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Most theories of health care justice account inadequately for hospice. They tend to regard death as an external force rather than as something to be integrated into an overall theory of care. They tend to be very individualistic. And they tend to assume relationships of equal power among independent agents whose conception of justice is the delineation of fair rules.
Yet for most of health care, and especially for the care of the dying, these assumptions make no sense. First, as hospice workers know well, death can be a friend. Second, health care is consummately about relationships. Hospice workers also understand this clearly. Third, health care relationships, especially in attending to the dying, are characterized by profound inequality, dependence, and loss of control. And in the face of sickness and death, the ultimate question is whether life itself, not any rules, is really fair.
To account for these clinical realities, an adequate theory of health care justice must have something substantive to say about human beings. Here, I will merely assert that human beings are characterized by three features that are especially relevant. First, as Aristotle insists, human beings are naturally social. This is sometimes referred to as a principle of social solidarity. Second, human beings are finite. Death is an intrinsic element of our humanity. Theories of health care justice must take human finitude seriously. Third, human beings have a radically equal intrinsic worth or dignity that commands the respect of others, independent of our preferences.
A human need many be defined as something required for human flourishing. Indisputably, the finitude of the body of each and every human being is both the limiting term of all possible individual human flourishing and also precisely the need that medicine, nursing, and the other health care professions serve. Health care professionals all profess publicly to serve the needs of those whose bodily finitude renders them vulnerable, diminished in power and control, and unable to help themselves. Health care professionals recognize the claims made on them by the dignity of the sick and by their own solidarity with them.
The finitude that the health professions address manifests itself in three ways - death, disease or injury, and symptoms. These correspond (roughly) to the traditional medieval aphorism about the goals of medicine - "To cure sometimes, to relieve often, and to comfort always."
Meeting these needs requires resources. But the resources human beings may use to serve each other in their unequal bodily finitude and their equal human dignity are always scarce. By what criteria can one judge how best to apportion scarce health care resources in order to promote human flourishing? This is a question of justice, and justice requires criteria by which to make such judgments. I suggest six material considerations. The first five are commonly involved in discussions of scarce medical resources, but are not usually considered in the context of human finitude, dignity, and solidarity. The sixth is almost never considered except as the sum of the other five. These material considerations are (1) individual need, (2) prevalence, (3) prospect of success, (4) alternatives, (5) cost, and (6) contribution to the common good. For the sake of illustration, let us compare flu shots, liver transplants, and hospice according to these material considerations.
This exercise suggests that, weighing all these material considerations, hospice compares well with prevention and high-tech medicine. Hospice can claim, in justice, significant medical resources vis-à-vis other medical interventions. Human flourishing is well served if people do not die miserable deaths, both for the individuals themselves and the community with which those individuals are in solidarity.
As evidence, one need only look to the poorest of poor nations. Those with no resources palliate, as best they can, their dying kinspeople. Ask any clinician what he or she would take to a desert island. I suspect the list might include aspirin, morphine, two antibiotics, a few vaccines, and a textbook of surgery. These are the fundamentals. To palliate the dying is to give them their due. This is what we owe each other, out of mutual respect for our common dignity and in solidarity with each other as fellow mortals. As a matter of justice, hospice is the least we can do.
Daniel P. SulmasyDaniel Sulmasy is Sisters of Charity Chair in Ethics at St. Vincent's Hospital Manhattan and director of the Bioethics Institute of New York Medical College.
This essay appears in the report Access to Hospice Care: Expanding Boundaries, Overcoming Barriers.
Cite As: Daniel P. Sulmasy, "Health Care Justice and Hospice Care," Hastings Center Report Special Supplement 33, no. 2 (2003), pp S14-S15.