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The International Library of Bioethics 92 Eike-Henner W. Kluge The Right to Health Care: Ethical Considerations The International Library of Bioethics FoundingEditors DavidC.Thomasma DavidN.Weisstub ThomasineKimbroughKushner Volume 92 SeriesEditor DennisR.Cooley,NorthDakotaStateUniversity,History,Philosophy,&Religious Studies,Fargo,ND,USA AdvisoryEditor DavidN.Weisstub,FacultyofMedicine,UniversityofMontreal,Montréal,QC, Canada EditorialBoard TerryCarney,FacultyofLawBuilding,UniversityofSydney,Sydney,Australia MarcusDüwell,PhilosophyFacultyofHumanities,UniversiteitUtrecht,Utrecht, Utrecht,TheNetherlands SørenHolm,CentreforSocialEthicsandPolicy,TheUniversityofManchester, Manchester,UK GerritKimsma,RadboudUMC,Nijmegen,Gelderland,TheNetherlands DanielP.Sulmasy,EdmundD.PellegrinoCenterforClinical,Washington,DC, USA DavidAugustinHodge,NationalCenterforBioethics,TuskegeeUniversity, TuskegeeInstitute,AL,USA NoraL.Jones,CenterforUrbanBioethics,TempleUniversity,Philadelphia,USA TheInternationalLibraryofBioethics–formerlyknownastheInternationalLibrary of Ethics, Law and the New Medicine comprises volumes with an international and interdisciplinary focus on foundational and applied issues in bioethics. With this renewal of a successful series we aim to meet the challenge of our time: how to direct biotechnology to human and other living things’ ends, how to deal with changedvaluesintheareasofreligion,society,andculture,andhowtoformulatea newwayofthinking,anewbioethics. TheInternationalLibraryofBioethicsfocusesontheroleofbioethicsagainstthe backgroundofincreasingglobalizationandinterdependencyoftheworld’scultures and governments, with mutual influencing occurring throughout the world in all fields.Theserieswillcontinuetofocusonperennialissuesofaging,mentalhealth, preventivemedicine,medicalresearchissues,endoflife,biolaw,andotherareasof bioethics,whilstexpandingintoothercurrentandfuturetopics. Wewelcomebookproposalsrepresentingthebroadinterestofthisseries’inter- disciplinaryandinternationalfocus.Weespeciallyencourageproposalsaddressing aspectsofchangesinbiologicalandmedicalresearchandclinicalhealthcare,health policy,medicalandbiotechnology,andotherappliedethicalareasinvolvingliving things, with an emphasis on those interventions and alterations that force us to re-examinefoundationalissues. Moreinformationaboutthisseriesathttps://link.springer.com/bookseries/16538 Eike-Henner W. Kluge The Right to Health Care: Ethical Considerations Eike-HennerW.Kluge DepartmentofPhilosophy FRSC,UniversityofVictoria Victoria,BC,Canada ISSN2662-9186 ISSN2662-9194 (electronic) TheInternationalLibraryofBioethics ISBN978-3-030-93837-6 ISBN978-3-030-93838-3 (eBook) https://doi.org/10.1007/978-3-030-93838-3 ©TheEditor(s)(ifapplicable)andTheAuthor(s),underexclusivelicensetoSpringerNature SwitzerlandAG2022 Thisworkissubjecttocopyright.AllrightsaresolelyandexclusivelylicensedbythePublisher,whether thewholeorpartofthematerialisconcerned,specificallytherightsoftranslation,reprinting,reuse ofillustrations,recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway,and transmissionorinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilar ordissimilarmethodologynowknownorhereafterdeveloped. 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ThisSpringerimprintispublishedbytheregisteredcompanySpringerNatureSwitzerlandAG Theregisteredcompanyaddressis:Gewerbestrasse11,6330Cham,Switzerland ForHeather Preface At first glance, the title of this study—The Right to Health Care: Ethical Considerations—indicates clearly and unambiguously what the study is all about: namely,thatitdealswiththequestionwhether,ethicallyspeaking,healthcareisa right,whatethicalargumentscanbeadducedeitherforanaffirmativeoranegative answer,andwhatconsequenceseachoftheseanswersentails. However, that clarity may be more deceptive than real, for it assumes that the notion of health itself is clear, that the concept of ethics is unambiguous, and that the notion of a right is not open to interpretation. However, there are at least four