The Nhs's 50th Anniversary As others see us: views from abroad

Justice and health care in a caring society

BMJ 1998; 317 doi: (Published 04 July 1998) Cite this as: BMJ 1998;317:53
  1. Grant Gillett, professor in medical ethics. (
  1. Department of Neurosurgery, Otago Medical School, University of Otago, PO Box 913, Dunedin, New Zealand

    Concept of a national health

    The NHS was founded on the idea that every person, regardless of wealth or position, would have access to excellent health care. The ethical position expressed in this idea is the kind of commitment that one finds in a society that accepts a role in caring for its citizens. This ethical intuition we could call the “caring imperative,” recognising that it is the hallmark of a civilised society. When we look at the underpinning of such a commitment in political philosophy it is found to rest on a judicious balance of liberal concern for individual autonomy and property and a Marxist concern for social justice.

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    Such a liberal position on welfare accepts the liberal economic principle—respect for personal choice and the right to disposal of income according to individual preference—but also accepts that the individual owes some dues to the community as a whole. One might justify this attitude by appealing to the fact that a society is given its character by the participation of all those who share in creating it, however small their contribution may be. In fact, most of us want to live in a society where the caring imperative operates and the good health of the citizens is thought to contribute to the wellbeing of all. Health care, from this view, is a public good in that its benefits are shared rather than exclusively individual or private (although they also directly benefit the individual). Without a national health service the burden of illness falls on those who suffer the unpredictable vicissitudes of life, and the implicit laissez-faire attitude to the resultant suffering both represents a deterioration in the overall quality of society and exposes individuals to the risk of being caught out by the cruel chances of disease and injury.

    Summary points

    The ideal of access for all …

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