Rights to Health Care in Health Care Allocations PDF

776 PA R T 4 : J U S T I C E A N D H E A LT H C A R E Rights to Health Care, Social Justice, and Fairness in Health Care Allocations: Frustrations in the Face of Finitude H. TRISTRAM ENGELHARDT, JR. Engelhardt asserts that “a basic human secular moral right to health care does not exist— not eve...

776 PA R T 4 : J U S T I C E A N D H E A LT H C A R E Rights to Health Care, Social Justice, and Fairness in Health Care Allocations: Frustrations in the Face of Finitude H. TRISTRAM ENGELHARDT, JR. Engelhardt asserts that “a basic human secular moral right to health care does not exist— not even to a ‘decent minimum of health care.’” He distinguishes between losses that people suffer because of bad fortune and those due to unfairness. The former do not establish a duty of aid to the unfortunate (there is no moral right to such aid), but the latter may constitute claims on others. Out of compassion or be- nevolence, society may freely consent to help those in need, but there is no forced obligation to do so. The imposition of a single-tier, all-encompassing particular visions of beneficence and justice. It is health care system is morally unjustifiable. It is a materially impossible both to respect the freedom coercive act of totalitarian ideological zeal, which of all and to achieve their long-range best inter- fails to recognize the diversity of moral visions that ests. Loose talk about justice and fairness in health frame interests in health care, the secular moral care is therefore morally misleading, because it limits of state authority, and the authority of indi- suggests that there is a particular canonical vision viduals over themselves and their own property. It of justice or fairness that all have grounds to is an act of secular immorality. endorse.... A basic human secular moral right to health care Rights to health care constitute claims on services does not exist—not even to a “decent minimum of and goods. Unlike rights to forbearance, which re- health care.” Such rights must be created. quire others to refrain from interfering, which show The difficulty with supposed right to health the unity of the authority to use others, rights to be- care, as well as with many claims regarding justice neficence are rights grounded in particular theories or fairness in access to health care, should be ap- or accounts of the good. For general authority, they parent. Since the secular moral authority for require others to participate actively in a particular common action is derived from permission or con- understanding of the good life or justice. Without an sent, it is difficult (indeed, for a large-scale society, appeal to the principle of permission, to advance materially impossible) to gain moral legitimacy for such rights is to claim that one may press others into the thoroughgoing imposition on health care of labor or confiscate their property. Rights to health one among the many views of beneficence and jus- care, unless they are derived from special contrac- tice. There are, after all, as many accounts of benefi- tual agreements, depend on particular understand- cence, justice, and fairness as there are major ings of beneficence rather than on authorizing religions. permission. They may therefore conflict with the de- Most significantly, there is a tension between cisions of individuals who may not wish to partici- the foundations of general secular morality and pate in, and may indeed be morally opposed to, the various particular positive claims founded in realizing a particular system of health care. Individ- uals always have the secular moral authority to use From Foundations of Bioethics, 2d ed., by H. Tristram their own resources in ways that collide with fash- Engelhardt, Jr., (1996). Reprinted by permission of Oxford ionable understandings of justice or the prevailing University Press. consensus regarding fairness. vau03268_ch11_741-810.indd 776 05/02/19 07:51 PM  Chapter 11: Dividing Up Health Care Resources 777 Health Care Policy: The Ideology . endorse setting a price on saving human life of Equal, Optimal Care as a part of establishing a cost-effective health It is fashionable to affirm an impossible commit- care system established through communal ment in health care delivery, as, for example, in the resources. following four widely embraced health care policy Even though all health care systems de facto enjoy goals, which are at loggerheads: inequalities and must to some extent ration the . The best possible care is to be provided for all. health care they provide through communal re- . Equal care should be guaranteed. sources, this is not usually forthrightly acknowl- . Freedom of choice on the part of health care edged. There is an ideological bar to recognizing provider and consumer should be maintained. and coming to terms with the obvious. . Health care costs are to be contained. Only a prevailing collective illusion can account for the assumption in U.S. policy that health care One cannot provide the best possible health care for may be provided () while containing costs () with- all and contain health care costs. One cannot provide