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Volume: 34 Issue: MonthlYear: 1992 Pages: 467-474
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Article Author: Article Title: Medical Resources in Rural America: Alternative Perceptions of Justice ISSN: 0277-9536
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Soc. Sci. Med. Vol. 34, No.5, pp. 467-474, 1992 Printed in Great Britain. All rights reserved
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ALLOCATING MEDICAL RESOURCES IN RURAL AMERICA: ALTERNATIVE PERCEPTIONS OF JUSTICE NANCYS. JECKERland ALFREDO.BERd 'University of Washington School of Medicine, Department of Medical History and Ethics Seattle WA 98195, U.S.A. and 2University of Washington School of Medicine, Department of Family Medicine, Seattle, WA 98195, U.S.A. A~tract-In nati~nal debates concerning the .allocation of medical resources rural America is a neglected tOpIC, and the voices of rural health professionals are seldom heard. This paper highlights the special problems encountered in allocating medical resources within the rural setting and indicates the strategies that rural residents compose for dealing with them. Our findings are based on a study consisting of in-depth open-ended interviews with family physicians in the rural northwest United States. We contrast the approach to justice expressed by these rural physicians with the conception of justice that dominates Western philosophy and bioethics. In the course of our discussion, the diversity within Western culture becomes apparent. We discuss strategies for incorporating different perspectives into local and national allocation debates, clarify the reasons why a more encompassing approach to justice is necessary, and review the implications of our work for future research. Key words-professional ethics, justice, rural health care, allocation containment, physician-patient relationship
Recent years have witnessed an enormous growth of interest in the area of justice in health care. While popular debates about the allocation of medical resources often focus on celebrated cases, or on broad issues of national policy, the allocation of resources within America's small towns and rural communities is a neglected topic that poses special problems. First, the difficulty of allocating resources within the rural health care setting is compounded by the fact that rural residents have higher rates of chronic illness, yet are more likely to be without a regular source of care than their urban counterparts [1]. Second, a disproportionate share of the nation's poor live in rural areas: almost one third of the poor are rural residents, and rural poverty rates are higher than those for urban areas in all regions in the country [2]. Third, rural dwellers lack private health insurance more often than non-rural residents. This is because they are more frequently employed in agricultural industries and small businesses that are less likely to offer health insurance benefits to employees [3]. Finally, physician shortages and health resources problems result in less care availability, longer travel and waiting times and often inferior quality care in rural areas [2]. For example, resources required for successful outcomes following secondary or tertiary treatment are often unavailable, and place surgical patients and high risk mothers and infants at risk [4]. Combined with these factors are lifestyle differences that lead to divergent conceptual and philosophical orientations to allocating scarce medical resources. Rural physicians are not only physicians on the job, they are also members of small, often tightly knit, communities, where they may function in a variety of community roles. The social and interper-
of resources, rationing, cost
sonal dynamics found within the rural health care milieu provide the lens with which we propose to view the problem of allocating medical resources in the rural environment. Specifically, this paper contrasts the approaches to allocating medical resources expressed in Western philosophical and bioethical literature with the perception of justice expressed by primary care physician who practice in northwest American rural health care settings. One of the most striking features of this comparison is the wide divergence of understanding and' reasoning about justice. Since approximately one fourth of the United States population consists of rural dwellers [5], the concern our analysis raises is that scholarly debate about justice in health care fails to represent the clinical concerns of a major segment of the American health care system. For, despite the widespread use of high technology medical care, the majority of medical care continues to be provided by community hospitals with less than 200 beds, 46% of which are located in rural areas, and 71% of which are located in hospitals with less than 100 beds [6]. We suggest how .the perspective of rural dwellers might be incorporated into allocation debates and local allocation decision making. Such. an approach is sorely needed in order to build viable solutions to the ethical problems of rural medical underservice and health care rationing. THE CONCEPT OF JUSTICE IN PHILOSOPHICAL AND MEDICAL ETHICS
Although contemporary bioethical debates about justice in health care embrace a spectrum of issues and views, the views stated and the issues addressed
