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CASE: DISTRIBUTING HEALTH CARE RESOURCES

Two committees are meeting at the same hour many miles from each other. One is the Secretary’s Priorities Committee of the federal Department of Health and Human Services. It is assisting the secretary of health and human services to respond to the president’s proposed priorities for the federal health care program in the next fiscal year’s budget. The total amount of dollars in the draft is fixed. The secretary and her advisers must determine whether they support the particular dollar allocations among a large number of health care concerns in the president’s draft. They must also determine if there are concerns the president’s staff left out that also should be included, along with the corresponding loss of dollars in other areas. They are charged, then, with rationing health care dollars for the American people. They are charged to do this carefully and efficiently and in a way that is consistent with the moral norms of justice.

One member of this committee, Dr. Willard Brenford, DDS, is director of the National Institute for Dental Research. He was formerly the president of the American Dental Association and before that of the American Dental Education Association. He was also a longtime dean of a highly respected American dental school. Appointed to this committee, Dr. Willard is now the strongest advocate for America’s oral health needs that the dental community has ever had in the federal government. Today’s meeting is a prime opportunity for him to seek funding for improved oral health care, especially among underserved children and their families in America’s inner cities and rural communities. But these very real needs are not the only unmet health care needs that the committee must weigh and prioritize.

The other committee meeting is the board of directors of the newly founded Lancaster Health Trust. The trust came into being when the Lancaster Regional Health System was bought by a still larger health system. Buyers of not-for-profit health systems are prohibited by law from acquiring the endowments of the purchased organizations in order to prevent them from buying organizations simply for the cash in their often-sizable endowments. So, Lancaster’s endowment has become separately incorporated as a not-for-profit charitable trust, and its board is meeting for the first time to set priorities for its philanthropic work over the next five years. Every dollar the trust contributes to the health of the public—since it is just beginning operations—will be a new dollar, not one taken away from some other health care service or organization. On one hand, this is a chance for the trust’s board to take a fresh look at health care needs in the community and respond to needs that have not been well met to date. On the other hand, the resources available to the board are finite and there are far more unmet health care needs in the community than the board could ever possibly meet. So they, too, are charged with rationing health care dollars, even though these are new dollars, and they, too, have an obligation to the community to do so carefully and efficiently and in as just a way as they can.

The former director of the Lancaster Health System’s dental service, Dr. Bernice Lichtmann, DDS, has been appointed to the new trust’s board. She is widely respected in the community for her work in establishing and developing financial support for public health clinics. She has always made sure that basic oral health care was part of the mix of health care services provided to these clinics’ patients. Now, with the unusual opportunity of financing new programs with new dollars, she is hoping the board will see the wisdom of investing in basic dental care for many more patients who currently lack access to it.

How ought these two groups think through the challenges they face? What would a just distribution of these health care resources look like? What are the criteria for just distribution in a rationing plan? Among the many kinds of benefits that health produces for people, and among the many kinds of harms that health care corrects or prevents for people, which should receive greater priority and which less? And, in particular, how ought these boards prioritize oral health care among health care services, and among oral health care needs, which should count as basic needs, and how much priority should they receive?

In actual practice, such committees are typically comparing the benefits and costs of very specific proposals: for example, a set number of dollars for a program to support perinatal care programs or early childhood nutrition programs in inner cities and rural areas, a certain number for the purchase of magnetic resonance imaging (MRI) machines for small hospitals too far from large medical centers to conveniently refer patients to them, and a fixed number of dollars to provide visiting nurses’ assistance to elderly home-bound diabetics or dental hygienists to visit schools in areas with no dental offices. But suppose these committees were able to step back and ask the questions in the previous paragraph more generally so they could develop broader guidelines about justice and the ethical distribution of the limited health care resources they need to ration. How might they carry out this thought process?

JUSTICE AT THE SOCIETAL LEVEL

Dental care is not only a matter of relationships between individual dentists and individual patients. Those relationships occur in the context of a complex social institution, the dental profession, whose norms are the product of an ongoing dialogue between dentists as a group and the larger community. Whether a dentist’s particular actions toward a particular patient are ethical or not cannot be resolved without considering the dentist as a professional—and therefore examining the dental profession and its dialogue with the larger community and the norms of dental practice that are this dialogue’s result. Dentistry, even when it consists mostly of one-to-one interactions, is also by its very nature a broadly social enterprise as well.

The point of this chapter is that there is another broad social structure, or set of social structures, that is directly involved in dental practice, even in the most direct one-to-one encounter of dentist and patient. This is the set of social structures that distributes a society’s resources and governs their exchange so some are used or exchanged by some people, others by other people. Moreover, like the institution of profession and the particular profession of dentistry with its particular norms, the set of structures that governs the distribution and exchange of a society’s resources can be ethically sound as it exists in a given society, or it can be ethically defective. Since our own society’s structures for the distribution of resources have such great impact on what kinds of dental care are available to the people of our society, these social structures deserve to be examined here and the question explored of whether they are ethically sound in their impact on dental care or whether they ought to be rejected in favor of other, more just structures for distributing dental care resources.