out setting a price on saving lives and preventing equal health care for all and respect the freedom of suffering when using communal funds and at the individuals peaceably to pursue with others their own same time () ignoring the morally unavoidable in- visions of health care or to use their own resources equalities due to private resources and human free- and energies as they decide. For that matter, one dom. This false consciousness shaped the deceptions cannot maintain freedom in the choice of health central to the Clinton health care proposal, as it was care services while containing the costs of health introduced in . It was advanced to support a care. One may also not be able to provide all with health care system purportedly able to provide all equal health care that is at the same time the very best with () the best of care and () equal care, while care because of limits on the resources themselves. achieving () cost containment, and still () allow- That few openly address these foundational moral ing those who wish the liberty to purchase fee-for- tensions at the roots of contemporary health care service health care.  While not acknowledging the policy suggests that the problems are shrouded in a presence of rationing, the proposal required silent collective illusion, a false consciousness, an estab- rationing in order to contain costs by limiting lished ideology within which certain facts are politi- access to high-cost, low-yield treatments that a Na- cally unacceptable. tional Health Board would exclude from the “guar- These difficulties spring not only from a conflict anteed benefit package.”  In addition, it advanced between freedom and beneficence, but from a tension mechanisms to slow technological innovation so as among competing views of what it means to pursue further to reduce the visibility of rationing choices.  and achieve the good in health care (e.g., is it more One does not have to ration that which is not avail- important to provide equal care to all or the best pos- able. There has been a failure to acknowledge the sible health care to the least-well-off class?). The pur- moral inevitability of inequalities in health care due suit of incompatible or incoherent health care is to the limits of secular governmental authority, rooted in the failure to face the finitude of secular human freedom, and the existence of private prop- moral authority, the finitude of secular moral vision, erty, however little that may be. There was also the the finitude of human powers in the face of death and failure to acknowledge the need to ration health suffering, the finitude of human life, and the finitude care within communal programs if costs are to be of human financial resources. A health care system contained. It has been ideologically unacceptable to that acknowledges the moral and financial limita- recognize these circumstances.... tions on the provision of health care would need to . endorse inequality in access to health care as Justice, Freedom, and Inequality morally unavoidable because of private re- Interests in justice as beneficence are motivated in sources and human freedom; part by inequalities and in part by needs. That some vau03268_ch11_741-810.indd 777 05/02/19 07:51 PM 778 PA R T 4 : J U S T I C E A N D H E A LT H C A R E have so little while others have so much properly These tragic outcomes are the deliverances of evokes moral concerns of beneficence. Still,... the nature, for which no one, without some special moral authority to use force to set such inequalities view of accountability or responsibility, is responsi- aside is limited. These limitations are in part due to ble (unless, that is, one recognizes them as the results the circumstance that the resources one could use of the Fall or as divine chastisements). The circum- to aid those in need are already owned by other stance that individuals are injured by hurricanes, people. One must establish whether and when in- storms, and earthquakes is often simply no one’s equalities and needs generate rights or claims fault. When no one is to blame, no one may be against others. charged with the responsibility of making whole those who lose the natural lottery on the ground of The Natural and Social Lotteries accountability for the harm. One will need an argu- “Natural lottery’’ is used to identify changes in for- ment dependent on a particular sense of fairness to tune that result from natural forces, not directly show that the readers of this volume should submit from the actions of persons. The natural lottery to the forcible redistribution of their resources to shapes the distribution of both naturally and so- provide health care for those injured by nature. It cially conditioned assets. The natural lottery con- may very well be unfeeling, unsympathetic, or un- trasts with the social lottery, which is used to charitable not to provide such help. One may face identify changes in fortune that are not the result of eternal hellfires for failing to provide aid. But it is natural forces but the actions of persons. The social another thing to show in general secular moral terms lottery shapes the distribution of social and natural