Healthcare as a Universal Human Right

Sustainability in Global Health

Rui Nunes

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000530353
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This important book outlines how, despite varying levels of global socio-economic development, governments around the world can guarantee their citizens' fundamental right to basic healthcare.

Grounded in the philosophical position that healthcare is an essential element to human dignity, the book moves beyond this theoretical principle to offer policy-makers a basis for health policies based on public accountability and social responsiveness. Also emphasizing the importance of global co-operation, particularly in the area of health promotion and communication, it addresses, too, the issue of financial sustainability, suggesting robust mechanisms of economic and social regulation. New opportunities created by e-health, evidence-based data and artificial intelligence are all highlighted and discussed, as is the issue of patient rights.

Students and researchers across bioethics, public health and medical sociology will find this book fascinating reading, as will policy-makers in the field.

1 Fair Equality of Opportunity in Healthcare¹

DOI: 10.4324/9781003241065-2

The allocation of resources for health, besides the distribution of other social goods, is a political problem. It can also be observed as belonging to the universe of distributive justice, in which all citizens must have the necessary means for an acceptable physical, psychological, and social performance. Individual autonomy, which is the paradigm of full citizenship in a modern society, cannot otherwise be achieved. However, the principle of solidarity, as an ethical and social imperative, can also be invoked to protect the worse-off members of society. The principle of solidarity via the tax effort of citizens can allow a balanced allocation of resources in society. In Europe, the Convention on Human Rights and Biomedicine (Council of Europe 1996) promotes this ideal by appealing to a universal right of access to healthcare. The ethical and social implications of this convention may determine the acceptance of this right as a fundamental one in accordance with the Universal Declaration of Human Rights.

Indeed, in most civilized countries, the welfare state formula promoted by Bismarck transformed the ideal of justice into an integral element of social and community life. The acceptance of health as a social good brought about a health protection policy that was adapted to this perspective (Ruger 2004). However, the welfare state crisis, mainly related to the increase in life expectancy and the increase in the costs of providing healthcare (mainly due to scientific and technological progress), suggested a different approach to this problem. It generated the urgent need to establish priorities in healthcare (Wilson 2018). Moreover, the overall improvement of the population’s living conditions (at a social, cultural, educational, and economic level) is responsible for the sustained evolution of health indicators in developed countries together with the provision of medical care.

Nowadays, and in a global society, citizens are more critical of their healthcare systems due to the information obtained through different channels of communication. Information regarding new treatment methods and sophisticated technology is rapidly being introduced into the health market. Thus, we must review the very concept of right of access to healthcare: if the demand for healthcare based on individual needs is unlimited, it is essential to limit the supply and, therefore, access to healthcare. However, the methods that lead to the establishment of priorities must be transparent and previously legitimized by the democratic process (Nunes and Rego 2014).

Equal Opportunity: An Aspirational Value?

A priori, one may question the plausible justification for fundamental equality between all persons (Sen 1999). This equality could be because all people belong to the human moral community, owing the obligation of support and solidarity to each other. In essence, the human being is a relational being who is living and interacting constantly with their fellow citizens. This is not to say that all people are equal in the strictest sense of the term. In fact, we are all biologically and intellectually different. Indeed, rationality is the supreme attribute of the human species and distinguishes and characterizes everyone’s personality. Moreover, true social equality at all levels and in all contexts is perhaps an intangible reality. The concept of equality refers to the inclusion in a group that gives equal rights to all its members, at least regarding certain basic and fundamental rights.

This concept does not imply behavior standardization; uniformity is opposed to the very essence of human nature, given that intellectual creativity is a factor that argues in favor of the existence of the moral community itself. Thus, there will always be differences between people, regardless of their fundamental rights. The inalienable rights to life, food, constitution of family, and access to healthcare do not imply that everyone is the same nor that they have the same ambitions to carry out the same life projects. It implies that whatever their intellectual skills may be and hence, their ability to flourish within society, they are guaranteed a reasonable level of social conditions consistent with the dignity of the human being. This principle of equal dignity of human beings seems to be decisive in the implementation of a policy of fair equality of opportunity with respect to access to social goods.

However, note that different aspects of justice have a general application regarding the distribution of wealth and property. Society, regardless of the diversity of cultures and traditions within it, is generally organized around a state with rules of social coexistence, which are translated into the creation and approval of own orders in the ethical and legal sphere. According to Thomas Hobbes, the organization of the state is based on the assumption that human beings are constantly fighting for survival, as they are according to the law of nature, “the enemy of every human being” (Hobbes [1651] 1994). In fact, the constant search for happiness requires a human being to always desire more power and, therefore, more wealth as a guarantee of their survival. Thus, power implies more power, always at the expense of other human beings. Happiness is observed as the continuous progression of individual desire and is also achievement beyond possessions. This innate desire among human beings to always wish for more power leads the human community to organize itself via civil laws to ensure its survival.

