Health, Capability, and Justice: Toward a New Paradigm of Health Ethics, Policy and Law

Abstract:     
This Article offers an alternative theoretical framework for health ethics, policy and law, integrating both substantive criteria and procedural mechanisms - a joint scientific and deliberative approach - to guide health-system reform and allocation of scarce health resources. It appeals to a particular vision of the good life: human flourishing, which values health intrinsically and more highly than non-intrinsic or solely instrumental social goods, such as income. This view gives special moral importance to what I have called health capability. Health capability constitutes a person's ability to be healthy; it includes health functioning and health agency. This paradigm sketches a joint scientific and deliberative approach, employing a public scientific process that combines the evidence base of medicine and public health with the expert opinions of physicians and public health experts with input from individuals. This view contrasts with paradigms in which consumers alone, physicians or public health experts alone, strict algorithms or cost-benefit calculations, shared decision making within an informed consent model, fair procedures, or third parties, such as insurers, make health care decisions. The main focus of the article is on what I call shared health governance, a paradigm in which individuals, providers, and institutions work together to empower individuals and create an enabling environment for all to be healthy. Shared health governance extends beyond the individual patient-doctor relationship to the institutions that oversee the health sector. Shared health governance incorporates individuals' decisions for themselves and for their society at large. This shared health governance model can potentially improve individuals' health and health agency and decrease costs. Evaluation must consider costs because we live in a world of scarce resources and every resource has an alternative use, so its expenditure corresponds with an opportunity cost. Therefore, some limits are necessary and individuals and society, through shared health governance, must use these resources parsimoniously by evaluating both equity and efficiency.

Keywords: capability approach, Amartya Sen, public health, public policy, justice

JEL Classifications: H51, H53, I18, I00, K32

Accepted Paper Series