Duquesne University Duquesne Scholarship Collection Electronic Theses and Dissertations Fall 2010 American Health Care: Justice, Policy, Reform Carolyn Conti Follow this and additional works at: https://dsc.duq.edu/etd Recommended Citation Conti, C. (2010). American Health Care: Justice, Policy, Reform (Doctoral dissertation, Duquesne University). Retrieved from https://dsc.duq.edu/etd/432 This Immediate Access is brought to you for free and open access by Duquesne Scholarship Collection. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Duquesne Scholarship Collection. For more information, please contact [email protected]. AMERICAN HEALTH CARE: JUSTICE, POLICY, REFORM A Dissertation Submitted to the McAnulty College and Graduate School of Liberal Arts Duquesne University In partial fulfillment of the requirements for the degree of Doctor of Philosophy By Carolyn Ann Conti December 2010 Copyright by Carolyn Ann Conti 2010 AMERICAN HEALTH CARE: JUSTICE, POLICY, REFORM By Carolyn Ann Conti Approved October 4, 2010 _________________________________ _________________________________ Aaron L. Mackler, Ph.D. Gerard Magill, Ph.D. Associate Professor Professor Department of Theology Healthcare Ethics Program (Dissertation Director) (Committee Member) _________________________________ Charles J. Dougherty, Ph.D. President Duquesne University (Committee Member) _________________________________ __________________________________ Christopher M. Duncan, Ph.D. Henk Ten Have, M.D., Ph.D Dean, McAnulty College and Graduate Director, Center for Healthcare Ethics School of Liberal Arts Professor, Healthcare Ethics iii ABSTRACT AMERICAN HEALTH CARE: JUSTICE, POLICY, REFORM By Carolyn Ann Conti December 2010 Dissertation supervised by Professor Aaron L. Mackler The American health care system is seriously flawed and in need of reform. American health care is expensive and rationed by the ability to pay. More than forty- five million Americans lack regular access to health care because they have no health insurance and cannot afford to pay for care on their own. An even greater number of Americans have inadequate access to health care because their health insurance provides insufficient coverage. Even well-insured Americans, most of whom get their health insurance through their employers, have problems because their out-of-pocket expenses are escalating while their coverage is shrinking. Contemporary public discourse suggests that many if not most Americans are dissatisfied with the health care system as it is currently structured and are ready for change but are uncertain about how to achieve reform. Although the American people disagree about what a reformed health care system should be they are nearly unanimous iv in their dissatisfaction with both access to and cost of health care. The voice of the American people needs to be focused into a coherent, cohesive message calling for reform and the message must be honed and repeated to exert pressure on the government to act in accord with the will of the people rather than that of special interest groups. This dissertation will address the issue of what the American people can do to effect comprehensive reform of the American health care system, focusing on how to begin the process and not on what the reformed system should be. The thesis of this dissertation is that a social reform movement is in order and might be necessary in order to accomplish comprehensive reform of American health care. The thesis will develop in three parts, examining American health care from three perspectives, justice, policy, and reform. Part One will focus on why reform is necessary. Part Two will focus on why a social reform movement is in order. Part Three will focus on what the American people can do to accomplish the successful reform of the American health care system that has so far eluded the political and legislative processes. v DEDICATION Dedicated to My Beloved Holy Spirit, Who inspired me to begin this journey and guided me at every step along the way… And My very dear friend and mentor, Father Herbert Ryan, S.J., who believed in me more than I believed in myself… And My beloved family: My mother Irene who would not let me quit, My brother Frank, who opened his home to me, and My niece Stacy, who convinced me to get up and dance. vi ACKNOWLEDGMENT I wish to acknowledge the outstanding support of The staff of the Duquesne University Gumberg Library, The research librarians of the Georgetown University Bioethics Center, especially Martine Darragh and Laura Bishop, and The advice, patience, and unfailing good humor of my dissertation director, Dr. Aaron Mackler. vii TABLE OF CONTENTS Abstract…………………………………………………………………………………..iv Dedication………………………………………………………………………………..vi