When a society’s structures for distributing resources are ethically sound, a common adjective used to describe such a society is “just.” When a society’s distributive structures are ethically deficient, one proper term is “unjust.” Aristotle labeled as distributive justice the effort to determine which kinds of distributive structures are ethically sound and which are not, and the label has stuck.

What, then, are the characteristics that make a society’s distributive structures just? This is not an easy question to answer. Aristotle’s description of justice at the most general level provides a starting point. He observed that justice of every sort, in every aspect of life where talk of justice is appropriate, has to do in general with treating like cases alike and different cases differently in proportion to their relevant similarities and differences. This tells us something important about ethical distributions, but we won’t be able to apply it to any practical area of life until we can answer a further question: In the area of human life under consideration, which similarities and differences between people should be considered ethically relevant? With regard to the recipients of dental care, then, we need to ask which kinds of similarities and differences should determine differences in how much and what kinds of dental care resources each patient ought to receive. The next six sections will examine this issue, first in general terms and then in connection with the current structures for distributing dental care resources in the United States. The final section will return to the chapter’s introductory case to comment on the work of the two committees and to propose an exercise for the reader to think about the just distribution of society’s health care resources and ethical rationing.

EQUALITY, BASIC NEEDS, AND JUST DISTRIBUTION

What should the norms of justice be for distributing a society’s resources among its people? A number of criteria have been proposed, but there is room in this chapter for only a brief explanation of some of the most important criteria. As each is discussed here, the reader should be asking, is this the criterion (or one of several) that should determine what and how much dental care ought to be available to each dental patient in an ethical, just society, and why or why not?

The values of American culture and those of cultures and peoples in many parts of the world today make it fairly easy to reject one historically important criterion for distributing resources—namely, social class and birth-based social status. There is a broad consensus that these are not relevant characteristics for determining the distribution of dental care, or any other form of health care, so a society that distributes dental care on the basis of social class or birth-based social status is considered unethical and unjust. It would be a useful exercise for the reader to pause here to ask why this is (or is not) a correct conclusion.

A more complicated criterion supported by many thinkers in recent centuries is equality. The claim is that there are no relevant differences between people when it comes to the distribution of dental care resources or other kinds of resources to which this criterion is applied. These thinkers therefore argue that a society’s distributive structures should be arranged so these resources—in this case, its dental care resources—are distributed equally. But equally in regard to what? That is a question that must be answered before this view of just distributions will be clear enough to be put into practice. For example, does “equality” here mean that every person in the society gets exactly the same resources as the next person? So everyone would get the same number of porcelain-fused-to-metal restorations as the next person, for example? This makes no sense. People’s needs for particular forms of dental care vary, and most people would agree that the dental care a person ought to receive should be determined by his or her need for that care. So the interpretation of equality that means “equal stuff for all” does not seem very useful here. Instead, when equality is proposed as a criterion of just distributions at the societal level, it is usually understood to refer to responding equally to people’s needs. On this view, equality in distribution would exist when the people of the society were equally able to fill their needs. But this way of putting it leaves two important questions unanswered. What should count as equal ability to fill one’s needs? And are we talking about every kind of need (i.e., everything that anyone might describe as something they need), or, when justice is understood in terms of needs, is the focus only on a certain class of needs, and if so, then which ones and why? With regard to dental care, for example, equal ability to fill one’s needs is most often interpreted to refer to equal time, effort, and equal resources that people have to expend to get access to a certain form of dental care that they need. This is how the concept of equal ability to fill one’s needs will be understood in this book.

Regarding what counts as needs when the question is about a society’s distributing its resources justly, a common distinction within health care is useful—namely, the distinction between treatments that are needed or essential, and treatments that are nonessential and therefore optional. Within health care this distinction is widely taken to be quite clear (although cases that are difficult to call do occur). In contemporary literature on health care ethics and health care policy, this distinction is often expressed by calling essential matters “basic.” Thus, the expression “basic health care” has come into common usage as the collective term for health care that is essential for humans. This is in contrast with other kinds of health care that are judged nonessential and that respond to the wants and desires that people have in addition to their basic needs.

But obviously this explanation is still incomplete. When are human needs basic? We must ask: Essential for what? Basic to what? Needed for what? For dentistry and the health professions generally, this question is answered by reference to what is considered to be normal and appropriate human functioning. Thus, the discussion of Oral Health as part of the hierarchy of dentistry’s Central Practice Values in chapter 5 specified Oral Health to be “appropriate and pain-free oral functioning.” Declaring that a certain kind of functioning—for example, pain-free functioning—is an essential part of human health and is a way in which humans ought to function depends on answering serious philosophical questions about human nature that are well beyond the scope of this book. (But the reader would do well to think carefully about these matters since one goal of such reflection is, in fact, to determine what health consists of for humans, and this is obviously relevant to understanding what dentists are ultimately aiming at for their patients.)