that individuals owe others such help in a way that assets. The natural and social lotteries, along with would morally authorize state force to redistribute one’s own free decisions, determine the distribution their private resources and energies or to constrain of natural and social assets. The social lottery is their free choices with others. To be in dire need does termed a lottery, though it is the outcome of per- not by itself create a secular moral right to be rescued sonal actions, because of the complex and unpre- from that need. The natural lottery creates inequali- dictable interplay of personal choices and because ties and places individuals at disadvantage without of the unpredictable character of the outcomes, creating a straightforward secular moral obligation which do not conform to an ideal pattern and be- on the part of others to aid those in need. cause the outcomes are the results of social forces, Individuals differ in their resources not simply not the immediate choices of those subject to them. because of outcomes of the natural lottery, but also All individuals are exposed to the vicissitudes of due to the actions of others. Some deny themselves nature. Some are born healthy and by luck remain so immediate pleasures in order to accumulate wealth for a long life, free of disease and major suffering. or to leave inheritances; through a complex web of Others are born with serious congenital or genetic love, affection, and mutual interest, individuals diseases, others contract serious crippling fatal ill- convey resources, one to another, so that those who nesses early in life, and yet others are injured and are favored prosper and those who are ignored lan- maimed. Those who win the natural lottery will for guish. Some as a consequence grow wealthy and most of their lives not be in need of medical care. others grow poor, not through anyone’s malevolent They will live full lives and die painless and peaceful actions or omissions, but simply because they were deaths. Those who lost the natural lottery will be in not favored by the love, friendship, collegiality, and need of health care to blunt their sufferings and, associations through which fortunes develop and where possible, to cure their diseases and to restore individuals prosper. In such cases there will be nei- function. There will be a spectrum of losses, ranging ther fairness nor unfairness, but simply good and from minor problems such as having teeth with cav- bad fortune. ities to major tragedies such as developing childhood In addition, some will be advantaged or disad- leukemia, inheriting Huntington’s chorea, or devel- vantaged, made rich, poor, ill, diseased, deformed, or oping amyelotrophic lateral sclerosis. disabled because of the malevolent and blameworthy vau03268_ch11_741-810.indd 778 05/02/19 07:51 PM  Chapter 11: Dividing Up Health Care Resources 779 actions and omissions of others. Such will be unfair constitutes the basis for a form of taxation as rent to circumstances, which just and beneficent states provide fungible payments to individuals, whether should try to prevent and to rectify through legiti- or not they are in need. Finally, there are likely to be mate police protection, forced restitution, and char- resources held in common by groups that may es- itable programs. Insofar as an injured party has a tablish bases for their distribution to meet health claim against an injurer to be made whole, not care concerns. The first two forms of entitlement or against society, the outcome is unfortunate from ownership exist unconstrained by medical or other the perspective of society’s obligations and obliga- needs. The last form of entitlement or ownership, tions of innocent citizens to make restitution. through the decision of a community, may be con- Restitution is owed by the injurer, not society or ditioned by need. others. There will be outcomes of the social lottery The existence of any amount of private re- that are on the one hand blameworthy in the sense sources can be the basis for inequalities that secu- of resulting from the culpable actions of others, lar moral authority may not set aside. Insofar as though on the other hand a society has no obligation people own things, they will have a right to them, to rectify them. The social lottery includes the expo- even if others need them. Because the presence of sure to the immoral and unjust actions of others. permission is cardinal, the test of whether one Again, one will need an argument dependent on a must transfer one’s goods to others will not be particular sense of fairness to show that the readers whether such a redistribution will not prove oner- of this volume should submit to the forcible redistri- ous or excessive for the person subjected to the dis- bution of their resources to provide health care to tribution, but whether the resources belong to that those injured by others. individual. Consider that you may be reading this When individuals come to purchase health care, book next to a person in great need. The test of some who lose the natural lottery will be able at whether a third person may take resources from least in part to compensate