Rights and the Health Care Debate: Part III

by Richard Pimentel

In past articles in this series, I’ve focused on the concept of rights; particularly the much-discussed “right to health care.” We examined the question as to whether there is a legitimate “right to health care” by looking at the grounding and nature of rights. From Aristotle to Locke to Montesquieu, there are many philosophers who have written about rights. However, there are two modern philosophers who have greatly influenced our views on rights and the role of rights in modern society-John Rawls and Robert Nozick. These two men were the most influential American political philosophers of the 20th century. The scope of this article will be on the late John Rawls, specifically on what he had to say about the concept of justice. This concept is significant to Rawls’s view on rights because of the role of rights in his concept of justice.

Rawls grew in fame with his 1971 book, A Theory of Justice. In this book, Rawls describes the justice as “fairness” which is a just arrangement of a liberal society’s political and social institutions. “Justice as fairness” consists of two principles. Rawls describes the “liberty principle” by the following statement: “Each person is to have an equal right to the most extensive scheme of equal basic liberties compatible with a similar scheme of liberties for others.” For Rawls, basic liberties include political liberties such voting and running for office, freedom of speech and assembly, liberty of conscience, freedom of personal property, and freedom from arbitrary arrest. However, Rawls acknowledged that this list may exclude other liberties (liberties not as basic as these) which are necessary in order to create a more just society. The second principle, termed the “difference principle”, stated that social and economic inequalities can be accepted if and only if this produces the greatest benefit to the least advantaged in society.

According to Richard Epstein of the Hoover Institution, the great engine that drove Rawls’s analysis was the “veil of ignorance.” The veil of ignorance was the phrase that Rawls employed to demonstrate the necessary conditions for the existence of a just society. The veil of ignorance refers to the impartiality that the members of a society must possess. That is, these impartial members must detach from and set aside their own gender, economic status, race, personality, etc. and choose to look at the world around them with equal care and concern. Only then can a just society be born because the members of this society will be thinking of the good of the whole and not merely of themselves. According to Rawls, this device will initiate the pursuit of justice in modern society.

Recognizing Rawls’s two principles of justice along with the driving force behind it--the veil of ignorance--draws the discussion closer to rights. In the first installment of this series, I concluded, “Not every good needs to be positioned as a right in order to establish that it is indeed a good.” However it seems that Rawls does not make this distinction between goods and rights. Rawls’s conception of justice derives from an assumption that citizens are free and equal along with being reasonable and rational. The citizen’s freedom consists of two moral powers: “a sense of justice” and “the conception of the good.” The former refers to the reasonableness of citizens to cooperate with one another and put aside their own interests in conjunction with others. The latter refers to the fact that citizens are seen as rational. Rawls argues that free and equal citizens have the rational ability to pursue what is valuable in life. In order for citizens to exercise the two moral powers, Rawls argued that they must be provided with “primary goods.” These primary goods come in five different types: basic rights and liberties, freedom of movement and choice of occupation, the powers of office, income and wealth, and the social bases of self-respect. Rawls considered the equitable distribution of these primary goods as the most significant political issue. Rawls offers a more detailed exposition of these goods in his writings.

Applying Rawls’s principles to the current debate on universal health care can be daunting for two reasons.  First of all, to my knowledge, there is no explicit promotion of universal health care by Rawls but this does not mean that Rawls did not advocate universal health care and consider it a right. Second, Rawls’s extensive view of a just society involves the application of numerous philosophical principles to particular policy issues--surely a complex task. Nonetheless, there is one modern philosopher who has referred to Rawls’s “justice as fairness” when discussing health care.

Norman Daniels, a professor of ethics at Harvard University, has done extensive work in the fields of health care and public policy. Through numerous articles, essays, and books, especially his 1985 book, Just Health Care, Daniels champions the idea that a theory of health care is necessary in a society that reflects Rawls’s conception of justice. He utilizes Rawls’s liberty principle and difference principle to demonstrate the need for an equality of opportunity and just distribution of health care in modern society. He argues that addressing economic inequities is the best remedy for health care inequities. In addition, Daniels has done extensive work on the issue of fair and unfair limits to health care that can be imposed by governments and other institutions. Daniels leverages the concept of legitimacy as promoted by Rawls in his political philosophy.

Rawls argued that two issues arise when a law is imposed upon citizens. The first is legitimacy and the second is stability. The former applies to the legitimate use of political power. Rawls asked the question, “How can it be legitimate for a democratic people to coerce all citizens to follow just one law, given that citizens will inevitably hold to different worldviews?” Rawls contended that legitimacy imposes an obligation upon the government to pass a law in which all citizens can reasonably be expected to endorse. Whereas legitimacy focuses on the party imposing the law, stability focuses on those who have to obey the law and it deals with how a citizen can obey a law that is not similar to his own sets of beliefs and values. Daniels refers to the legitimacy concept when answering the following questions: Under what conditions should society grant authority to individuals or institutions to set limits to health care? Under what conditions should people put their lives in the hands of others in this way and give legitimacy to the authority they exercise? As Daniels has demonstrated in his numerous works, the ideas of John Rawls in the field of political philosophy are significant when looking at the justification for the right to health care. Although utilizing Rawlsian philosophy does not explicitly decide the issue, understanding Rawls’s conception of justice is vital to forming an informed view on the right to health care.

