Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Doctor of Philosophy

Program

Philosophy

Supervisor

Smith, Maxwell

2nd Supervisor

Skelton, Anthony

3rd Supervisor

Jones, Charles

Abstract

Existing accounts of health justice operate one or more steps removed from the practical difficulties inherent to providing healthcare services across a territory as vast and diverse as Canada’s. This is, in part, because the philosophical examination of health justice has largely failed to appreciate an important level of decision-making between the macro level of healthcare delivery, responsible for funding, priority setting and system design, and the micro level, responsible for clinical, bed-side care. The meso level, situated between the two, is where scarce healthcare resources are allocated according to the priorities set by the macro level, to be utilized for patient care by micro level. Allocative decisions made at the meso level are, in large part, responsible for inequities of the sort that motivate this dissertation and, as such, require normative guidance, if justice is to obtain.

This dissertation begins with and argument for, and defense of, a meaningful distinction between the ‘big’ and ‘smaller’ problems in the just allocation of scarce healthcare resources. A gap exists between what a publicly-funded healthcare system owes the population (e.g., as a result of legislation, or as a matter of justice) and what the healthcare system can deliver once constraints (e.g. human, financial) are considered. This is the ‘big’ problem. How a healthcare system goes about allocating scarce healthcare resources in light of that gap is a distinct, ‘smaller’ problem, that disproportionately affects rural communities.

The ‘smaller’ problem is then situated at the meso level of healthcare delivery, a level that has, to date, been largely ignored by philosophers, or conflated with other levels. I proceed to show that adequate normative guidance does not yet exist for the just allocation of scarce healthcare resources by meso level actors.

Finally, consideration is given to how this lack of normative guidance might be addressed. I argue that arriving at suitable normative guidance will not be achieved by simply working out details based on principles and methods contained in existing theories or approaches to health justice. The dissertation concludes with an examination of fairness contractualism as a possible means of generating normative guidance.

Summary for Lay Audience

It is no secret that Canada’s healthcare system is coming under ever greater strain. Emergency room closures, specialist wait times and lack of primary care are well documented problems. As more Canadians go without the care promised to them by the Canada Health Act, a secondary problem begins to emerge. The distribution of shortages and closures is not equal.

Rural communities, in particular, bear the brunt of system-level scarcity. My project explores how these decisions are made, and what kind of ethical guidance healthcare system administrators would benefit from in order to make the allocation of scarce healthcare resources fairer.

At present, there is little ethical guidance for healthcare administrators to draw upon. I propose viewing allocative decisions as small instances of social cooperation, and applying fairness contractualism to address the problem. Fairness contractualism imagines what a group of people would agree to, if they bargained from positions of equal strength. The agreements the contractors come to in these hypothetical situations should help to guide healthcare administrators make fairer allocative decisions, to the benefit of all Canadians.

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