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share a common conceptual framework. American bioethicists draw on the work of contemporary philosphers of justice, who in tum assume a historical framework that dates back to Aristotle and Plato. Included in this framework is the idea that discrimination must be avoided and that persons who. are equal must be treated alike. This idea, often attributed to Aristotle, is expressed in the language of contemporary bioethics in terms of formal and material principles of justice. A standard bioethics text [7], for example, defines the principle of formal justice as requiring that equals must be treated equally and unequals may be treated unequally, and contrasts it with material principles that specify the morally relevant differences between persons. Material principles might hold, for instance, that goods should be distributed so as to give each person an equal share, or to each according to need, effort, contribution, merit or free-market exchanges. While different sides in contemporary justice debates may support different standards for allocating medical resources, most share the more fundamental assumption that principles of justice must identify the bases for treating people differently. In other words, people are assumed to be equal unless they are shown to be different. In addition to assuming formal and material principles of justice, contemporary bioethical debates about justice make certain core assumptions about the notion of justice itself. In what follows we briefly sketch three core ideas about justice that are prominent in the writings of currently favored philosophers of justice. Our focus throughout is on the Western tradition of justice and its central spokespersons. The ideas about justice we relate comprise a prominent philosophical heritage within which many debates about justice in health care occur. (1) Justice versus beneficence First, different conceptions of justice all claim to tell us what people deserve as a matter of right or entitlement, as opposed to what it would be kind or compassionate to provide. The association. between justice and entitlement dominated Western. philosophy from the ancient Greeks, through the middle ages and into the modem period. It continues to serve as a primary assumption in most leading theories of justice [8]. In the words of one contemporary author, John Rawls, the primary subject of justice consists of the major social institutions that 'distribute fundamental rights and duties.' [9]. Contemporary utilitarian, social contract, and libertarian theorists of justice all associate justice with the notion of desert or entitlement and with the principle of giving to others their due. In this sense, justice is distinguished from other moral concepts, such as charity and beneficence, which deal primarily with moral kindness and generosity toward persons in need. The contrast between. giving to others because of their right or entitlement and giving to ..others out of
and
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kindness and response to needs leads many philosophers to assume that justice has no place, or no central place, in close personal relationships. Such relationships are thought to be motivated by moral compassion, rather than by' moral duties or rights. For example, Aristotle reckoned that justice does not apply to relationships between parents and offspring [10]. Hume also reasononed that the stronger mutual benevolence is among individuals, the nearer one isto suspending principles of justice [11]. Within families or between married persons, Hume considered "the cement of friendship" to be "so strong as to abolish all division of possessions." More recently Rawls has rendered the family immune to claims of justice by deriving his theory of justice as fairness from the choices that heads of families would make under ideal conditions [12, 13]. Related to the idea that justice concerns individuals' rights and entitlements is the idea that justice represents only part, not all, of the moral picture. To claim that an action is just is not the same thing as claiming that it is justified or right. This is because actions maybe justified or right for other kinds of moral reasons. For example, an action may fall short of moral ideals and virtues, or it may evince a failure of moral compassion or empathy. (2) Justice as impartial A second feature common to diverse philosophical conceptions of justice is that justice demands impartiality. For some, this feature conjures up the picture of an even-handed judge meting out justice without regard to differences between persons. Expressing this idea, Aristotle asserts that "the law looks only to the distinctive character of the injury, and treats the parties as equals" [10]. Referring specifically to. t~e figure of the judge, Aristotle explains that "ThIS IS why, when people dispute they take refuge in the judge; and togo to the judge is to go to justice; for the nature. of the judge is to be a sort of animate justice" [14]. . The exact meaning of impartiality in current ethical debates is multifaceted. In one sense, "impartiality implies a kind of equality-not that all cases should be treated alike but that the onus rests on whoever would treat them differently to distinguish them in relevant ways" [14]. To declare that an action or policy is impartial is also to acknowledge it publicly. Impartiality suggests conformity with the basic moral standard that. "any position for which people co~pete, and where the victory of one constitutes a SOCIal or economic advantage over the others mu~t ~ distributed ... in accordance with advertised cntena and transparent procedures" [15]. A related point is that impartiality connotes. public approval and forbids privileging close ..associates simply because they stand in special relationships to oneself. It would violate impartiality in this sense if "some private person, for reasons of his own or for no publicly ... approved reason .at all, simply. handed