for those losses through you to help that individual in need will not be their winnings at the social lottery. They will be able whether you will suffer from the transfer, but to afford expensive health care needed to restore rather whether you have consented—at least this is health and to regain function. On the other hand, the case if the principle of permission functions in those who lose in both the natural and the social general secular morality.... The principle of per- lottery will be in need of health care, but without mission is the source of authority when moral the resources to acquire it. strangers collaborate, because they do not share a common understanding of fairness or of the good. The Rich and the Poor: As a consequence, goal-oriented approaches to the Differences in Entitlements just distribution of resources must be restricted to If one owns property by virtue of just acquisition or commonly owned goods, where there is authority just transfer, then one’s title to that property will to create programs for their use. not be undercut by the tragedies and needs of Therefore, one must qualify the conclusions of others. One will simply own one’s property. On the the  American President’s Commission for the other hand, if one owns property because such Study of Ethical Problems that suggest that exces- ownership is justified within a system that ensures sive burdens should determine the amount of tax a beneficent distribution of goods (e.g., the achieve- persons should pay to sustain an adequate level of ment of the greatest balance of benefits over harms health care for those in need.  Further, one will have for the greatest number or the greatest advantage strong grounds for morally condemning systems for the least-well-off class), one’s ownership will be that attempt to impose an all-encompassing health affected by the needs of others.... Property is in care plan that would require “equality of care [in part privately owned in a strong sense that cannot the sense of avoiding] the creation of a tiered system be undercut by the needs of others. In addition, all [by] providing care based only on differences of need, have a general right to the fruits of the earth, which not individual or group characteristics.” Those who vau03268_ch11_741-810.indd 779 05/02/19 07:51 PM 780 PA R T 4 : J U S T I C E A N D H E A LT H C A R E are rich are always at secular moral liberty to pur- view, things would have been different if the federal chase more and better health care. government had in some culpable fashion injured one’s heart. So, too, if promises of treatment had Drawing the Line Between the Unfortunate been made. For example, to suffer from appendicitis and the Unfair or pneumonia and not as a qualifying patient receive How one regards the moral significance of the natu- treatment guaranteed through a particular govern- ral and social lotteries and the moral force of pri- mental or private insurance system would be unfair, vate ownership will determine how one draws the not simply unfortunate. line between circumstances that are simply unfor- Drawing the line between the unfair and the tunate and those that are unfortunate and in addi- unfortunate is unavoidable because it is impossible tion unfair in the sense of constituting a claim on in general secular moral terms to translate all the resources of others. needs into rights, into claims against the resources Life in general, and health care in particular, of others. One must with care decide where the line reveal circumstances of enormous tragedy, suffering, is to be drawn. To distinguish needs from mere de- and deprivation. The pains and sufferings of illness, sires, one must endorse one among the many com- disability, and disease, as well as the limitations of de- peting visions of morality and human flourishing. formity, call on the sympathy of all to provide aid and One is forced to draw a line between those needs give comfort. Injuries, disabilities, and diseases due (or desires) that constitute claims on the aid of to the forces of nature are unfortunate. Injuries, dis- others and those that do not. The line distinguish- abilities, and diseases due to the unconsented-to ac- ing unfortunate from unfair circumstances justi- tions of others are unfair. Still, outcomes of the unfair fies by default certain social and economic actions of others are not necessarily society’s fault and inequalities in the sense of determining who, if any- are in this sense unfortunate. The horrible injuries one, is obliged in general secular immorality to that come every night to the emergency rooms of remedy such circumstances or achieve equality. Is major hospitals may be someone’s fault, even if they the request of an individual to have life extended are not the fault of society, much less that of unin- through a heart transplant at great cost, and per- volved citizens. Such outcomes, though unfair with haps only for a few years, a desire for an inordinate regard to the relationship of the injured with the in- extension of life? Or is it a need to be secure against jurer, may be simply unfortunate with respect to soci- a premature death?... Outside a particular view of ety and other citizens (and may licitly be financially the good life, needs do not create rights to the ser- exploited). One is thus faced with distinguishing the vices or goods of others.  