This work offers a philosophical appraisal of accounts of social justice in health care. By analyzing and comparing seven different accounts, it shows what is involved in advancing such an account and discloses what is involved in providing a moral justification, identifying a tripartite interplay among moral accounts, theories, and perspectives regarding the proper allocation of health care. Based on a distinction between substantive and procedural accounts of justice in health care allocation, (...) it concludes that the prospect of agreement regarding substantive accounts of health care justice is unlikely. This study illustrates that it is moral perspectives, rather than moral theories, that are foundational to accounts of justice in health care. A moral perspective includes the complete content of a morality lived by a group of people, while a moral theory identifies general statements formulatable within a moral perspective, a moral account restructures in a systematic way a moral perspective regarding a domain of issues, such as that of justice in health care. Although a moral theory contributes to an account a general framework that arranges moral commitments into a discursive system, only a full-bodied moral perspective can provide a moral account the substance that it needs. Through closely looking at various moral perspectives embodied by different accounts of just health care, it becomes clear that disagreements in morality are extensive and deep. It is impossible to justify a particular substantive account of just health care without begging the question. Finally, a theoretical reconstruction of Singapore's Confucian moral perspective regarding health care justice is provided so as to offer a picture of a quite different theoretical foundation as well as a substantively different moral perspective from those that are often taken for granted in the West. It shows that moral perspectives are different from people to people, from community to community. A successful account of just health care will thus require more than what can be drawn from theories of justice. (shrink)

This chapter contains section titled: I Equality of Resources II Justice in Health Care III Why Universal Access Requires In‐kind Transfers IV Conclusion Acknowledgement.

Edmund Pellegrino has pioneered work in medical ethics calling for a reconstruction of Hippocratic ethics. In particular, he has spoken of incorporating principles that concern justice and the common good. This article traces his commitment to the common good, concern for the poor, opposition to libertarianism, acknowledgement of the necessity of rationing, and reluctance to give clinicians social allocational tasks. It asks how Pellegrino relates distributive justice to the common good. Drawing on his theory relating autonomy to patient-centered (...) beneficence (in which autonomy is one element of the good rather than a side constraint on the good), the author argues that Pellegrino appears to make justice one element of the common good rather than a distributional moral constraint on promoting the good. He suggests that Pellegrino stands in three consequentialist or teleological moral traditions: professional physician ethics, Aristotelianism, and Catholic moral theology, but that there are the makings of a more independent, more egalitarian theory of justice in his writings. Keywords: autonomy, common good, consequentialism, Edmund Pellegrino, justice CiteULike Connotea Del.icio.us What's this? (shrink)

In this discussion, we will consider arguments against the view that one person is entitled to medical care at the expense of another person, just because the one person might be able to extend it to the other. We all accept the view that we are entitled to nonviolence from each other, which in the medical case is roughly that we are entitled to other people not making us sick, at least insofar as this is something they can readily (...) avoid. But how are we also entitled to their help in making us well when we are sick? Few of us think that we are entitled to other people's new cars, or half of their incomes for our general use. Why, then, are we entitled to a hefty fraction of that income to pay our medical bills? (shrink)

This article tries to analyze the meaning and relevance of the concept of solidarity as compared to the concept of justice. While ‘justice’ refers to rights and duties , the concept of solidarity refers to relations of personal commitment and recognition . The article wants to answer the question whether solidarity and liberal justice should be seen as mutually exclusive or whether both approaches should be regarded as complementary to each other. The paper starts with an analysis (...) of liberal theories of justice which are followed by an analysis of the descriptive and a moral understanding of the concept of solidarity. The importance of solidarity lies in its relational aspects, particularly its emphasis on cooperation and commonality. The paper argues that while solidarity is more fundamental than justice, both concepts are important for the arrangement of health care practices. The paper gives special attention to the concept of decent care, reflective solidarity and humanitarian solidarity which is seen as fundamental for all health care policies and care practices. (shrink)

This paper compares and contrasts three different substantive principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing (...) principle. In conclusion, it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions. (shrink)

