Governance for what?
A well-ordered, efficient and effective social institution can still produce unjust outcomes. Such an insight applied to discussions on governance of health systems raises the question, governance for what?
In the introduction to his seminal modern treatise in political philosophy titled A Theory of Justice, John Rawls writes, “Justice is the first virtue of social institutions, as truth is of systems of thought. A theory however elegant and economical must be rejected or revised if it is untrue; likewise laws and institutions no matter how efficient and well-arranged must be reformed or abolished if they are unjust” (1971, p. 3). What motivates me to start an essay on ethics and health systems is Rawls’ assertion that laws and institutions can be efficient and well-arranged but still unjust. Rawls is not the only or first one to assert this point. Plato also identified this point long before. And more recently, Amartya Sen and Jean Drèze showed how large scale famine-related mortality and morbidity occurred under an ordered and well performing legal system. The important point here for those interested in health systems is that a well-ordered, efficient and effective social institution can still produce unjust outcomes. Such an insight applied to discussions on governance of health systems raises the question, governance for what?
Since the 1980s, we have had much experience with seeing that public health laws and systems can be effective but also excessively abusive of international human rights and basic constitutional rights. Or, in other words, public health systems can be effective and possibly unjust. One of the legal and ethical challenge that repeatedly appears in public health policy and planning is the conflict between individual rights of various kinds (e.g. privacy, mobility, expression, religion) and the health of the greater population. And protecting the public’s health is one of the few occasions in both domestic and international human rights law when a state is allowed to violate basic rights and liberties. Many in public health would assert that protecting the public’s health is a just outcome despite the rights and liberties of some people being violated. This perennial conflict in public health has recently been flipped on its head. Social epidemiologists and philosophers have argued that unjust social conditions or violations of basic rights lead to vulnerability to disease and mortality. Violating the basic rights of the few for the sake of protecting the health of the many can be doubly unjust. First, unjust social conditions lead to disease and impairments, and social inequalities in health. And then, public health policies violate the rights of those who are sick or vulnerable again in order to protect others from becoming ill.
A health system is clearly more than public health laws, policies and programmes. Which means that it contains far more ethical issues than the conflict between individual versus the greater good. A good health system must establish the norms and govern the interactions between the healthcare provider and patient, the researcher and human subject, and public health policies. And beyond that, a health system must be understood to be distributing valuable benefits and burdens, to individuals and groups. Sometimes the benefits are the ability to stay alive or be born. Whether one conceives of a health system as being about healthcare, or a broader system that also encompasses the non-healthcare, global and national determinants of health and health inequalities, ethical issues and ethical reasoning is unavoidable.
It would be a significant lost opportunity to not explicitly consider ethics and justice in the discussions about good governance of health systems.
It would be incorrect to think that discussions on governance of health systems should now begin including ethics. That is because ethical norms, theories and practices are already operating in health systems and in the scholarly and policy discussions. What is needed is the purposeful identification of those ethical ideas, and the introduction of alternative approaches. At a time when many societies are seeking to withdraw from global norms and institutions, a general or universal schema for a good health system with an implicit ethic is bound to run aground for at least two reasons. First, while the schema might be advocated as being elegant, effective, and economical, if the ethics run counter to the ethics of the particular society, it will not be implemented as expected. Second, deploying a conception of a health system which has an implicit ethical system onto societies is in effect dominating one set of ethics over another. It is comparable to making another person act according to your own values irrespective of how they want to act or live their life.
A health system is one of the most important and basic social institutions of a society. Aside from addressing health, it must also realize justice. It would be a significant lost opportunity to not explicitly consider ethics and justice in the discussions about good governance of health systems. And it would be profoundly wrong to impose a particular conception of ethics and justice onto others, including societies, knowing full well that they are likely to be holding different conceptions.
Sridhar Venkatapuram, King's College London & WHO
Faden, Ruth and Shebaya, Sirine, "Public Health Ethics", The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2016/entries/publichealth-ethics/>.
Sen, A. (2002). Why health equity? Health Economics, 11(8), pp.659-666.
Venkatapuram, S. (2011). Health justice. Cambridge: Polity Press.
Wikler, Dan and Brock, Dan. (2008) Population-level bioethics: mapping a new agenda. In Ronald Michael Green, Aine Donovan & Steven A. Jauss (eds.), Global Bioethics: Issues of Conscience for the Twenty-First Century. Oxford University Press.