Allocation of scarce healthcare resources is a hot issue. We all believe resources should be distributed justly, the trouble is no one seems quite sure what is just. Should resources be distributed according to need, according to a legal or regulatory entitlement or according to what a person has earned? And who should decide?
John Rawls offered us a thought experiment. Imagine that you and a few others were put in a room together but somehow none of you can remember your previous role in society: you can’t remember if you are a barrister or a barista, a cardiologist or a cleaner, a trust fund manager or a tramp. When the experiment is over you will return to society. Together you are charged with creating the rules that determine resource allocation within society: who will earn what, and who will get what when trouble strikes.
Rawls claims that we will create a meritocracy that maximises our freedoms in good times and bad. Hard work will be rewarded, we can even become filthy rich if we are worth it. But we will also want to preserve our interests if we are less fortunate on our return; what if I am unskilled or sick? We will make sure that the rules particularly look after those who are out of luck. Rawls wrote A Theory of Justice in 1971 and it has perhaps become the most important work of political philosophy in the 20th century, defining the socially liberal consensus.
But Rawls did not remain unchallenged for long. In 1974 Robert Nozick wrote Anarchy, State and Utopia. His claim is simple: it is unjust for the state to deprive me of my fair earnings or interfere with my lawful trading with my neighbour. There should be a minimalist state that exists to ensure defence and the rule of law. It is up to me to earn a living to clothe and educate my children and pay their doctors’ bills. Why should the state take away my earnings to pay for my neighbour’s bills? If my skilful trading with my neighbour leads to me being very rich and my neighbour very poor, then on what moral grounds could the state redistribute my wealth? If this is beginning to ring any bells then you are right: Nozick was a major influence on Keith Joseph who was the mentor to Margaret Thatcher. Philosophy does matter in the real world!
So who was right? I guess your answer will be determined by which way you vote. But Nozick has a huge conceptual flaw — he assumes (to borrow and misuse a phrase) that there is no such thing as society — that we are all separate individuals in perpetual competition. In reality we all have complex interrelationships. Remember Hobbes: I can only make my millions because I live in a stable society where my neighbours are happy to keep the rules, maintain the roads and keep my kids safe. Rich or poor I know which alternative vision of society I would prefer to live in.
CPD further study and reflective notes
The notes in Boxes 1 and 2 will help you to read and reflect further on any of the brief articles in this series. If this learning relates to your professional development then you should put it in your annual PDP and claim self-certified CPD points within the RCGP guidelines set out at http://bit.ly/14GS5NS.
Box 1. Reflective notes
In what sense is a notion of justice relevant to the healthcare that you provide?
How do we allocate the precious resource of our time between our patients?
How do we counter the ‘inverse care law’ in our own practice? How do we ensure that those most in need of healthcare interventions have access to them?
Box 2. Further reading
Primary source
Rawls J. A Theory of Justice. Cambridge MA: Harvard University Press, 1971.
Further study
Nozick R. Anarchy, State and Utopia. Oxford: Blackwell Publishing, 1974.
If your reading and reflection is occasional and opportunistic, claims in this one area should not exceed 10 CPD credits per year. However if you decide to use this material to develop your understanding of medical philosophy and ethics as a significant part of a PDP, say over 2 years, then a larger number of credits can be claimed so long as there is evidence of balance over a 5-year cycle. These credits should demonstrate the impact of your reflection on your practice (for example, by way of case studies or other evidence), and must be validated by your appraiser.
- © British Journal of General Practice 2013