distinct ways in which the notion of a right may be interpreted: legally, socially, naturally, and ethically. Likewise, “health” may be understood in different ways: statistically, valuationally, and functionally being but three obvious examples; and theterm“ethics”isalsoambiguous:Itmaybeunderstoodfromaphilosophical,a religious,asocial,andevenaculturalperspective. Therefore,aninitialtaskofthisstudyistoprovideclarityaboutitssubjectmatter, whichwillbedoneinthefirstchapter.Morespecifically,thefirstchapterdealswith thenotionsofrights,ethics,andhealth,respectivelyandindicateshowtherelevant termswillbeunderstoodintherestofthestudyandwhytheywillbeunderstoodin thatway.Thefollowingchapterswillthenpresentreasonswhyhealthcareshouldbe consideredarightratherthanacommodity,dealwiththeextentofthatrightandwith whatthisentailsforthosewhoareengagedinprovidinghealthcareinaprofessional oraninstitutionalcapacity.Afinalchapterwillconsiderwhatallofthismeansforthe individualstowhomtherightbelongs:namely,persons.Amongotherthings,itwill besuggestedthattherearecertainobligationsthatbelongtosocietiesinwhichhealth careisprovidedbutthat,bythesametoken,thisalsoimposescertainobligationson themembersofthesocietiesthemselves.Aspecialchapterisdevotedtotheethics ofresourceallocation,bothatthelevelofhealthcareframeworks—i.e.,atthelevel ofpolicyorwhatisoftenreferredtoasmacro-allocation—andatthehands-onlevel, orwhatisoftenreferredtoasmicro-allocation. Thereisconsiderableoverlapbetweenthetopicsthatarediscussedinsomeofthe chapters,whichmeansthatthereisafairamountofcross-referencingbetweenthem. This is both inevitable and intentional. It is inevitable because essentially similar vii viii Preface issuesariseforthevariousplayersinthefieldofhealthcare.Itisintentionalbecause althoughtheissuesaresimilarandsometimeseventhesame,theyariseindifferent ways. This makes it important to discuss how this is the case and what way their respectiveimplicationsdiffer—whichcanbedoneonlybyrelatingthevariousissue toeachother. Moreover,thedifferentchaptersofthisstudytendtobesomewhatrepetitiousin thesensethatessentiallysimilarreasoningisusedtosupporttheparticularclaims that are being made. Again, this is both inevitable and intentional. It is inevitable because,inonewayoranother,thevariousclaimsareallultimatelygroundedinthe sameethicalprinciplesand,beinginterrelated,referencestothesameprinciplesare boundtooccur.Itisintentionalbecausebycitingthesameprinciples,itispossible toshowclearlyhowtheinterrelationshipbetweentheclaimscomesabout,andthat thestudyasawholepresentsanintegratedargumentfortherighttohealthcareand whatthismeans. TheAppendixtothisstudyexpandstheanalysissomewhatbyconsideringwhat implicationstherighttohealthcarehasforcorporationsthatsupplysomeofthetools that are used when providing health care, with particular focus on pharmaceutical corporations. The reason for separating this analysis from the core of the study is that while such corporations are engaged in the field of health care, they are not healthcareprovidersinthestrictsenseofthattermandthereforearenotsubjectto quitethesameconsiderationsthatapplytosocietyitselfortohealthcareinstitutions andhealthcareprofessionals.Thesecorporationsarecommercialentities,andtheir mandateisnottoprovidehealthcarebuttoprovidetheirstockholderswithareturn fortheirinvestment.Thefactthattheydosobydevelopingandsupplyingsomeof the tools that are used in healthcare delivery is merely their way of fulfilling their stockholder-directedobligations. Carehasbeentakentosupportwhateverpointsthataremadeeitherbyindicating whatfactualsupportforsuchclaimscanbefoundorbycitingappropriateauthorities. This has the effect of making the study somewhat reference-heavy. However, this isa study in applied ethics. Applied ethics does not consist indeveloping theories ordesigninghypotheticalsbutinapplyingethicalprinciplestoreallife.Therefore, although hypothetical situations are sometimes constructed, this is only done to illustrate a point when it would be too lengthy to provide an actual example; and although theoretical considerations play an important role