Abstract

In lieu of an abstract, here is a brief excerpt of the content:A Just Share: Justice and Fairness in Resource Allocation*Pat Milmoe Mccarrick (bio) and Martina Darragh (bio)Each of us has some basic sense of what the words “fair” or “just” or “fairness” or “justice” mean. Each of us probably also has an idea of what is “fair” in health care. The attempt by the state of Oregon in the mid-1980s to quantify this notion made a previously private exercise a public one. This transition has been chronicled in the bioethics literature that focuses on resource allocation. These works examine both theories of justice and concepts of “health”; the fair distribution of health resources has been of continuing interest since the beginning of bioethics in the 1960s. Early writing on justice includes authors Tom L. Beauchamp, Robert H. Blank, James F. Childress, H. Tristram Engelhardt, Paul T. Menzel, Paul Ramsey, and Robert M. Veatch (VII).During the 1980s, bioethicists such as Daniel Callahan and Norman Daniels proposed thinking of health care decisions not as moments of personal crisis but as choices that span a lifetime, possibly involving tradeoffs in other areas of one’s life, e.g., education. The Oregon experience added another dimension to the discussion. The initial rank-ordering of health services by cost produced a skewed list—for example, surgery for life-threatening conditions ranked below minor, elective procedures. For the project to make sense, the ranking algorithm could not be based on cost alone, but rather on a combination of costs and benefits both to individuals and to the community—“concatenations of individual and group goods” (I, Jecker and Jonsen 1995). Various metaphors have been used in the literature to facilitate discussion of this shift from individual to individual/community trade-offs: medical services as a “commons” (I, Asch 1995, Jecker and Jonsen 1995, Michels 1994); resource allocation as a “lifeboat” (I, Campbell 1995; III, Kaveny 1994); medical care as “shares” in a community health (III, Nelson 1992, Ford and Kissick 1995; II, Anderson 1993); and rationing as traveling through the desert with one jug of water for two people (a story from the Halachah literature) (I, Zoloth-Dorfman 1995). [End Page 81]Such metaphors do not promote any one “theory of justice” but rather draw from the work of a number of bioethicists as well as from theological, sociological, economic, and business literature. The five major conceptions of justice that are referenced most frequently are: “(1) a libertarian conception, which takes liberty to be the ultimate political ideal; (2) a socialist conception, which takes equality to be the ultimate political ideal; (3) a welfare liberal conception, which takes contractual fairness or maximal utility to be the ultimate political ideal; (4) a communitarian conception, which takes the common good to be the ultimate political ideal; and (5) a feminist conception, which takes a gender-free society to be the ultimate political ideal” (I, Sterba 1995).The use of new metaphors also draws on expanded concepts of “health.” “As health care is currently practiced, the most powerful symbols for public and professional alike are those that promise the defeat of time” (I, Campbell 1995). When medical care is perceived as an unrelated series of individual cures, the fact that health care resources are finite cannot be addressed.Reflections concerning the difficulties in limiting the use of health care resources have an ancient lineage and reveal a tight bond with the obsession to postpone death at all costs. Plato in Book 3 of the Republic recognizes the quandary of infinite expectations and finite resources that characterizes the challenge of health care choices. (I, Engelhardt 1996)The proliferation of expensive medical technologies and the loss of autonomy by health care professionals further complicates perceptions of the crucial issues at hand. Some have said that Americans place too much emphasis on individualism to address these issues. Daniels et al. believe that this is too pessimistic a view and that the American commitment to protecting equal opportunity for all provides a firm basis for developing a public consensus on what is fair in health care (III, Daniels, Light, and Caplan 1996). Finally, several authors suggest that the nature of all four principles of medical ethics, not justice alone, must be...