Applying Norman Daniels’ Theory of Justice for Health to the U.S. Healthcare System

In recent elections, the question of unequal access health care in the US and its implications on health equity and justice appears to have precipitated roughly along party lines — one side evoking xenophobic and aporophobic images of the unhealthy poor “freeloading” off of model hardworking American citizens, and the other side erupting against a profiteering system feeding off the suffering and destruction of disadvantaged bodies. Notably, each argument addresses a role played by low socioeconomic status — either being a somehow earned condition from which sick patients should “lift themselves up by their bootstraps” so that they can pay for their care fair-and-square, or a coercive and cost-prohibiting life circumstance that prevents sick patients from accessing necessary care. What each of these perspectives share is that one’s low SES and health status meet primarily in the doctor’s office. At the moment a person becomes ill, their health potential becomes subject to whether or not they are able to afford their care. By implementing Norman Daniels’ liberal egalitarian theory of justice in healthcare, we may complicate both perspectives and view the individual’s interaction with healthcare more completely as existing in a social, cultural, and economic matrix of health-determining factors that begin at birth and permeate the formation of the individual’s health status and potential. Furthermore, we may come to better understand the failings of federal programs which have attempted to bridge the healthcare gap.

In Just Health, Norman Daniels expands upon arguments which frame justice in health care in terms of equal access to formal healthcare, i.e. medical care and treatments (Daniels). In doing so, he highlights the roles of “socially-controllable” factors laid over individuals’ identities which contribute to obstructing or facilitating their access, not only to health care, but to health. Daniels concludes that this necessarily constitutes injustice because health comprises a gateway to accessing opportunity, which, according to John Rawls’ basic liberties upon which Daniels builds his analysis, ought to be distributed equally amongst people. By including access to nonmedical resources among his health needs, Daniels introduces a means of connecting diverse forms of inequality — economic, geographic, racial, educational, etc. — to health injustice. All forms of injustice which limit one’s access to health limit one’s access to opportunities contingent upon health. Applied, this would allow us to recenter our focus away from applying expensive treatments to acute illness and onto creating conditions that promote healthful living.

One example where we are able to see the utility of such a model of justice in healthcare persists in the assignment and support criteria surrounding kidney transplantation. Particularly in our nation’s current climate of predatory costs of care, kidney disease offers a uniquely informative vignette as the only disease singled out for federal funding in Medicare (Levine). This funding was originally conceived to cover a relatively small number of patients with genetically-linked polycystic kidney disease, but has followed U.S. health trends and now predominantly funds the treatment of patients with renal failure following diabetes and hypertension. This allotment of Medicare funding specifically covers the costs of dialysis while the patient waits for a donated kidney to become available, covers the cost of the transplantation, and significantly defrays (80%) the cost of necessary immunosuppressants for three years following the transplant (Gordon, Prohaska and Sehgal).

Although this appears to be an exceptional example in which patients in renal failure are all given access to gold standard of care, the government having thoughtfully leveled the financial playing-field, the reality is less inspiring and much more complex. Unfortunately, for many low SES patients, when their three years of coverage for immunosuppressants end, they are often unable to pay for the cost, now increased by 500%. They are forced off of their immunosuppressants — the only thing preventing their body’s immune system from rejecting and destroying the donor kidney. Of course, the rejected kidney fails, and the patient is once again reliant on dialysis for survival — not an ideal health outcome, but at least Medicare will once again cover the cost of dialysis until another kidney (which is rare) becomes available to them. What this cycle frequently demonstrates is that the lack of access to intensive, monitored care is not the only thing standing between kidney patients and their cure; rather their decreased economic access makes them patently unequipped to provide for their lifelong medical needs following transplantation (Gordon, Prohaska and Sehgal).

Where this current system fails most disappointingly, though, is in how this reality has been interpreted by transplant providers and redoubled in its negative impact on low SES patients. This phenomenon by which low SES patients are more likely to “allow” their transplanted kidney to fail counts against the same patients in the criteria by which donor organs are allocated. Most significantly, the criterion of “graft survival,” which reasons that, since donated organs are an immensely limited and valuable resource, they should be preferentially placed in recipients whose situation — medical and otherwise — will offer the organ the greatest chance at survival, so as not to “waste” the donation (U.S. Department of Health & Human Services). To accomplish this, veiling factors such as “financial and social support, [and] patient adherence” are named to identify patients less “worthy” of a lifesaving transplant without directly singling out uninsured and low SES patients. So even while these patients experience subsidized access to the procedure, their access to health remains out of reasonable reach due to unjust distribution of socially controllable factors.

This realization ought to weigh heavily on voters as they consider proposed formulations of subsidized and universal healthcare. Can healthcare truly be universal — guaranteed by the state — while other unaddressed disparities undermine the health potential of certain groups? Furthermore, can such a system sustain itself when unhealthy living conditions and economic realities essentially “waste” medical efforts, as demonstrated by the transplant case?

Works Cited

Daniels, Norman. Just Health: Meeting Health Needs Fairly. Cambridge University Press, 2008.

Gordon, Elisa J., Thomas R. Prohaska and Ashwini R. Sehgal. “The Financial Impact of Immunosuppressant Expenses on New Kidney Transplant Recipients.” Clinical Transplantation 22.6 (2008)): 738–748.

Levine, Carol. “The Seattle ‘God Committee’: A Cautionary Tale.” Health Affairs (2009): Project HOPE.

U.S. Department of Health & Human Services. Organ Procurement and Transplantation Network. “Ethical Principles in the Allocation of Human Organs.” 2015



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