in the conduct of the analysis,theyareusedonlytooutlinetheethicalstructureofthevarioussituations. Analmostinevitableoutcomeofthisstudyisthatifthereasoningthatitcontains is sound, then it will challenge the validity of certain healthcare-related practices. That should not be unexpected. Not everything that happens in real life is ethical, policies and laws not being excluded, nor istraditionnecessarily asound guide to whatisethical. Finally, this study deals with the right to health care, not with the right to health.Thismaystrikethereaderaspeculiar,particularlysincetheUnitedNations CommitteeonEconomic,SocialandCulturalRights,inits“GeneralCommentNo. 14”, states that there is a fundamental right to “the highest attainable standard of Preface ix health”,1andinturnbasesthisonArticle25ofTheUniversalDeclarationofHuman Rights. However,asacloserreadingofthecommentshows,therightinquestionisnotthe righttohealthbuttherighttothehighestattainablestandardofhealth.Thetwoare notthesamething.Moreover,whatcountsasthehighestattainablestandardofhealth isfunctionallyrelatednotonlytotheprevailingconditionsinagivensocietybutalso to the resources that the society has available for providing health care; because, as will also be discussed later, there are other types of services that a society is ethically obligated to provide for its members, and each of these types of services is resource-intensive. Consequently, a given society can apportion only a limited amountofitsresourcestoprovidinghealthcare,andtherewillbevariationsinthe levelsandtypesofhealthcareservicesthattheindividualsindifferentsocietiescan claimasamatterofright.Thisinturnmeansthatwhileaso-calleddevelopednation is obligated to provide its members with different—and indeed more—healthcare services and at a higher level than a so-called underdeveloped nation, this is not inherentlyunethical.Theresourcepoolsthatareavailabletothemrespectivelyare simplydifferent.However,itwouldbeunethicalifthevarioussocietiesornations didnotprovidehealthcareservicesatall,oriftheydidnotadheretotheprinciples andconditionsthatwillbeoutlinedinthechaptersthatfollow. Victoria,Canada Eike-HennerW.Kluge 1https://undocs.org/E/C.12/2000/4. Contents 1 ADefinitionalPreamble ........................................ 1 1.1 Introduction .............................................. 1 1.2 Right .................................................... 1 1.2.1 SomeCommonFactors .............................. 2 1.2.2 LegalRights ....................................... 3 1.2.3 SocialRights ....................................... 4 1.2.4 NaturalRights ...................................... 4 1.2.5 EthicalRights ...................................... 5 1.3 EthicsandEthicalApproaches .............................. 5 1.3.1 ReligiouslyBasedEthics ............................. 6 1.3.2 SocialConsensusBasedEthics ....................... 7 1.3.3 LegallyBasedEthics ................................ 8 1.3.4 TraditionBasedEthics ............................... 8 1.3.5 PhilosophicallyBasedEthics ......................... 9 1.3.6 CompetingPhilosophicalTheoriesofEthics ............ 10 1.4 TheNatureofHealth ...................................... 19 1.5 Conclusion ............................................... 21 References ..................................................... 22 2 EthicalTheory:Persons,EthicalRulesandPrinciples ............. 25 2.1 Introduction .............................................. 25 2.2 ThePrinciplesofEthics .................................... 26 2.2.1 RightsandDuties ................................... 26 2.2.2 ThePrincipleofAutonomy ........................... 27 2.2.3 PrincipleofImpossibility ............................ 29 2.2.4 PrincipleofEquality ................................ 31 2.2.5 PrincipleofBeneficence ............................. 34 2.2.6 PrincipleofNonmaleficence .......................... 37 2.2.7 BestPractices ...................................... 39 2.3 Conclusion ............................................... 41 References ..................................................... 41 xi