Indeed, outside of a par- difficult line between acts of God, as well as immoral ticular moral vision there is no canonical means acts of individuals that do not constitute a basis for for distinguishing desires from needs. societal retribution on the one hand, and injuries that There is a practical difficulty in regarding major provide such a basis on the other. losses at the natural and social lotteries as generat- A line must be created between those losses that ing claims to health care: attempts to restore health will be made whole through public funds and those indefinitely can deplete societal resources in the that will not. Such a line was drawn in  by Patri- pursuit of ever-more incremental extensions of life cia Harris, the then secretary of the Department of of marginal quality. A relatively limited amount of Health, Education, and Welfare, when she ruled that food and shelter is required to preserve the lives of heart transplantations should be considered experi- individuals. But an indefinite amount of resources mental and therefore not reimbursable through can in medicine be committed to the further pres- Medicare.  To be in need of a heart transplant and ervation of human life, the marginal postponement not have the funds available would be an unfortunate of death, and the marginal alleviation of human circumstance but not unfair. One was not eligible for suffering and disability. Losses at the natural lottery a heart transplant even if another person had inten- with regard to health can consume major resources tionally damaged one’s heart. From a moral point of with little return. Often one can only purchase a vau03268_ch11_741-810.indd 780 05/02/19 07:51 PM  Chapter 11: Dividing Up Health Care Resources 781 little relief, and that only at great costs. Still, more permission, requires the imposition of a particular decisive than the problem of avoiding the possibly vision of beneficence or justice.... overwhelming costs involved in satisfying certain health care desires (e.g., postponing death for a Conflicting Models of Justice: while through the use of critical care) is the prob- From Content to Procedure lem of selecting the correct content-full account of John Rawls’s A Theory of Justice and Robert Nozick’s justice in order canonically to distinguish between Anarchy, State, and Utopia offer contrasting under- needs and desires and to translate needs into rights. standings of what should count as justice or fairness. They sustain differing suggestions regarding the Beyond Equality: An Egalitarianism of nature of justice in health care. They provide a con- Altruism Versus an Egalitarianism of Envy trast between justice as primarily structural, a pat- The equal distribution of health care is itself prob- tern of distributions that is amenable to rational lematic, a circumstance recognized in Securing disclosure, versus justice as primarily procedural, a Access to Health Care, the  report of the Presi- matter of fair negotiation.  In A Theory of Justice dent’s Commission.  The difficulties are multiple: Rawls forwards an expository device of an ahistori- cal perspective from which to discover the proper . Although in theory, at least, one can envisage pattern for the distribution of resources, and there- providing all with equal levels of decent shel- fore presumably for the distribution of health care ter, one cannot restore all to or preserve all in resources. In this understanding, it is assumed that an equal state of health. Many health needs societally based entitlements have moral priority. cannot be satisfied in the same way one can Nozick, in contrast, advances a historical account of address most needs for food and shelter. just distributions within which justice depends on . If one provided all with the same amount of what individuals have agreed to do with and for each funds to purchase health care or the same other. Nozick holds that individually based entitle- amount of services, the amount provided ments are morally prior to societally based entitle- would be far too much for some and much ments. In contrast with Rawls, who argues that one too little for others who could have benefited can discover a proper pattern for the allocation of from more investment in treatment and resources, Nozick argues that such a pattern cannot research. be discovered and that instead one can only identify . If one attempts to provide equal health care in the characteristics of a just process for fashioning the sense of allowing individuals to select health rights to health care.... care only from a predetermined list of available The differences between Nozick of Anarchy, therapies, or through some managed health State, and Utopia and Rawls of A Theory of Justice care plan such as accountable (to the govern- express themselves in different accounts of entitle- ment) health care plans or regional health alli- ments and ownership, and in different understand- ances, which would be provided to all so as to