This paper was first presented at the Annual Meeting of the American Society of Christian Ethics, Toronto School of Theology, Toronto, Ontario in January 1977. Robert Shelton aims to focus on the concept of 'right to health care,' its related principle, 'distributive justice' in an attempt to suggest 'where we are' at present and where we perhaps ought to be heading. The paper is divided into three parts, which in their turn explore the moral grounds, the US (...) general public's policy and the part justice and government are likely to play in the development and distribution of health care. He concludes by highlighting 'omissions', an intentional one of his own and the other a major gap in the literature. (shrink)

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims (...) on health care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well. (shrink)

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of (...) prioritisation of the resources available for healthcare or of rationing such resources must be governed by this principle. -/- This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational ‘reasons based consequentialism’ is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended. (shrink)

During the last decade a “technical” approach has become increasingly influential in health care priority setting. The various country reports illustrate, however, that non-technical considerations cannot be avoided. As they often remain implicit in health care package decisions, this paper aims to make these normative judgements an explicit part of the procedure. More specifically, it aims to integrate different models of distributive justice as well as the principle of solidarity in four different phases of a (...) decision-making procedure, and to identify important moral choices which present themselves. First four important justice models are discussed, then a justification is given for their inclusion in a four-step decision making procedure. This is followed by a discussion of different justice and solidarity problems—with their inherent conceptual difficulties in each of these stages. The paper concludes with a summary of the major moral choices that are to be made in health care package decisions. (shrink)

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and (...) class='Hi'>health care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms. (shrink)

In this article, we develop a non-rights-based argument based on beneficence (i.e., the welfare of individuals and communities) and justice as the disposition to act justly to promote equity in health care resource allocation. To this end, we structured our analysis according to the following main sections. The first section examines the work of Amartya Sen and his equality of capabilities approach and outlines a framework of health care as a fundamental human need. In the (...) subsequent section, we provide a definition of health equity based on the moral imperative to guarantee that every individual ought to have the freedom to pursue health goals and well-being. In the later part of the article, we outline a non-right approach to health care based on three pillars: (1) human flourishing, (2) justice as a disposition not a process, and (3) solidarity. (shrink)

In this book, an international group of philosophers, economists and theologians focus on the relationship between justice, luck and responsibility in health care. Together, they offer a thorough reflection on questions such as: How should we understand justice in health care? Why are health care interests so important that they deserve special protection? How should we value health? What are its functions and do these make it different from other goods? Furthermore, (...) how much equality should there be? Which inequalities in health and health care are unfair and which are simply unfortunate? Which matters of health care belong to the domain of justice, and which to the domain of charity? And to what extent should we allow personal responsibility to play a role in allocating health care services and resources, or in distributing the costs? With this book, the editors meet a double objective. First, they provide a comprehensive philosophical framework for understanding the concepts of justice, luck and responsibility in contemporary health care; and secondly, they explore whether these concepts have practical force to guide normative discussions in specific contexts of health care such as prevention of infectious diseases or in matters of reproductive technology. Particular and extensive attention is paid to issues regarding end-of-life care. (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or (...) demands in and by the ‘exterior environment’. Social systems must be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

: The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed (...) the philosophical landscape and encouraged some in bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice. (shrink)

Health-care goods are goods with peculiar properties, and where they are scarce, societies face potentially explosive distributional conflicts. Animated public and academic debates on the necessity and possible justice of limit-setting in health care have taken place in the last decades and have recently taken a turn toward procedural rather than substantial criteria for justice. This article argues that the most influential account of procedural justice in health-care rationing, presented by Daniels (...) and Sabin, is indeterminate where concrete properties of rationing institutions are concerned. Such properties inscribe substantial norms into institutions. These norms can derive validity only from democratic majority decisions, which must be seen as an instance of pure procedural justice. We therefore have to move the discussion to a meta-level and ask how concrete properties of institutions are being chosen. I suggest four criteria for sufficiently democratic institutional design choice and conclude that as institutional properties are likely to have effects on the resulting distribution of health care, design choices should be empirically informed and taken both democratically and deliberately. (shrink)

