What makes a just healthcare system?

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7072.1567 (Published 21 December 1996) Cite this as: BMJ 1996;313:1567
  1. Solomon R Benatar
  1. Professor Department of Medicine and Bioethics Center, University of Cape Town and Groote Schuur Hospital, Observatory 7925, Cape, South Africa

    Broader professional ethics, including considerations of the public interest and the common good

    After the first world war, many industrialised countries fostered publicly supported sickness insurance, realising that equitable access to health care could improve the health of their populations. By the early 1970s, universal health coverage had been achieved in Europe and the developed countries of the former British Commonwealth.1 Within the developed world, the United States was a striking exception, and this anomaly led to comparisons with South Africa, a country riven by racial policies, which had also turned its back on a national health system in the 1940s.2 Since the 1970s the pendulum has swung in many countries towards privatisation and managed care, no doubt at least in part due to American influence. Interest in universal access to health care in the United States at the start of the Clinton era was short lived at a time of resource constraints and was soon eclipsed by a renewed thrust towards managed care.3 While the potential impact of managed care remains hotly debated,1 4 the question of what constitutes a just healthcare system has not been adequately addressed.

    Privatisation of health care, seen by many as a panacea in the face of resource constraints, is usually attacked by critics on two fronts: firstly, as failing to achieve the benefits invoked to justify it (greater choice for consumers and providers, increased efficiency, and higher quality of services); and, secondly, as being destructive of the physician-patient relationship.5 There is evidence that privatisation of health insurance is costly, has growing administrative costs, offers less rather than more choice for consumers and providers, and fails to improve the quality of care.6 In a masterly presentation on American health care, Professor Allen Buchanan, professor of philosophy at the …

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