Acknowledgment………………………………………………………………………..vii Part One: Title Page…………………………………………………………………….1 Chapter One: Justice: In Theory, A General Understanding……………………2-36 I. Introduction………………………………………………………………………2 A. Map of Part One……………………………………………………………………….3 B. Map of Part Two………………………………………………………………………5 C. Map of Part Three……………………………………………………………………..6 D. Scope of Part One……………………………………………………………………..7 E. Scope of Chapter One…………………………………………………………………9 F. Golden Rule or Ethic of Reciprocity………………………………………………….9 II. Justice as Theory: A Brief Overview…………………………………………10 A. Justice as a Philosophy……………………………………………………………….12 1. Augustine and Aquinas…………………………………………………………..13 B. Common Threads Unifying Justice as a Philosophy………………………………...13 C. Shared or Minimalist Concept of Justice…………………………………………….14 1. Thin Concept of Justice or Morality……………………………………………..14 2. Locus of Certitude………………………………………………………………..15 D. Recap…………………………………………………………………………………17 III. Social Justice…………………………………………………………………….17 A. Social Justice and Religious Traditions……………………………………………...18 1. Judaism and Social Justice……………………………………………………….18 2. Justice and Catholic Social Teaching……………………………………………20 3. Social Justice and Other Religious Traditions…………………………………...24 B. Social Justice and Secular Political Philosophy……………………………………...25 IV. Distributive Justice……………………………………………………………..29 A. Theories of Distributive Justice……………………………………………………...30 1. Libertarianism……………………………………………………………………30 2. Utilitarianism…………………………………………………………………….31 3. Egalitarianism: Strict……………………………………………………………31 4. Egalitarianism: Qualified………………………………………………………..32 viii V. Justice: Theories of Distributive Justice and Health Care…………………..32 VI. Justice: A Summary ……………………………………………………………33 Chapter Two: Justice: In Practice, Applied to Health and Health Care………37-82 I. Introduction……………………………………………………………………..37 A. Scope of Part One……………………………………………………………………39 B. Recap of Chapter One………………………………………………………………..39 C. Scope of Chapter Two……………………………………………………………….40 II. Developing a Just Health Care System: Practical Considerations………….42 A. Daniel Wikler………………………………………………………………………...42 1. Consensus that Reform Is Necessary…………………………………………….43 2. Equitable Access: What Is Meant by ―Equitable”………………………………44 3. Equitable Access: What Is Meant by ―Access”…………………………………45 4. Priority Problems: Health Care as One of Many Social Goods…………………46 5. Priority Problems: Which Health Care Services to Include……………………..46 6. Priority Problems: Specifying Principles for Choosing Health Care Services….47 B. Norman Daniels……………………………………………………………………...48 1. Special Moral Priority of Health…………………………………………………49 2. Unjust Health Inequalities………………………………………………………..50 3. Meeting Health Needs Fairly under Resource Constraints………………………51 4. How We Should Think about Health and Health Care…………………………..52 5. Benchmarks of Fairness………………………………………………………….53 C. Powers and Faden……………………………………………………………………54 1. Six Essential Dimensions of Well Being………………………………………...55 2. Health Care Financing: Market-Based Health Care…………………………….58 D. Loewy and Loewy……………………………………………………………………60 1. Declaration of Independence…………………………………………………….61 2. Preamble to the Constitution……………………………………………………..61 III. Analysis of Works Examined: Points of Convergence and Divergence…….63 1. Wikler……………………………………………………………………………64 2. Daniels…………………………………………………………………………...64 3. Powers and Faden………………………………………………………………..65 4. Loewy and Loewy………………………………………………………………..66 B. Common Threads and Unifying Factors……………………………………………..67 1. Overlapping Consensus………………………………………………………….67 2. Social Obligations………………………………………………………………..68 ix IV. Is Consensus Sufficient to Support the Need for Health Care Reform?……69 A. Recap: Part One……………………………………………………………………..69 1. Chapter One……………………………………………………………………...70 2. Libertarianism……………………………………………………………………70 3. Utilitarianism…………………………………………………………………….71 4. Egalitarianism: Strict……………………………………………………………71 5. Egalitarianism: Qualified………………………………………………………..71 6. Chapter Two……………………………………………………………………...72 B. Charles Dougherty…………………………………………………………………...73 1. Moral Duty to Render Aid……………………………………………………….74 2. Plural Foundations……………………………………………………………….75 3. Modified Social Contract: Right to Health Care………………………………...76 C. Larry Churchill……………………………………………………………………….77 1. Egalitarian Theories……………………………………………………………...77 2. Utilitarian Theories………………………………………………………………78 3. Libertarian Theories……………………………………………………………...78 4. Plural Foundations for a Right to Health Care…………………………………...79 V. Conclusion………………………………………………………………………81 Part Two: Title Page…………………………………………………………………...83 Chapter Three: What Others Have Done……………………………………….84-131 I. Introduction……………………………………………………………………..84