Justice and Health Care: Selected Essays collects, in a systematic but non-chronological fashion, ten of Buchanan’s most significant essays on justice and health care, written over a period of almost three decades. As the Obama administration continues to struggle to implement much-needed comprehensive health care reform in the hopes of controlling rising health care costs and extending affordable health care to over 46 million uninsured Americans, there could hardly (...) be a more appropriate time to read Buchanan’s selected essays. (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or (...) demands in and by the ‘exterior environment’. Social systems must be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

Recent disputes over whether older people should pay more for health insurance, or receive lower priority for transplantable organs, highlight broader disagreements regarding the legality of using age-based criteria in health care. These debates will likely intensify given the changing age structure of the American population and the turmoil surrounding the financing of American health care. This Article provides a comprehensive examination of the legality and normative desirability of age-based criteria. I defend a distributive (...) class='Hi'>justice approach to age-based criteria and contrast it with two prevailing theoretical approaches to age-based criteria, nondiscrimination and discretion. I propose a detailed normative framework for the use of age-based criteria in health care, the lifetime justice approach, that considers the future life patients can gain from treatment and the past years of life they already have experienced. -/- This paper is available by open access from the Boston College Law School Digital Commons. (shrink)

This paper argues that societal duties of health promotion are underwritten (at least in large part) by a principle of beneficence. Further, this principle generates duties of justice that correlate with rights, not merely “imperfect” duties of charity or generosity. To support this argument, I draw on a useful distinction from bioethics and on a somewhat neglected approach to social obligation from political philosophy. The distinction is that between general and specific beneficence; and the approach from political philosophy (...) has at times been called equality of concern. After clarifying the distinction and setting out the basis of the equality of concern view, I argue that the result is a justice-based principle of “specific” beneficence that should be reflected in a society’s health policy. I then draw on this account to criticize, refine, and extend some prominent health care policy proposals from the bioethics literature. (shrink)

This book brings together ten influential essays on justice and healthcare, written by a major figure in bioethics and political philosophy. What emerges is a systematic and unified approach to the issues that challenges widely-held dogmas and unsettles the framing assumptions of a number of prominent debates. Unlike most work in bioethics, this book takes the problem of implementing justice seriously, exploring the relationship between institutions, incentives, and moral commitments.

This volume comprises a collection of ten essays by Allen Buchanan, and in some cases Buchanan and co-authors as well, on various topics under the general rubric of justice and health care. The essays were originally published over the span of some twenty-four years in various publication venues including edited books and journals in bioethics, public affairs, and law and policy. As Buchanan notes, the selected essays do not comprise an overall theory of justice and (...) class='Hi'>health care or justice and health, and indeed a major motivation of this effort is to project a deep skepticism about the very task of attempting to put forth such a theory, which Buchanan eschews as too ambitious. He offers instead a more "modest" "thought-journey" to gain "a deeper appreciation of the complexities of thinking systematically, self-critically, and realistically about justice in health care". (shrink)

This volume consists of nine substantial papers and an introduction by the editors on justice and health care. The first five papers are primarily concerned with the state of health care in the USA while the authors of the remaining papers address issues related to Canadian and European systems of health care.

Among the myriad longstanding political, socioeconomic, and moral debates focused on the fair distribution of health-care resources within the United States, those addressing intergenerational justice tend to produce the most heat and, often, the least amount of light. The familiar narratives tend to be binary ones of opposing generational stakeholders. While a great number of proposed solutions focus on reconfiguring rationing priorities, this paper will instead shift the discourse to intergenerational interdependence, suggesting that these conflict-born moral dilemmas (...) are in important ways false. The alternative view of intergenerational relations defended here is grounded in an interdependent, rather an oppositional, model of human relationships. I argue that this interdependence can best be realized through a deliberate movement toward intergenerational narrative understandings, as well as through physical proximities. I conclude by considering several ongoing intergenerational projects directed at just such a goal. (shrink)

In this paper I argue that the metaphysical ethics of Emmanuel Levinas captures some essential moral intuitions that are central to health care. However, there is an ongoing discussion about the relevance of ethical metaphysics for normative ethics and in particular on the question of the relationship between justice and individualized care. In this paper I take part in this debate and I argue that Levinas' idea of an ethics of the Other that guides politics and (...) justice can shed important light on issues that are central to priorities in health care. In fact, the ethics of Levinas in seeking the foundation of normativity itself, captures the ethical coreand central values of health care. (shrink)

