Why should we consider health equity? The rationale for treating health as a special good rests on the idea that a certain level of health is a precondition for achieving any of the other outcomes in life that we value. Sen identifies that health contributes to a person’s ability to choose the life she has reason to value. Our functioning is impaired by disability and particularly by death; Andrew Marvel writes in a 1681 poem, ‘The grave’s a fine and private place,/ But none, I think, do there embrace.’ As such we value health equity, but what then is the role of healthcare in promoting health equity?
In the UK we take pride in the idea of a health service that provides healthcare only on the basis of need. It is important then that there is equitable access to healthcare; everyone should have an equal capability of benefiting from that health care. It would be a poor state of affairs if socioeconomic variables, such as income, determined a person’s access to healthcare rather than need. But socioeconomic factors do determine need. As an example (there are many examples to have, consider much of the work by Sir Michael Marmot), women from areas of high deprivation are far more likely to have premature, sick babies (see here) but given the characteristics that determine need (such as gestational age, congenital anomalies etc.) the provision of care and rate of mortality is the same (see here). So deprivation goes some way to determining the characteristics that affect mortality but not the access to care or clinical outcomes conditional on need. We might therefore judge healthcare to have played its role in health equity; the social issue of health inequalities is not a concern for healthcare since there is nothing it can do beyond treating patients fairly.
It is quite possible to argue that we should favour poor people since this would reduce overall health inequalities in the whole population. Alan Williams’s idea of a ‘fair innings’ would seem to support this. The fair innings argument says that everybody has a right to a certain quality adjusted life expectancy and we should favour interventions to support this. But, as Williams points out, there is a gender difference in health outcomes; women live longer than men. As Williams says ‘We males are not getting a fair innings!’ But we certainly would object to a system where we systematically favoured men over women; health equity cannot be judged in isolation of ideas of fairness.
One of the most pervasive arguments against cost-effectiveness analysis (CEA), and utilitarianism in general, is that it is distribution blind. Williams’s argument was an attempt to find a solution to that. But in terms of equity in relation to socioeconomic factors, the poorest are normally the sickest (whichever way the arrow of causality may lie). The current system does not favour the sickest; a gain of 0.2 QALYs is treated the same for a person at 0.1 or 0.7 QALYs. Derek Parfit suggests that one way of reducing inequality would be to reduce the standard of those at the top. However, while this may increase equality we would not say that this contributes to equity in any meaningful way, and would soon reject this as a solution. This would imply that we would rather help those at the bottom of the distribution as a means of reducing inequality. So why should we not favour the sickest? It not only appeals to our sense of justice but would reduce socioeconomic health gaps too.
But could the argument above be extended to systematically favouring the poor in healthcare settings? No, because this would be unfair, not only at the individual level but also for healthcare practitioners. It would place an unfair moral burden on a doctor to treat those on the right side of an income threshold.
So I would say then that the role of healthcare should be to provide equitable access to healthcare resources, but that this should entail providing resources that favour treatment for the sickest since this would be a policy that would favour the poorest without placing any unfair restraints on practitioners or patients.