Gender Justice and the Health Care System

Karen L. Baird

• Publisher: Routledge
• Year: 2019
• Topic: Social Sciences
• eBook ISBN:
  9781317732648
• Subtopic: Sociology
• Index: Social Sciences

This book focuses on gender justice and the health care system. It will be divided into two parts. In Part One, a framework of gender justice will be developed. What is gender justice? What would a gender just public policy look like? What criteria should such policies meet? In Part Two, the framework will be applied to the area of health care policy, specifically medical research and health care financing and delivery. An analysis of past policies will be made, as well as an analysis of the recently enacted and proposed changes. First published in 1998. Routledge is an imprint of Taylor & Francis, an informa company.

CHAPTER 1
Introduction: Women, Justice, and Health Care

The following issues are now glaringly undeniable truths:

• Women will constitute the larger population and will be the most susceptible to disease in the future.

• Overall, women have worse health than men.

• Certain health problems are more prevalent in women than in men.

• Certain health problems are unique to women or affect women differently than they do men.

These words are from the Executive Summary of the Report of the National Institutes of Health: Opportunities for Research on Women’s Health (U.S. DHHS, NIH 1992, 7). Women live longer than men and thus experience more of the health problems that accompany old age—for example, osteoporosis and Alzheimer’s disease. But even in their younger years, the quality of women’s lives is affected more frequently and more deeply by their health than is the case for men. Women have more acute symptoms, more chronic conditions, and more short- and long-term disabilities arising from health problems. In addition, more women than men die from strokes; women have a higher incidence of mental disorders than men; more women than men acquire sexually transmitted disease; and women are the fastest growing population with AIDS. But despite all of this, women have been systematically excluded from most medical studies. One example is the widely published study reporting that one to two aspirins a day could reduce one’s chance of having a heart attack (Ameswith 1990). That study used 22,000 male subjects and not a single female subject, even though heart disease is the number one killer of men and women in the U.S.

Women also disproportionately constitute the poor or near poor and thus account for 60 to 70 percent of Medicaid recipients (many of the rest are their dependent children). Women are disproportionately segregated into lower-paying, lower-status, part-time jobs that are less likely to have health insurance as a benefit. The consequence of this is that women have to devote a disproportionate share of their income to health care costs. Women are also far more likely to provide care in the home to children, spouses, and parents. Unfortunately, the costs of health care fall disproportionately on women. The U.S. health care system results in many injustices for women.

1992 was labeled the “Year of the Woman.” The nation elected 24 new female representatives and five new female senators to the United States Congress.¹ This is the largest increase ever in U.S. history. The nation also elected Bill Clinton as president, and by so doing the country gained the most powerful and active first lady. Hillary Rodham Clinton was appointed head of the President’s Task Force on Health Care Reform, a group that labored for months to produce recommendations for improving our health care system. The resulting report and legislation, the Health Security Act, called for radical changes to the way we finance and deliver health care in the United States.

Since Clinton was inaugurated, the Family Leave Act was passed, mandating employers to provide up to twelve weeks leave to parents to care for newborn or ill children, as well as other family members. The “Gag rule,” which mandated that workers in Federally funded clinics could not give information about the availability of or procedures associated with abortions to patients, has been lifted. RU-486, which has been banned in the U.S. for years, is finally being tested for approval by the Food and Drug Administration (FDA), and the new female condom was approved in April 1993. Furthermore, the FDA, which had a policy forbidding the use of women of childbearing age in medical drug research, announced that any research submitted by drug manufacturers for new drug approvals will need to include data regarding effects on women. Moreover, in 1996, the Health Insurance Portability and Accountability Act limiting pre-existing condition exclusions and increasing the portability of insurance when one leaves a job, and the Newborns’ and Mothers’ Health Protection Act allowing women to stay in the hospital at least 48 hours after giving birth, were passed.

In 1990, the National Institutes of Health (NIH) established the Office on Research on Women’s Health, with the goals of strengthening and enhancing research related to diseases, disorders, and conditions affecting women and to ensure that women are appropriately represented in biomedical and biobehavioral research studies. In 1991, the Women’s Health Initiative was created, a 14-year $625 million effort, to study 150,000 women at 45 clinical centers across the U.S. It is the largest clinical study ever undertaken in this country on the health of either men or women.