Tännsjö’s book Setting Health-Care Priorities defends the view that there are three main normative theories in the domain of distributive justice, and that these theories are both highly plausible in themselves, and practically convergent in their normative conclusions. All three theories point to a somewhat radical departure from the present distribution of medical resources: in particular, they suggest redirecting resources from marginal life extension to the care of mentally ill patients. In this paper I wish to (...) argue, firstly, that prioritarianism should not be considered as an amendment to utilitarianism, as it is in Tännsjö’s view, but as a distinctive fourth option. This can best be appreciated if we focus on a reading of the theory that emphasizes its derivation from egalitarianism and its attempt to develop an intermediate approach between utilitarian and egalitarian intuitions. Secondly, in response to Tännsjö’s central objection to prioritarianism, I will argue that the theory does not apply in intrapersonal cases but is only relevant for decisions regarding the interpersonal distribution of benefits. Finally, I will suggest that a practical convergence of the four theories on specific issues such as artificial reproduction or mood enhancement is far less likely than Tännsjö seems to believe. (shrink)

All health care systems face problems of justice and efficiency related to setting priorities for allocating a limited pool of resources to a population. Because many of the central issues are the same in all systems, the United States and other countries can learn from the successes and failures of countries that have explicitly addressed the question of health care priorities. We review explicit priority setting efforts in Norway, Sweden, Israel, the Netherlands, Denmark, New Zealand, (...) the United Kingdom and the state of Oregon in the US. The approaches used can be divided into those centered on outlining principles versus those that define practices. In order to establish the main lessons from their experiences we consider the process each country used, criteria to judge the success of these efforts, which approaches seem to have met these criteria, and using their successes and failures as a guide, how to proceed in setting priorities. We demonstrate that there is little evidence that establishment of a values framework for priority setting has had any effect on health policy, nor is there evidence that priority setting exercises have led to the envisaged ideal of an open and participatory public involvement in decision making. (shrink)

Health care organization is entering a new age. Focus is increasingly shifting from individual health care institutions to interorganizational collaboration and health care networks. Much hope is set on such networks which have been argued to improve economic efficiency and quality of care. However, this does not automatically mean they are always ethically justified. A relevant question that remains is what ethical obligations or duties one can ascribe to these networks especially because networks (...) involve many risks. Due to their often amorphous and complex structure, collective responsibility and accountability may increase while individual responsibility goes down. We argue that a business ethics approach to ethical obligations for health care networks, is problematic and we propose to opt for a patient perspective. Using the classic four principles of biomedical ethics it is possible to identify specific ethical duties. Based on the principle of justice, health care networks have an ethical duty to provide just and fair access for all patients and to be transparent to patients about how access is regulated. The principle of nonmaleficence implies an obligation to guarantee patient safety, whereas the principle of beneficence implies an obligation for health care networks to guarantee continuity of care in all its dimensions. Finally, the principle of autonomy is translated into a specific obligation to promote and respect patient choice. Networks that fail to meet any of these conditions are suspect and cannot be justified ethically. Faced with daunting challenges, the health care system is changing rapidly. Currently many hopes ride on integrated care and broad health care networks. Such networks are the topic of empirical debate, but more attention should be given to the ethical aspects. Health care networks raise new and pressing ethical issues and we are in need of a framework for assessing how and when such networks are justified. (shrink)

The dominant emphasis in medical ethics during the last decade has been on specific moral problems of individual or small group decision-making. Justice and Healthcare attempts to correct the imbalance of focus by 1) examining the health care institutions within which micro problems arise; 2) investigating the larger array of institutions of which the health care sector is only one part.

Limited resources and rationing are "buzz words" today in health care across the globe. This book, a collection of essays that discuss particular problems relating to health care allocation in the light of experiences drawn from a number of jurisdictions, is thus a timely publication.