Hobbes further argues that this natural situation of the social man is only possible because in the natural state, human beings are very similar to each other within physical and spiritual spheres. This natural equality among human beings has three aspects: a) agency/competence; b) mutual mistrust; and c) the desire for success. It is also argued that these decisions have nothing to do with just or unjust, given that the concept of justice does not fit into the biological evolution of humanity. The institutional creation of the state by mutual agreement seeks to prevent the process of self-destruction of humans by humans. The state, civitas in Latin, derives from this human social pact that was created by and for humans by exercising its power according to the sovereign will of those it represents. However, an idea of the state as a centralized and maximalist structure of power can be clearly contradicted, not in the sense of anarchic coexistence but in the sense of a minimalist state or a limited government. This government seeks to guarantee sovereignty and public order but allows individual energies to have free expression, thus ensuring social cohesion. Hence, the importance of a social protection system, including access to healthcare, can be upheld.

Norman Daniels refers to the social obligation through the government’s direct intervention to provide healthcare, based on the “normal functioning” standard (Daniels 1985). Universality of healthcare access should be promoted to guarantee each citizen’s access to a normal performance and, therefore, to a reasonable range of social opportunities. In this perspective of justice, the existence of disease, disability, and incapacity are observed as unfair and not just as the result of random forces of nature as they restrict the opportunities that would otherwise be available to the individual. From this viewpoint, one may deduce that the right of access to healthcare is decisive for exercising fair equality of opportunity. That is, the right to healthcare access imposes a duty on society to allocate resources according to its citizens’ health needs (World Health Organization 1996).

The conviction that fair and equal opportunity for citizens reflects the need to ensure “normal,” but not necessarily “equal,” performance should be emphasized. This distinction is fundamental since no person is equal to another in a strict sense. In fact, all citizens should have the right of access in accordance with their intrinsic dignity to certain essential goods so that it is possible to at least guarantee a reasonable physical, psychological, and social performance. Thus, talents and individual capacities are likely to be achieved, even if only in specific circumstances.

However, equal opportunity may be limited by resource scarcity in society if the choices in healthcare delivery are transparent, public, and periodically submitted to an audit process in accordance with democratic rules (Daniels et al. 1996). This perspective of distributive justice is based on the notion of democratic accountability. It justifies the scope and limitations of the provision of healthcare services. According to Daniels (1998), the concept of procedural justice may imply transparency and accountability in the context of provisioning healthcare (Daniels 1998). Citizens have the right to be informed about the reasons that led to the establishment of priorities. This concept of public accountability assumes that decisions are not only transparent and democratic but also taken in accordance with what “reasonable people” would decide under different sets of circumstances (Nunes and Rego 2014).

According to Wikler and Marchand (1998), society’s intervention is growing with respect to the macro-allocation of resources for provisioning healthcare. This is partly due to the lack of consensus on the principles by which this allocation should be guided. Again, democratic accountability and its practical application seem to be the most transparent way of applying the principle of justice, at least as far as procedural justice is concerned, although theoretically, it may not be the ideal of distributive justice. In this context, access to new technologies, such as innovative and expensive treatments, can be legitimately restricted but only if this decision is determined by society and imposed by financial constraints of the system.

To achieve fair equality of opportunity, it is fundamental to promote the values in which a society that is constantly changing can contribute to this ideal of distributive justice. In the field of healthcare access, solidarity in financing and equity in access have been proposed. Equity can refer also to equality of liberty, indicating that in a more economic than philosophical sense, it can be said that everyone prefers to decide on the allocation of resources instead of accepting what was proposed by another person. Of course, an assumption will be that the individual has the necessary means to make that choice. Thus, equity includes the concept of equality in individual self-actualization (Parijs 1991).

Achieving equity in access to social goods implies a systematic reduction of disparities between individual citizens and different social groups. One of the main factors leading to the overall improvement in population health lies both in the reduction of cultural, economic, and social disparities between the best and the worst-off citizens and in the quality of health services. As a political and ideological option, the concept of equity can have different social and economic implications: a) equity in the resource allocation; b) equity in the provision of healthcare; and c) equity in the payment of healthcare.

The application of the principle of justice can give rise to a distinction between horizontal and vertical equities. Horizontal equity means the provision of equal treatment to equal individuals. Vertical equity presupposes unequal treatment for unequal individuals. Therefore, it is possible to determine relevant properties in individuals who give expression to this perspective of justice (Beauchamp and Childress 2013) and thus, promote vertical equity. In this context, justice is perhaps related to the concepts of necessity and normal functioning, which are possibly the starting points for an equal opportunity policy. The adoption of measures conducive to vertical equity intends to meet the well-documented sociological reality that the worse-off citizens, based on the economic point of view, are also those with the worst health indicators (Chisholm 2018).

However, in market economies, solidarity does not materialize on purely altruistic grounds to achieve equity in the access and distribution of social goods. If solidarity means the perception of unity and the will to suffer the consequences thereof, the concept of unity indicates the presence of a group of people with a common history and with similar values and convictions. According to the Report by the Government Committee on Choices in Health Care (1992), “Solidarity can be voluntary, as when people behave out of humanistic motives, or compulsory as when the government taxes the population to provide services to all.” Again, in most modern democracies, the state feels the need to find ways to guarantee the fundamental rights of citizens through the tax structure....