ings of nonprincipled fortune and misfortune. For prevent the rich from having access to better Rawls, one has justifiable title to goods if such a title health care than the poor, one would have im- is part of a system that ensures the greatest benefit morally confiscated private property and have to the least advantaged, consistent with a just- restricted the freedom of individuals to join in savings principle, and with offices and positions voluntary relationships and associations. open to all under conditions of fair equality and op- That some are fortunate in having more resources is portunity, and where each person has an equal right neither more nor less arbitrary or unfair than some to the most extensive total system of equal basic lib- having better health, better looks, or more talents. erties compatible with a similar system of liberty In any event, the translation of unfortunate cir- for all. In contrast, for Nozick, one simply owns cumstances into unfair circumstances, other than things: “Things come into the world already at- with regard to violations of the principle of tached to people having entitlements over them.” If vau03268_ch11_741-810.indd 781 05/02/19 07:51 PM 782 PA R T 4 : J U S T I C E A N D H E A LT H C A R E one really owns things, there will be freedom-based which has strikingly different implications for the limitations on principles of distributive justice. One allocation of health care resources. may not use people or their property without their permission or authorization. The needs of others . Freedom- or permission-based justice is con- will not erase one’s property rights. The readers of cerned with distributions of goods made in this book should consider that they may be wearing accord with the notion of the secular moral wedding rings or other jewelry not essential to their community as a peaceable social structure lives, which could be sold to buy antibiotics to save binding moral strangers, members of diverse identifiable lives in the third world. Those who keep concrete moral communities. Such justice such baubles may in part be acting in agreement will therefore require the consent of the indi- with Nozick’s account and claiming that “it is my viduals involved in a historical nexus of justice- right to keep my wedding ring for myself, even regarding institutions understood in conform- though the proceeds from its sale could save the ity with the principle of permission. The prin- lives of individuals in dire need.” ciple of beneficence may be pursued only Nozick’s account requires a distinction between within constraints set by the principle of someone’s secular moral rights and what is right, permission. good, or proper to do. At times, selling some (perhaps . Goals-based justice is concerned with the all) of one’s property to support the health care of achievement of the good of individuals in those in need will be the right thing to do, even society, where the pursuit of beneficence is though one has a secular moral right to refuse to sell. not constrained by a strong principle of per- This contrast derives from the distinction Nozick mission, but driven by some particular makes between freedom as a side constraint, as the understanding of morality, justice, or fair- very condition for the possibility of a secular moral ness. Such justice will vary in substance as community, and freedom as one value among others. one attempts, for example, to (a) give each This contrast can be understood as a distinction be- person an equal share; (b) give each person tween those claims of justice based on the very pos- what that person needs; (c) give each person a sibility of a moral community, versus those claims of distribution as a part of a system designed to justice that turn on interests in particular goods and achieve the greatest balance of benefits over values, albeit interests recognized in the original po- harms for the greatest number of persons; (d) sition. For Nozick, one may not use innocent free per- give each person a distribution as a part of a sons without their consent, even if that use will save system designed to maximize the advantage lives by providing needed health care or securing of the least-well-off class with conditions of equality of opportunity. Even if such would be a good equal liberty for all and of fair opportunity. thing to do (e.g., in this sense of saving lives), no one has a right to do it. Because for Nozick one needs the Allocations of health care in accord with freedom- actual consent of actual persons in order to respect or permission-based justice must occur within the them as free persons, their rights can morally fore- constraint to respect the free choices of persons, close the pursuit of many morally worthy goals. In including their exercise of their property rights. Al- contrast, Rawls treats freedom or liberty as a value. locations of health care in accord with goals-based As a consequence, in developing just institutions, justice will need to establish what it means to pro- Rawls does not require actual consent of those in- vide a just pattern of health care, and what consti- volved. As a result, Rawls would allow rights to