Justice in the Distribution of Health Care

By Ronald Dworkin

(1993) 38 McGill L.J. 883

In this lecture, Professor Dworkin begins by identifying two questions about justice in the distribution of health care: (1) How much, in the aggregate, should society spend on health? (2) Once established, how should this amount be distributed?

He then examines the ancient insulation model of health care distribution, which postulates that health care is chief among all goods and that it is to be distributed in an equal way. He concludes that this model provides no satisfactory answer to either of the two questions. It cannot answer the first, for it would require that society spend all it could on health care until the next dollar would buy no gain in health or life expectancy, something which is manifestly absurd, particularly in our age of ever-expanding medical technology. Nor he tells us, does the insulation model provide much guidance with the second question, since its egalitarian spirit ultimately leads us to apply notions of efficiency and need which are philosophically controversial and therefore impossible to apply.

By means of a thought experiment, Professor Dworkin then develops an alternative model which he feels does provide an answer to his two questions. He asks us to imagine a society with fair equality in the distribution of resources, in which the public at large has knowledge about the cost and value of medical procedures, but in which no one has any knowledge about the antecedent probability of contracting any particular disease. Moreover, health care is not provided by the government, but, rather, each individual is free to allocate to health care (by purchasing health insurance, for example) as much or as little of his resources as he wishes. Professor Dworkin claims that whatever that society spent on health care would be just—both in the aggregate and in its distribution. Carrying the model through, he discusses its implications for our own society and analyzes possible objections to it. He concludes by stressing the importance of the question of justice in health care and by putting it in its broader political context.