Defining the medical sphere

Abstract

Part of the debate on cost containment in health care systems can be characterized as applied political philosophy. Three philosophical directions can be traced. (1) Norman Daniels and Ronald Dworkin advocate a health care distributional system based on a Rawls' A Theory of Justice. (2) Tristram Engelhardt defends a market based approach, reminiscent of Nozick's Anarchy, State, and Utopia. (3) Daniel Callahan advocates a communitarian strategy which resembles the work of Christopher Lasch and Robert Bellah. In the first part of this article these three strategies will be discussed. Occasionally health care philosophers also refer to Michael Walzer's Spheres of Justice. However, no one has undertaken the task to design a health care distributional system style Michael Walzer. According to the author this is to be regretted. Walzer argues that Americans ought to establish a health care system resembling the British National Health Service, because the concepts and categories in which they discuss the distribution of medical goods, as well as established institutions such as Medicare and Medicaid, reveal that they have been committed to something akin to the NHS all along. Walzer's critics point out that a large part of medical goods in the United States is bought and sold on the market. Why should the institution of private health care insurance not be taken as evidence that a straightforward market system is what Americans have wanted in their heart of hearts? In the second part of this article it will be argued that the controversy between Walzer and his critics is based on a serious mistake in Spheres of Justice. Once this mistake has been rectified Walzer's theory of justice might be a fruitful approach to the discussion of cost containment in health care services.