But whatever functions are considered to be normal and appropriate for humans, it seems clear that there are some human needs that must be fulfilled for a human to be able to perform any of these functions at all. These are the needs that are essential in a special sense, and the concept of basic needs will be used here to refer to this class of human needs. That is, even though there may be considerable disagreement about which human functions are those humans ought to be able to do, it is clear that there are some needs that must be met before a human could perform any of these functions. An obvious example is food (that is, adequate nutrition) because without adequate nutrition a human cannot perform any of the functions that might be considered important for human fulfillment, no matter which account of human fulfillment one accepts. Other examples include adequate clothing and shelter (and asking what “adequate” means here is simply another way of asking more concretely which needs are basic) as well as breathable air. Many people’s lists also include adequate assistance in maintaining one’s health—that is, health care—as well as adequate education, human companionship, and so on. (Discussions of basic needs sometimes prompt the question: “How much of a particular kind of resource will it take (i.e., to meet someone’s basic needs)?” The general answer to this question is however much of that resource it actually takes in order to enable the person to perform whatever functions are normal and appropriate for humans to perform. That is, the concept of basic need is very general, but what it means concretely with regard to a particular kind of resource on the part of a particular person or class of people will depend on the function to be preserved and what in fact it takes to preserve that kind of functioning for that person or class of people. Obviously, this can be determined only through empirical investigation of the relevant resources and what functions are made possible or impossible, respectively, for actual individuals by a certain degree of access or lack of access to them.)

Since the things being counted here as basic needs are absolutely necessary for humans to pursue every other kind of value, goal, or purpose that they might pursue, then it is reasonable to argue that—although they may not be more valuable in themselves than many other valued human goals—they are practically more important and therefore should take priority over all other human values and goals when a society is determining how to distribute its resources. According to this line of reasoning, in other words, if any aspects of oral health care are basic needs for humans, then responding to these needs for every member of the society ought to be the first goal of a society’s system of distribution if it is to be an ethical/just society. (There is much more that could be said about this line of reasoning that says that equality and basic needs should be the criterion by which a just society distributes its resources. While this position cannot be examined further here, the reader is again urged to give it serious thought and compare it carefully with the other approaches to justice examined in the following sections.) For present purposes, where dentistry’s ethics is our principal concern, the fact remains that the dental community and the community at large in dialogue do view certain kinds of pain-free oral functioning as what counts as oral health for humans, and this is therefore a proper goal for members of the dental profession to pursue. For this reason, from the point of view of the dental profession and the larger society in dialogue, the proper criterion for ethically distributing a society’s dental care resources is the need of patients for such care. From this it would follow that, if our society has enough resources to do this, then it ought to arrange its distributive structures so that whoever has dental care needs in our society can obtain the needed dental care resources to fill them. Moreover, if these oral health needs are indeed basic needs for humans generally, then any society that has sufficient resources to provide for them but fails to do so is in that measure an unjust society.

Of course, not everything that someone calls a need is a basic need in the sense explained above. So, what aspects of dental care are essential to oral health? What aspects of dental care are responses to basic oral health needs? This question will be discussed later in this chapter.

It is also important to point out that what counts in practice as a patient’s oral health need—whether a matter of basic need because it is essential to the patient’s oral health or nonessential and therefore optional from the point of view of treatment—is determined in particular cases by members of the dental profession because it is they who have the needed expertise and who have been authorized by the larger community to make these determinations on the basis of what the profession and the larger community in dialogue determine counts as oral health. These determinations happen at chairside for each individual patient for the matter at hand, and they also happen at a broader level by the dental profession collectively in dialogue with the larger community as they identify and authorize standards of competent dental practice. This is a very important point because, as chapter 13 will make clear, there is a very important difference between need as determined on the basis of professional expertise and need determined solely on the basis of a market consumer’s (or other market participants’) desires. Further discussion of the dialogue in which dentistry and the larger community determine what counts as oral health and what counts as oral health needs will be found in chapter 14.

Up to this point, the focus of this chapter has been chiefly oral health needs as the criteria of a just distribution of a society’s health care resources. There are, however, a number of other ways of thinking about justice that do not focus on either equality or need as the determinant of what counts as an ethical, just distribution of a society’s resources.

CONTRIBUTION AND EFFORT AS POSSIBLE CRITERIA

Some theorists hold that a society’s resources, including its dental and other health care resources, ought to be distributed according to the value of each person’s contribution to that society. The underlying idea here is that the resources that a society has are mostly produced

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