This initial posting will set the stage for many essays that will be featured in this space. We all know that our current reimbursement system curtails choices for citizens, either by narrowing networks, imposing stricter guidelines for coverage or setting deductibles so high that access to care is unrealistic due to the upfront out of pocket costs required before coverage starts. There is a reason for this, and it is called social justice.
Social justice implies fairness and mutual obligation in society: that we are responsible for one another, and that we should ensure that all have equal opportunities to succeed. Being reasonably healthy is a basic necessity to succeed at providing for oneself or one’s family.
Social justice is one of the four tenets of bioethics, along with autonomy, beneficence and non-maleficence. Bioethics concerns questions about basic human values and society’s responsibility for the life and health of its members. Bioethics involves issues relating to the beginning and end of human life, from in-vitro fertilization and abortion to euthanasia and palliative care. Essentially, social justice is about fairness in a world of limited resources.
The U.S. spends 50 percent more per capita on medical care than any other country in the world, some 17.9 percent of GDP in 2010. At the same time, the U.S. achieves poorer health than many Organisation for Economic Cooperation and Development (OECD) countries. These member countries include some of the most advanced countries and various emerging ones. From an economic perspective, curative medicine seems to produce decreasing returns in health improvement while expenditures increase.
The following is a breakdown of each dollar spent on healthcare in the U.S.:
Only 3 cents is devoted to public health activities, resulting in the neglect of many social and environmental determinants of health.
Social determinants of health are factors in the social environment that contribute to or detract from our health. These factors include socioeconomic status, nutrition, education, transportation, housing, access to services, discrimination and social or environmental stressors. More specifically, social determinants of health refer to the set of factors that contribute to the social patterning of health, disease and illness. According to the World Health Organization, “the social conditions in which people live powerfully influence chances to be healthy. Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries.” In fact, medical care alone only impacts health by 10 percent.
As a result, the discussion around social justice is becoming more relevant in medical decision-making because the cost of care is squeezing out the ability to pay for the other influencers of health. Physicians are being asked to consider not only the right treatment but also the fair allocation of scarce resources in a society of burgeoning needs.
The essays you read here will raise questions about social justice and leave you with more questions than answers. When you finish reading, you will understand why scholars and ethicists have spent decades arguing various positions. Even though bioethical discourse can become very emotionally charged, serious dialogue must be supported by strong and well-researched arguments. Pure emotion does not make for a defensible position.
This is certainly true in end of life decisions, and is as true at the beginning of life and mid-life as well.
Martin A.B. et al. (2012) “Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009,” Health Affairs, retrieved from http://content.healthaffairs.org/content/31/1/208.short
Saward, E. & Sorensen A. (1980)The current emphasis on preventive medicine: Issues in health services (pp17-29). New York: John Wiley & Sons
World Health Organization.
The World Health Report: 2004: Changing History. ISBN 92 4 156265 X (NLM Classification: WA 540.1) ISSN 1020-3311