The Preintrinsic Value of Vital Needs and the Problem of Extreme Scarcity

A s i a n B i o e t h i c s R e v i e w S e p t e m b e r 2 0 0 9 Vo l u m e 1 , I s s u e 3 198 The Preintrinsic Value of Vital Needs and the Problem of Extreme Scarcity A L L E N A N D R E W A . A LVA R E Z Rationing Healthcare, the Social Minimum and Extreme Scarcity Many who are poor in Asia, like their counterparts in other regions in the world, suffer from lack of access to healthcare that could save them from premature death and protect their ability to work for a living. Governments in developing countries often allocate insufficient funding to their health ministries and so constrain the latter to ration the meagre allocation they receive to meet the healthcare needs of the poor. In these countries, we often hear the poor complain that government clinics lack the basic medicine they need. This situation does not just raise the issue of how to bear the consequences of political decisions on the amount of money allocated to health. It is also very much about how governments fail to enable their citizens to deal with poverty. Adequate access to healthcare could have been one way for the working poor to compensate for the deprivations they have already suffered for it is absolutely necessary for people to at least have the ability to work to earn a living. Consider the case of Karen, 43 years old, residing in the slums of Manila.1 She complained that she used to be able to earn a living by doing the laundry, cooking, or cleaning, but because of her ailment she is no longer able work. To add to the tragedy, she is also unable to get the treatment she needs. But should the government take away money allocated to building roads or schools to increase funding for health? Should a health ministry give more funds to combat degenerative diseases than vaccination programmes or treating and preventing infectious diseases? The problem of allocating scarce healthcare resources remains difficult to solve and there are several contending approaches. This is compounded by the often neglected fact that standard approaches to rationing, developed in view 198–217 Asian Bioethics Review September 2009 Volume 1, Issue 3 199 of moderate scarcity in more affluent settings, would yield more tragic results if applied directly to low-income countries where extreme scarcity is often prevalent. There is no space to review these standard approaches in detail so I will instead briefly mention the failures of some main approaches and focus on the relevance of vital needs and vital abilities in discussing the problem of allocating healthcare resources in situations of extreme scarcity. I will highlight the inconsistency of the idea that rationing decisions that result in depriving citizens of basic enabling healthcare could be accepted if they conform to certain ideals (e.g. equality, fairness, efficiency) that decision-makers adopt. Simply put, I will try to show why it is inconsistent for society to obligate citizens to fulfil their role as citizens without insisting on society’s corresponding duty to provide citizens sufficient means to fulfil their obligations. Setting Basic Standards for Healthcare Healthcare, as the word itself suggests, refers to services aimed to protect, preserve, or restore sufficient level of health. What “sufficient” means and what constitutes “health” are not uncontroversial. Even so, we could at least say that even contending definitions of “health” point to what health should minimally enable persons to achieve. The descriptivist definition of health as normal-speciestypical -functioning in the so-called medical or biostatistical model developed by Christopher Boorse2 led theorists like Norman Daniels3 to define health as something essential to having opportunities. Lennart Nordenfelt’s4 normativist account of health as ability-to-achieve-basic-vital-goals (which entails provision of “all the necessary conditions” for enabling) overlaps with Boorse and Daniels’ notion of normal functioning. Both definitions include some basic ability as absolute (i.e. regardless of specific intentions or goals). Rightly so, even if there could be different levels of abilities, there must at...