medical need, depending on the nature of health services required, he or she may have to wait until services become available.

Justice in the U.S. Health Delivery System In a quasi-perfect or imperfect market, such as the market for health care deliv­ ery in the United States, elements of both

market and social justice principles exist. In some areas, the principles of market and social justice complement each other. In other areas, the two present conflicts.

The two contrasting principles com­ plement each other in the employer-based health insurance available to most middle­ class working Americans (market jus­ tice) and the publicly financed Medicare, Medicaid, and CHIP coverage for certain disadvantaged groups (social justice). Insured populations access health care services delivered mainly by private prac­ titioners and private institutions (market justice). Tax-supported county and city hospitals, public health clinics, and com­ munity health centers can be accessed by the uninsured in areas where such services are available (social justice).

Market and social· justice principles create conflicts when health care resources are not uniformly distributed throughout the United States, and when there is a gen­ eral shortage of primary care physicians (an issue discussed in the Health Services Professionals chapter). Consequently, in spite of having public insurance, many Medicaid-covered patients have difficulty obtaining timely access, particularly in rural and inner-city areas. This conflict is partly created by artificially low reim­ bursement from public programs; in comparison, reimbursement from private ·payers is more generous.

Limitations of Market Justice The principles of market justice work well for allocating economic goods when their unequal distribution does not affect the larger society. For example, based on individual success, people live in dif­ ferent sizes and styles of homes, drive

different types of automobiles, and spend their money on a variety of things. In other cases, the allocation of resources has wider repercussions for society. In these areas, market justice has severe

limitations:

• Market justice principles fail to rec­ tify critical human concerns. Perva­ sive social problems, such as crime, illiteracy, and homelessness, can sig­ nificantly weaken the cohesion of a society. Indeed, the United States has recognized such issues and instituted programs based on the social justice principle to combat such problems. These programs have added police protection, publicly supported educa­ tion, and subsidized housing for many poor and elderly populations. Health care is an important social issue because it not only affects human pro­ ductivity and achievement but also provides basic human dignity.

• Market justice does not always protect a society. Individual health issues can have negative consequences for soci­ ety because ill health is not always confined to the individual. The AIDS epidemic is an example of how a society can be put at serious risk by illness originally affecting just a few subpopulations. The initial spread of the SARS epidemic in Beijing, China, was largely due to patients with SARS symptoms being turned away by hospitals because they were not able to pay in advance for the cost of the treatment. Similar to clean air and water, health care is a social concern that, in the long run, protects against the burden of preventable disease and disability-a burden that is ultimately borne by society at large.

Anthro-Cu/tural Beliefs and Values 9 1

• Market justice does not work well in health care delivery. On the one hand, growing national economy and pros­ perity in the past did not materially reduce the number of uninsured Amer­ icans. On the other hand, the number of m�insured people increases during eco­ nomic downturns. For example, dur­ ing the 2007 -2009 recession, 5 million Americans lost employment-based health insurance (Holahan, 2011 ).

Integration of Individual and Population Health It has been recognized that the typical emphasis on the treatment of acute ill­ ness in hospitals, biomedical research, and high technology has not significantly improved the U.S. population's health. Instead, the medical model should be integrated with a disease-prevention, health-promotion, primary care-based model to produce significant gains in health. Society will always need the ben­ efits of modern science and technology for the treatment of disease, but health promotion and primary care can prevent and delay the onset of many diseases, disability, and premature death. An inte­ grated approach will improve the overall health of the population, enhance peo­ ple's quality of life, and conserve health care resources.

The real challenge for the health care delivery system is incorporating medical and wellness models within the holistic context of health. For instance, the Ottawa Charter for Health Pro­ motion mentions caring, holism, and ecology as essential issues in develop­ ing strategies for health promotion (de Leeuw, 1989). "Holism" and "ecology"