Justice

The justice principle can be broadly defined as “fairness.” It is exemplified by the Aristotelian ideal that people in similar situations ought to be treated similarly, and people in different situations should be treated differently. A distinction is sometimes made between  distributive justice, which refers to the allocation of resources, and  procedural justice, the fairness and transparency of processes by which decisions are made.  The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, prepared by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979), offers guidelines on ethical principles; it states that “[a]n injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly”. This may occur in the clinic or in research. For example, there is some evidence that persons who are poor and thus have less access to care and information about options may also have less access to clinical trials. They also have less access to the benefits of findings and to drugs that are approved as a result of such studies. Charges of injustice regarding access to research involving women have also been made; women have proportionately been less often represented as research subjects. Data also indicate that persons belonging to some racial groups are treated differently when they appear at an emergency department (James et al., 2005; Selassie et al., 2003). Statistics have consistently shown differences in life expectancy by socioeconomic status (National Center for Health Statistics, 2012).

In 1971, the leading American political philosopher of the 20th century, John Rawls, wrote A Theory of Justice, a highly influential book that advances the idea that the best principles of justice are those that we would all agree to if we were all impartially situated as equals. This he arrives at through his famous thought experiment “the veil of ignorance,” in which we are asked to imagine an “original position” from which no one was better situated than anyone else (or at least that we’d be ignorant of any inequalities in such a utopian state-of-affairs).

A Rawlsian approach to distributive justice and health care ethics is one based on fairness. Therefore, even in cases where not everyone will have access to a certain good because it is scarce, there needs to be fair opportunity of access to the benefit. For Rawls, fair access was ensured by formal procedures that were themselves required to be fair. This leads us to the concept of  procedural justice.

In order for the justice principle’s requirements to be met, any formal procedures or mechanisms by which people attempt to decide dilemmas must be fair and just, or  equitable. Procedural justice requires that policy makers craft regulations, laws, and formal procedures that are free from bias that would render them inaccessible to some, or that would unduly restrict the chances of fair treatment for others. For example, a policy that recognizes employees’ rights to opt out of procedures when they have a strong conscientious objection states that employees must provide documentation in writing to the supervisor at least two weeks prior to the event. But given the nature of acute care, in which the unexpected happens routinely, how can a nurse know in advance that something will be demanded of her that strongly violates her conscience? When this issue came up in a local hospital, human resources had the policy rewritten to accommodate reality. Hospitals and nursing homes have to be clear about nurses’ rights and duties. For example, a policy might state that a nurse who has a strong moral objection to terminal extubations could be transferred to a unit where this procedure will not likely occur. Other policies might call for less supportive measures such as unpaid leave; such options could  trigger a union dispute.

Justice is a fundamental principle for health care administrators and practitioners—particularly in their responsibilities to make resource allocation decisions—and among those who work toward eliminating health inequities. The justice principle impacts many other day-today decisions that health care managers make. Examples include policies regarding unionization, working con