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To the Editor
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I was intrigued, depressed, and relieved by Daniel Callahan’s essay on rationing. I was intrigued because it was one of the first essays I have seen in bioethics that frankly admits that rationing decisions can and will shorten lives. I was depressed because the essay indicated what some bioethicists are willing to accept to achieve social justice. And finally, I was relieved by Callahan’s forecast that because of practical “political” concerns, his vision of “social justice” was not achievable. However, the real concern I have is the inappropriate application of the concept of justice to medicine.

Callahan’s vision of social justice for a national medical care system seems to be one where, based on resources appropriated by the national authority, a committee of learned individuals designs a medical entitlement program that maximizes “benefit” in an economic/public health model. All individuals would receive this entitlement and this entitlement only. Supplementing this entitlement from personal resources would not be allowed because that would be unjust. Presumably, disciplinary authorities would enforce this internally, and a Berlin Wall would be built to prevent medical tourism. The actual system of justice utilized is vague. It might be that an individual’s entitlement would be based on the individual’s worth to the national authority (as in the renal dialysis model Callahan cites). A “Lottery in Babylon” model system that assumes all are equally vulnerable, a maximum limit on resource expenditure (insurance cap), or some other system are possibilities as well.

Proponents of social justice for medicine seem to prefer to exist in a virtual world of political philosophy, rather than in the real biologic world where we all have to live and where medical care is a real human need and desire. For example, in the virtual world of political philosophy, a statement that “all men are created equal” is accepted as fact, or at least as unchallenged assumption. In the biologic world, this statement is absurd. However, for “justice,” this assumption is key. For example, in one system of justice, equals must be treated equally and unequals unequally. In the political, virtual world, one starts with the assumption that all are equal. All, then, can and must be treated equally. But since the assumption of equality is false, the systems ends up treating unequals equally and will therefore result in injustice, not justice.

Another example is justice as fairness. However, the originator of that doctrine understood that it could not be applied to nature (biology). While John Rawls never quite admitted that nature is unfair, nature is, in fact, unfair. Political philosophy is unable to change nature. Medicine, as an applied science, can and does change some aspects of nature and the natural history of disease. However, to claim that medicine can make nature just and fair or that, even when medicine is “successful” in relieving suffering, the result is “justice” is as absurd as the claim that all men are created equal.

The association of medicine, health care, and justice is a mirage. By focusing on justice, bioethicists are ignoring the actual goal of medicine: to relieve suffering inflicted on us by nature as a result of our humanity. If ethics is a study of what is “right” or good or moral, then medicine and health care systems must be evaluated on how well they meet their mission of relieving suffering, not according to some inappropriate and vague concept of justice. Political philosophers would not be excluded from this evaluation, since the classic question of individual liberties and responsibilities versus societal and governmental requirements and responsibilities still remains.

Copyright © 2011 The Hastings Center
Project MUSE® - View Citation
Eric J. Cassell. "Rationing and Reality." Hastings Center Report 41.6 (2011): 4-4. Project MUSE. Web. 9 Jul. 2014. <http://muse.jhu.edu/>.
Cassell, E. J.(2011). Rationing and Reality. Hastings Center Report 41(6), 4. The Hastings Center. Retrieved July 9, 2014, from Project MUSE database.
Eric J. Cassell. "Rationing and Reality." Hastings Center Report 41, no. 6 (2011): 4-4. http://muse.jhu.edu/ (accessed July 9, 2014).
T1 - Rationing and Reality
A1 - Cassell, Eric J.
JF - Hastings Center Report
VL - 41

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