In past articles in this series, I’ve focused on the concept of rights; particularly the much-discussed “right to health care.” We examined the question as to whether there is a legitimate “right to health care” by looking at the grounding and nature of rights. From Aristotle to Locke to Montesquieu, there are many philosophers who have written about rights. However, there are two modern philosophers who have greatly influenced our views on rights and the role of rights in modern society-John Rawls and Robert Nozick. These two men were the most influential American political philosophers of the 20th century. The scope of this article will be on the late John Rawls, specifically on what he had to say about the concept of justice. This concept is significant to Rawls’s view on rights because of the role of rights in his concept of justice.

Rawls grew in fame with his 1971 book, A Theory of Justice. In this book, Rawls describes the justice as “fairness” which is a just arrangement of a liberal society’s political and social institutions. “Justice as fairness” consists of two principles. Rawls describes the “liberty principle” by the following statement: “Each person is to have an equal right to the most extensive scheme of equal basic liberties compatible with a similar scheme of liberties for others.” For Rawls, basic liberties include political liberties such voting and running for office, freedom of speech and assembly, liberty of conscience, freedom of personal property, and freedom from arbitrary arrest. However, Rawls acknowledged that this list may exclude other liberties (liberties not as basic as these) which are necessary in order to create a more just society. The second principle, termed the “difference principle”, stated that social and economic inequalities can be accepted if and only if this produces the greatest benefit to the least advantaged in society.

According to Richard Epstein of the Hoover Institution, the great engine that drove Rawls’s analysis was the “veil of ignorance.” The veil of ignorance was the phrase that Rawls employed to demonstrate the necessary conditions for the existence of a just society. The veil of ignorance refers to the impartiality that the members of a society must possess. That is, these impartial members must detach from and set aside their own gender, economic status, race, personality, etc. and choose to look at the world around them with equal care and concern. Only then can a just society be born because the members of this society will be thinking of the good of the whole and not merely of themselves. According to Rawls, this device will initiate the pursuit of justice in modern society.

Recognizing Rawls’s two principles of justice along with the driving force behind it--the veil of ignorance--draws the discussion closer to rights. In the first installment of this series, I concluded, “Not every good needs to be positioned as a right in order to establish that it is indeed a good.” However it seems that Rawls does not make this distinction between goods and rights. Rawls’s conception of justice derives from an assumption that citizens are free and equal along with being reasonable and rational. The citizen’s freedom consists of two moral powers: “a sense of justice” and “the conception of the good.” The former refers to the reasonableness of citizens to cooperate with one another and put aside their own interests in conjunction with others. The latter refers to the fact that citizens are seen as rational. Rawls argues that free and equal citizens have the rational ability to pursue what is valuable in life. In order for citizens to exercise the two moral powers, Rawls argued that they must be provided with “primary goods.” These primary goods come in five different types: basic rights and liberties, freedom of movement and choice of occupation, the powers of office, income and wealth, and the social bases of self-respect. Rawls considered the equitable distribution of these primary goods as the most significant political issue. Rawls offers a more detailed exposition of these goods in his writings.

Applying Rawls’s principles to the current debate on universal health care can be daunting for two reasons.  First of all, to my knowledge, there is no explicit promotion of universal health care by Rawls but this does not mean that Rawls did not advocate universal health care and consider it a right. Second, Rawls’s extensive view of a just society involves the application of numerous philosophical principles to particular policy issues--surely a complex task. Nonetheless, there is one modern philosopher who has referred to Rawls’s “justice as fairness” when discussing health care.

Norman Daniels, a professor of ethics at Harvard University, has done extensive work in the fields of health care and public policy. Through numerous articles, essays, and books, especially his 1985 book, Just Health Care, Daniels champions the idea that a theory of health care is necessary in a society that reflects Rawls’s conception of justice. He utilizes Rawls’s liberty principle and difference principle to demonstrate the need for an equality of opportunity and just distribution of health care in modern society. He argues that addressing economic inequities is the best remedy for health care inequities. In addition, Daniels has done extensive work on the issue of fair and unfair limits to health care that can be imposed by governments and other institutions. Daniels leverages the concept of legitimacy as promoted by Rawls in his political philosophy.

Rawls argued that two issues arise when a law is imposed upon citizens. The first is legitimacy and the second is stability. The former applies to the legitimate use of political power. Rawls asked the question, “How can it be legitimate for a democratic people to coerce all citizens to follow just one law, given that citizens will inevitably hold to different worldviews?” Rawls contended that legitimacy imposes an obligation upon the government to pass a law in which all citizens can reasonably be expected to endorse. Whereas legitimacy focuses on the party imposing the law, stability focuses on those who have to obey the law and it deals with how a citizen can obey a law that is not similar to his own sets of beliefs and values. Daniels refers to the legitimacy concept when answering the following questions: Under what conditions should society grant authority to individuals or institutions to set limits to health care? Under what conditions should people put their lives in the hands of others in this way and give legitimacy to the authority they exercise? As Daniels has demonstrated in his numerous works, the ideas of John Rawls in the field of political philosophy are significant when looking at the justification for the right to health care. Although utilizing Rawlsian philosophy does not explicitly decide the issue, understanding Rawls’s conception of justice is vital to forming an informed view on the right to health care.