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered (...) to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution. (shrink)

This paper introduces this mini-series on vertical equity in health care. It reflects on the fact that by and large equity policies in health care have failed and that there is a need for positive discriminationto promote equity better in future. This positive discrimination is examined under the heading of`vertical equity'. The paper considers Varian's notion of 'envy' as a basis for equity in health care but concludes that this is not a helpful route (...) to go down. Better it would seem to pursue the idea from Sen of 'freedoms' and 'communitarian claims' (as raised previously by this author). While it is argued that procedural justice is to be preferred in the longer run as a basis for equity there are gains in adopting a short run goal of promoting distributive justice. Some preliminary evidence is presented on the weighting of health gains to reflect such vertical equity concerns. (shrink)

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical question is whether (...) efficiency is the correct criterion, in terms of social justice and individual needs. (shrink)

The central issue addressed in this CUP monograph is whether and how Christian ethics might be able to make a significant contribution to health care ethics today in the public forum of a Western, pluralistic society. It is the twenty-sixth monograph in the larger project (edited by Robin Gill) New Studies in Christian Ethics that has received considerable international attention. It offers a fresh basis for health care ethics derived from a detailed exegesis of the Synoptic (...) virtues of compassion, care, faith and humility in order to deepen the widely used secular principles of beneficence, non-maleficence, autonomy and justice in health care ethics. In an early review David Atkinson concluded that Gills excellent, clear, and well-written book is a significant contribution. (shrink)

This collection comprises ten essays authored or co-authored by Allen Buchanan. They concern issues that are of great importance: public and private health care, the problem of rationing and the existence and scope of the right to health care, among many others. In general, Buchanan is a clear and careful analyst. He is a pluralist, not an apologist for a specific normative theory, such as utilitarianism or the Rawlsian theory of justice. He defends and practises (...) the art of producing considered judgements from a plurality of intuitively plausible normative bases, proceeding in a way that is informed by the economic context in which health care decisions arise. (shrink)

This paper explores the implications of Roman Catholic teachings on social justice and rights to health care. It argues that contemporary societies, such as those in North America and Western Europe, have an obligation to provide health care to their citizens as a matter of right. Moral considerations provide a basis for evaluating concerns about the role of equality when determining health care entitlements and giving some precision to the widespread belief that the (...) right to health care requires equal entitlement to health care benefits. (shrink)

In recent works, Shlomi Segall suggests and defends a luck egalitarian approach to justice in health. Concurring with G. A. Cohen’s mature position he defends the idea that people should be compensated for “brute luck”, i.e. the outcome of actions that it would be unreasonable to expect them to avoid. In his defense of the luck egalitarian approach he seeks to rebut the criticism raised by Norman Daniels that luck egalitarianism is in some way too narrow and in (...) another too wide to uphold justice in health and health care distribution. He points out that a pluralistic outline of luck egalitarianism taking into account the moral requirement of meeting everyone’s basic needs can avoid this line of criticism. In this article I argue against the application of such pluralistic luck egalitarianism in matters of health distribution. First of all, Segall has not shown that luck egalitarianism handles well health distributions above a threshold of basic needs. Secondly, his way of avoiding Elizabeth Anderson’s abandonment objection is theoretically problematic. Finally, I argue that luck egalitarianism in general fails to acknowledge the moral foundation of health and health care as a basic human entitlement. Thus I conclude that luck egalitarianism fails to take health needs seriously and that it cannot therefore uphold justice in health. (shrink)

This paper examines the arguments presented by the Roman Catholic Bishops in their 1993 Pastoral Resolution, Comprehensive Health Care Reform: Protecting Human Life, Promoting Human Dignity, Pursuing the Common Good, concerning health care reform. Focusing on the meaning of equality in health care and traditional Roman Catholic doctrine, it is argued that the Bishops fail to grasp the force of the differences among persons, the value of the market, and traditional scholastic arguments concerning obligatory (...) and extraordinary health care. To attempt to equalize the distribution of health care would be ruinous. A more traditional understanding of Christian thought reveals an acceptance of inequality in health care distribution and a bias against using the secular state to coerce a solution to such concerns for social justice. (shrink)