self- tutes true needs, not mere desires, and how to rank determination to be limited in order to achieve im- the various health goals among themselves and in portant social goals.... comparison with nonhealth goals. Such approaches This contrast between Rawls and Nozick can be to justice in health care will require a way of appreciated more generally as a contrast between ahistorically discovering the proper pattern for the two quite different principles of justice, each of distribution of resources. vau03268_ch11_741-810.indd 782 05/02/19 07:51 PM  Chapter 11: Dividing Up Health Care Resources 783 Permission-based and goals-based approaches place for the expression of such inclinations. to justice in health care contrast because they offer A multitier system () should support individual competing interpretations of the maxim, “Justitia providers and consumers against attempts to inter- est constans et perpetua voluntas jus suum cuique fere in their free association and their use of their tribuens” (Justice is the constant and perpetual will own resources, though () it may allow positive to render everyone his due). A permission-based rights to health care to be created for individuals approach holds that justice is first and foremost who have not been advantaged by the social lottery. giving to each the right to be respected as a free in- The serious task is to decide how to define and dividual as the source of secular moral authority, in provide a decent minimum or basic level of care as the disposition of personal services and private a floor of support for all members of society, while goods: that which is due (ius) to individuals is re- allowing money and free choice to fashion special spect of their authority over themselves and their tiers of services for the affluent. In addressing this possessions. In contrast, a goals-based approach general issue of defining what is to be meant by a holds that justice is receiving a share of the goods, decent minimum basic level or a minimum ade- which is fair by an appeal to a set of ahistorical cri- quate amount of health care, the American Presi- teria specifying what a fair share should be, that is, dent’s Commission in  suggested that in great what share is due to each individual. Since there are measure content is to be created rather than dis- various senses of a fair share (e g., an equal share, a covered by democratic processes, as well as by the share in accordance with the system that maxi- forces of the market. “In a democracy, the appro- mizes the balance of benefits over harms, etc.), there priate values to be assigned to the consequences of will be various competing senses of justice in health policies must ultimately be determined by people care under the rubric of goals-based justice.... expressing their values through social and politi- cal processes as well as in the marketplace.”  The Moral Inevitability of a Multitier The Commission, however, also suggested that the Health Care System concept of adequacy could in part be discovered... In the face of unavoidable tragedies and con- by an appeal to that amount of care that would trary moral intuitions, a multitiered system of meet the standards of sound medical practice. health care is in many respects a compromise. On “Adequacy does require that everyone receive care the one hand, it provides some amount of health that meets standards of sound medical practice.”  care for all, while on the other hand allowing those But what one means by “sound medical practice” with resources to purchase additional or better ser- is itself dependent on particular understandings vices. It can endorse the use of communal re- within particular cultures. Criteria for sound sources for the provision of a decent minimal or medical practice are as much created as discov- basic amount of health care for all, while acknowl- ered. The moral inevitability of multiple tiers of edging the existence of private resources at the dis- care brings with it multiple standards of proper or posal of some individuals to purchase better basic sound medical practice and undermines the moral as well as luxury care. While the propensity to seek plausibility of various obiter dicta concerning the more than equal treatment for oneself or loved centralized allocation of medical resources.... ones is made into a vicious disposition in an egali- tarian system, a multitier system allows for the ex- pression of individual love and the pursuit of  private advantage, though still supporting a gen- . The White House Domestic Policy Council, The President’s Health Security Plan (New York: Times Books, ). eral social sympathy for those in need. Whereas an . The White House Domestic Policy Council, The President’s egalitarian system must suppress the widespread Health Security Plan, p. . human inclination to devote private resources to . Innovation would be discouraged as drug prices are the purchase of the best care for those whom one subject to review as reasonable. The White House Domestic loves, a multitier system can recognize a legitimate Policy Council, The President’s Health Security Plan, p. . vau03268_ch11_741-810.indd 783 05/02/19 07:51 PM