By Peter P. Budetti, MD, JD
JAMA
January 2, 2008
In the United States, health care competes for consumers with other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self-interest, personal effort, and voluntary behavior. The contrasting approach, social justice, allocates goods and services according to the individual’s needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity. Social justice in health care requires universal coverage and ensured access to care, whether through social insurance, private insurance, or some combination.
The End of Market Justice
The dominance of market justice as the vehicle for allocating health resources in the United States has been associated with numerous troubling characteristics of its health system. The US population has clearly rejected using pure market justice to apportion health care goods and services, yet has expressed no collective demand that society achieve equity through social justice. The general public has insisted on the buffer of insurance, but has focused on coverage for individuals and their respective families, not the population as a whole. Consequently, health care coverage, although desired by the vast majority of Americans, is incomplete. Now, the key element, employment-based insurance, is disintegrating in both the population that is covered and the benefits provided.
Simultaneously, health care has become a valuable commodity that created enormously influential vested commercial interests with little motive to abandon market justice. Medicine, which might have played a role in promoting social justice, has not done so, and has been transformed by the imperatives of market justice. Fragmented and struggling to come to terms with externally imposed pressures, medicine is losing both its political force and moral compass. The medicalization of health has simultaneously enhanced the investment in health care goods and services while distracting clinicians and policy makers from attention to the needs for health promotion and disease prevention and constraining the capacity to meet the expanding challenges to public health. Market justice may have outlived its role in US health care.
http://jama.ama-assn.org/cgi/content/full/299/1/92
Comment:
By Don McCanne, MD
The quasi-electromagnetic fields of market justice have screwed up our moral compass. Let’s take it over to the terrain of social justice and see if we can get it to work again.