Health care: a social contract in transition

Health care reform around the world is born in considerable measure of the need to reconcile our growing capacity to provide effective health care with diminishing economic means to sustain this capacity indefinitely. It is precisely under these circumstances that the conflict between individual rights to health care and the state's responsibilities to provide it becomes unavoidable. Although it cannot be eliminated, the conflict can be managed. But the task requires us to go beyond formulating economic policies or designing new structural systems for delivering health care. It requires an understanding of the purpose of health care for individuals and society. It includes stipulating limitations for individual rights and state responsibilities. Because of these limitations, the task must be guided by the requirements of justice. Health care as both a private and common good is at the center of a distributive struggle. At one level the focus of this struggle is economic and political. At another level it is moral and revolves around the concept of health itself, considered in its biological, psychological and social dimensions. Here the issue becomes health as a right, together with the implications such a right has for our efforts to balance the freedom of individual health-related behavior with the interests of the public's health. What, in that balance, are the rights of the individual and the responsibilities of the state? Can the individual citizen hold the state accountable for securing the conditions necessary for health? Can the state hold its citizens accountable for irresponsible health-related behavior? A discussion of providing liver transplantation sheds considerable light on these questions, while suggesting a paradigm for use with general health care services. Central to this paradigm is the welfare concept of right, balanced by the understanding that a citizen's claim on health care services is limited. In the final analysis, justice in health care will be achieved through a division of labor, at the center of which there is a set of reasonable and binding expectations shared reciprocally between the individual and the state.