post by Paul Kelleher
In “Playing Fair: Fairness Beliefs and Health Policy Preferences in the United States,” Julia Lynch and Sarah Gollust draw on survey data “to describe Americans’ beliefs about fairness in the health domain.” Here are the authors’ two central findings:
- “Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes” (where life expectancy is the key outcome).
- People who say health care is the social good most crucial for a “good life” also tend to hold that “health care is not important mainly because it provides opportunities to get ahead in life, but because the outcome it affords—‘to be in decent health’—is a right in itself” (my emphasis).
I believe there is reason to question each of these findings.
Lynch and Gollust report that 70+ percent of respondents said inequalities in health care are unfair, “while only 31 percent perceived health status inequalities to be unfair.” But they immediately issue an important qualification:
We suspect that the magnitude of this gap may be at least partially due to a priming effect, as respondents were asked to consider causal responsibility in advance of the fairness evaluation in the life expectancy vignette but not in the health care vignettes. Considerations of blame and fault were thus likely to enter more strongly into judgments about the fairness of inequalities in life expectancy.
This qualification raises clear questions about Finding 1; it also introduces a problematic tension between Finding 1 and Finding 2. Here’s what I mean. Finding 1 (and its subsequent qualification) suggests that respondents’ were sensitive to facts about blame and fault: they saw little unfairness when an individual's poor health status was his own fault. But Finding 1 also suggests that respondents care that individuals receive equal access to the health care system. The best explanation of these two facts is that respondents believe, first, that individuals should have fair opportunities to be healthy (which requires equal access to health care), and, second, that there is no unfairness if individuals squander those opportunities. But then Finding 2 claims that respondents who say health is central to a good life care most about health outcomes, not health opportunities. This tension in the Findings needs an explanation.
I believe the tension stems from a faulty conceptual scheme employed by the authors. Crucially, Lynch and Gollust did not present their respondents with questions cast in the language of "outcomes" and "opportunities." Instead, respondents who said health care was crucial to a good life were asked the following question:
Some people think that health care is mainly important because it ensures that each person in society has an equal chance to get ahead in life. Other people think that having access to health care is mainly important because in a good society everyone has a right to be in decent health. Other people’s opinions lie somewhere in between. Where would you place yourself on this scale?
Lynch and Gollust refer to this as the "opportunity-outcome scale," but again the respondents were never presented with that language. Moreover, there is a more plausible way of characterizing the scale that casts both poles in terms of opportunity. Consider:
Probabilistic Opportunity: Everyone has an equal chance to get ahead.
Example: Lottery Ticket
Access Opportunity: Everyone has a right to have/be/do something.
Example: The right to vote
If everyone possesses one lottery ticket, then everyone has the same chance of winning. This is a kind of opportunity that each of them has; those who don’t have tickets don’t have an opportunity to win. Call this probabilistic opportunity.
Contrast probabilistic opportunity (having an equal chance) with what I call access opportunity, as exemplified by the right to vote. Voting is something that (I shall assume) each and every citizen can access if s/he wants to do it. But since this is a right they have, and not something they are forced to do, the effective opportunity to vote can be refused or squandered.
We can now resolve the apparent tension between Finding 1 and Finding 2. Respondents who said health care was crucial to the good life said it was crucial because everyone has a right to health. We now see, however, that it is possible both to enjoy a right to health—i.e. have access to a healthy life—and to squander it. This suggests that when respondents say individuals have a right to be in decent health, they are not saying they want everyone to face the same health outcome. Rather, they want everyone to have access to a healthy lifestyle. If individuals wish to squander the opportunity bestowed by that access, that is their own fault and there is no unfairness in the outcome. The tension is resolved because Finding 1 and Finding 2 each identifies a commitment to a conception of equal opportunity; no evidence of a commitment to equal outcomes is ever adduced.
Because they use a flawed conceptual scheme, Lynch and Gollust claim that Americans care most about equal outcomes and that “political appeals for health care equity may not rely primarily on norms of equal opportunity, as some authors suggested.” Here they call out philosopher Norman Daniels, who has indeed argued over many years that justice in health and health care rests on a principle of equal opportunity. As I have explained, I think Lynch and Gollust are wrong to characterize respondents’ belief in a right to decent health as a commitment to equal outcomes, rather than to equal (access) opportunities. I therefore see no reason to believe that these respondents would have bridled when, moments before health care reform passed the House, Nancy Pelosi proclaimed:
Health care reform and education: equal opportunity for the American people…And this legislation tonight, if I had one word to describe it, would be “opportunity.”