Health care is currently a very important issue. Costs have risen dramatically. In 1991, the nation spent 13.2 percent of national income on health care (Starr 1994). In 1970, we spent about 7 percent of our Gross National Product (GNP) and in 1980, about 9 percent, for health care; costs for 1992 were approximately $800 billion, 14 percent of our GNP (White House Domestic Policy Council 1993). Health care costs are growing at a dramatic and unbearable rate. Furthermore, we have 40 million uninsured people in the U.S. Approximately one-half of these are employed and one-quarter are the children of the uninsured employed. In addition, we have some 23 million underinsured. These problems have been well-documented in the last few years and many reform proposals have been put forth to address these difficulties.

The President’s Task Force on Health Care Reform and President Clinton prepared legislation for overhauling the United States’ health care system—the Health Security Act. The nation’s 40 million uninsured and 23 million underinsured were the main focus of the proposal, but new financing and distribution of costs and price controls were also main areas of concern. The bill did not pass, but it was the largest effort in decades to change the problematic health care system of the U.S. If such a reform ever does occur, the nation would experience fundamental changes in the way health care is delivered, paid for, and regulated.

In November 1994, many Republicans were elected to the House and the Senate, putting both under the control of the Republican party. This Republican victory was partially in response to the Democrats failed health care reform. Newt Gingrich became the Speaker of the House and proposed, along with other Republicans, the “Contract on America.” This “Contract” called for balancing the federal budget, limiting welfare programs, cutting the capital gains tax, revising Medicare, and so forth, but major health care reform was not included. Though the Republicans have proposed major changes in the Medicaid program by requesting that it, along with AFDC, be put in a block grant and distributed to the states, as well as dramatically cutting costs in Medicare, the health care system as a whole has been left intact and no major changes have been advanced.

Even though no longer a politically viable proposal, the Health Security Act called for a radical reform of the health care system. With many women in top positions in government and Hillary Clinton as the leader of the reform group, as well as the obvious support for women’s reproductive needs shown by President Clinton, one would hope that the newly envisioned system would dramatically improve health care for women. Would the new system finally institute justice in terms of health care? Would women’s specific health problems receive adequate attention, study, and funding? Would the costs of health care be distributed so as not to disproportionately burden women? Would women’s reproductive needs be adequately addressed and included in a basic health care package? Would Medicaid and Medicare be restructured so as to be more beneficial to women? How successful would NIH be in including women in medical studies so that diseases, disorders, and treatment of and for women can successfully be analyzed? These are just some of the issues that are important for women with regard to the health care system.

This book will focus on gender justice and the health care system. It will be divided into two parts. In Part One, a framework of gender justice will be developed. What is gender justice? What would a gender just public policy look like? What criteria should such policies meet? In Part Two, the framework will be applied to the area of health care policy, specifically medical research and health care financing and delivery. An analysis of past policies will be made, as well as an analysis of the recently enacted and proposed changes.

PART ONE: GENDER JUSTICE

To date, there is no agreed upon theory of justice for addressing gender inequities, inequalities, discrimination, and differences between the two sexes. Various theories abound, both within traditional political theory and feminist theory, but they differ widely. Gender has been addressed by traditional theorists as far back as Plato but, most often, is discussed only in the context of the proper roles and worlds for each sex—the public world of politics and business for men and the private world of the family for women—or gender is ignored all together.² Even contemporary theorists “have largely bypassed the fact that the society to which their theories are supposed to pertain is heavily and deeply affected by gender, and faces difficult issues of justice stemming from its gendered past and present assumptions” (Okin 1989b, 8). Sometimes gender is not mentioned explicitly, but is thought, at least by its author, to be implicitly addressed in the larger framework. But whether gender is excluded from analysis or included in a myriad of ways, no consensus has been reached about justifiable standards or the proper methodology for addressing gender issues. The literature is lacking a framework of gender justice. Developing and justifying such a framework is the subject matter of Part One of this book.

Justice

But what does it mean when one speaks of gender justice? What do we mean by justice? We speak of many things as being just and unjust. As stated above, this book is concerned with justice between the sexes and what a gender just public policy would encompass. So what do we mean when we speak of justice in this manner?

Generally, justice is a criterion by which we judge an action or an outcome of an action. If something is just then it is good, right, fair, and so forth, or if it is unjust, it is bad, wrong, and unfair. More specifically, it is a criterion that we use to judge human matters. We do not speak of just or unjust weather because we have no control over and make no decisions about the weather. Furthermore, justice helps guide and is a criterion by which we judge human decisions. For example, death is a human matter but is something about which we do not usually make decisions. Thus, we do not usually speak of just and unjust deaths, even though some deaths may be tragic, unfortunate, or unexpected. Also, we do not usually speak of the activities of animals as just or unjust. We do not think animals are rational beings who can decide things; they act on instinct. Generally, justice is a concept that is considered part of the realm of human decision making.

