Justice as a Frame for Health Reform

America is clamoring for health reform, but the current debate feels a bit like recitations of the tax code, with candidates from both parties arguing about mandates, tax credits, tax subsidies, market deregulation, and vouchers. Such a debate is more likely to make the American public's eyes glaze over than move it toward universal coverage. In this issue of the Report, David DeGrazia takes an important step toward a better debate. DeGrazia tries to defend a health care reform plan on specifically moral grounds, thereby making the debate turn on values. Unfortunately, he also gives up on the value most likely to win that debate.

DeGrazia claims that a single-payer system with managed care is the "most cost-effective means of achieving the goals of health care and therefore is the most morally defensible." But cost-effectiveness does not have enough moral heft to effect change. Following Aristotle's axiom that "in justice is the whole of virtue," the best way to make the moral case is to appeal to justice. Bioethics can best contribute to health reform by insisting that this is the moral issue at stake, and that justice entails that health care become a right.

DeGrazia considers and rejects this argument. He writes, "The strategy of justifying a health care reform plan on the basis of a theory of justice is undermined by persistent, deep disagreement even among reasonable people about which theory is best." That there is disagreement over theories of justice is certainly true, but that is not reason to throw up our hands. And DeGrazia does not escape disagreement anyway: as he notes, the reform he supports is closest to that endorsed by the Democratic candidates Dennis Kucinich and Mike Gravel, whose campaigns are widely seen as doomed.

It is too soon to give up on justice as the best way to frame the health care reform debate. The way to do this is to build the argument around the injustice induced by the current system. As Supreme Court justice Potter Stewart famously wrote about the difficulty of defining obscenity, "I know it when I see it." Likewise, we do not need to agree on a theory of justice to be revolted by injustice. Framing is increasingly recognized as a valuable tool for garnering public attention and approbation. It is a device that some fundamentalists have used to great advantage, as when their side in the evolution debate successfully promoted "intelligent design." As the linguistics scholar George Lakoff writes in Don't Think of an Elephant: Know Your Values and Frame the Debate, "Frames are mental structures that shape the way we see the world. . . . In politics our frames shape our social policies and the institutions we form to carry out policies. To change our frames is to change all of this. Reframing is social change."

Justice is a natural frame for American health reform. This nation was founded on the right to life, liberty, and the pursuit of happiness. Thomas Jefferson certainly saw health as necessary to that pursuit, writing in 1787, "Without health, there is no happiness." Our nation has a rich history of expanding rights, to include the right to a public education (which is perhaps most akin to the right to health care), the right to vote for women, the Civil Rights movement, the rights of the disabled, and gay rights. A right to health care, as a matter of justice, is a logical extension. As Dr. Martin Luther King, Jr.—arguably the American most identified with the expansion of rights—said, "Of all the forms of injustice, inequality in health care is the most shocking and in-humane."

Past expansions of rights were rooted in stories of injustice that resonated with Americans to overcome initial resistance. Stories provide a good framing device—a hook that the audience can connect to. Rosa Parks' refusal to give up her seat on a bus to a white rider started the Montgomery Bus Boycott and launched King to prominence; the U.S. Congress called Parks "the mother of the Civil Rights movement." There are also compelling stories of health care injustice...