David Miller (1976) notes that there are three principles involved in social justice, which is defined as giving each their due, and “their due” can be defined by rights (justice is getting what one is entitled to by a defined set of rights), deserts (justice is getting what one deserves through merit, efforts, work, personal characteristics, input, etc.) and needs (justice is getting what one needs). Justice also falls into the realm of human obligation—it is what we should feel obliged to do, not what we could do if we so wanted, had the extra resources, or were feeling generous. If there is a problem and two solutions are proposed and when analyzed one is found to be just and the other unjust, we feel obligated to choose the just solution. Morally, it is not a matter of choice after such evaluations are determined. This example also shows the sense in which people speak of justice as a primary good. Justice is the highest of our various moral goals and will always overrule any other goals. As John Rawls (1971) states, “[Mil injustice is tolerable only when it is necessary to avoid an even greater injustice” (4).

Since justice applies to human decision making, it follows that it applies to conflicts or problems that need a resolution. If there are an infinite quantity of resources for a group of people or a society, then we would not usually talk of how the resources are distributed as just or unjust. We do not think of justice as “getting everything one wants.” Issues of justice arise when there is a finite amount of something and it has to be distributed in some manner. This is the well-known form of distributive justice, which is the form one most often deals with in making public policies. Theories of distributive justice attempt to articulate principles that specify just distributions of benefits and burdens. As noted above, a just distribution is usually thought of as one in which each person receives what is due to them. The controversy or discrepancy occurs in deciding what is due to each person.³

Since Aristotle, one of the main components of justice is treating equals equally and unequals unequally in proportion to their relevant differences. We still have the problems discussed above, but with Aristotle’s definition we at least have a starting point by which to begin to untangle the problem of “to each according to what is due to them.” Initially, one should assume that all should be treated the same and receive the same benefits, bear the same burdens, experience the same rights, receive the same amount of any good, and so forth. But many times this is not what one would call just. A person with a heart disease requires more medical treatment than a healthy person. It would be just to give each what she or he needs in terms of health care; it would be just to treat the two unequals unequally. But we must remember that they only get treated unequally with respect to the one attribute that differentiates them. They should still, presumably, get treated equally with regard to all other matters.

This situation raises the problem of when do differences matter? People are different in almost every conceivable way: health, talents, intelligence, personality, preferences, tastes, wit, beauty, size, physical capabilities, etc. And we do not want everyone treated the same in every way. From the time children are very small, we set up reward systems to give extra benefits and recognition to those who accomplish more. There are many differences we wish to celebrate.

So when do differences turn into something that we call unequal and unjust? Giovanni Sartori (1987) states that we want to address an inequality when the issue becomes relevant, unjust, and remediable (348). These three characteristics are inextricably interwoven. When would a difference be relevant? Why would we care about one difference but not another? We would care about a difference when it is seen as unfair or unjust, meaning when it affronts our moral values. People dying of starvation is seen as relevant and unjust because it is against our value that all people have the right to some basic minimum necessities and our value that people should not needlessly suffer. So, a difference is seen as relevant when it is perceived as unjust, unfair, and against our moral standards. But this has not moved us very far forward in our analysis; we have just restated the question.

The characteristic of a situation being remediable is closely connected with the other two, but provides us more information. Situations are seen as unjust when we think we can control or have some influence over them. As stated above, the weather is not a topic of concern for justice because we have no control over it. This is regardless of the fact that hurricanes and tornadoes kill hundreds and thousands of people. Fatal illnesses that we cannot stop fall into the same category. Such situations are described as unfortunate, terrible, or sad, etc., but they are not described as unjust. But when we can control or influence the progression of an illness and we have to make a decision about such an intervention, issues of justice do arise. So, justice only applies to the realm of human problems that are seen as potentially remediable. This is very similar to the discussion above about finite resources and distributive justice; justice is a concept that is applied to conflicts or problems that need and are amenable to a resolution.

So, with regard to treating equals equally and unequals unequally, and determining when differences do make a difference, people should be treated the same when there are no differences that are perceived as affronting our moral values. Different treatment is warranted when there are differences between people that result in situations or actions that are against our moral standards and are something we can potentially control or influence.

Gender and Justice

Let us now turn our attention toward gender and justice. Gender is one particular way in which people differ.⁴ Not that gender is a small difference; many say gender is the most pervasive sociological and psychological facet of any human being. It describes us from the moment we are born and influences every experience in our lives. So, when should this difference matter? It wo...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• Chapter One: Introduction: Women, Justice, and Health Care
• Part One: The Problem of Gender and Justice
• Part Two: Gender Justice and the Health Care System
• Bibliography
• Index