NORMAN DANIELS

THE BIOMEDICAL MODEL AND JUST HEALTH CARE:

REPLY TO JECKER

I would like to make a small plea for truth in advertising. Despite

her title, Nancy Jecker not only does not advance a theory of

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justice between age groups, but her criticisms of my work do not
touch on what I take to be distinctive about the age-group
problem. Before replying to her criticisms, which really focus on
my use of a biomedical model of disease and disability in my
account of just health care, I want to explain this remark.
I was led to think about justice between age groups because I
wanted to show that my fair-equality-of-opportunity account of
just health care was not age-biased. Nevertheless, what is distinc-
tive about my approach to the age-group problem, the Prudential
Lifespan Account, can be separated from my fair-equality-of-
opportunity approach to health care. Justice between age groups
is a distinctive problem because we age. We can be treated equally
as persons, even if we are treated differently at different ages,
provided the policy for treating us remains stable over our
lifespan. Because differential treatment by age does not neces-
sarily generate inequalities between persons, unlike differential
treatment by race or sex, the age-group problem is distinctive.
Indeed, each of us may be able to benefit if we are treated dif-
ferently - but prudently - at each stage of life. It is this observa-
tion that underlies my suggestion that prudently allocating
lifetime fair shares of such goods as health care or income support
between the stages of life should be our guide to what is a just
distribution of goods between age groups.1 This account is not
specific to health care, and even if someone rejected everything
about my fair-equality-of-opportunity account, the general
approach to the age-group problem would remain untouched.
Jecker misses this point. She confuses the perfectly general
approach to the age-group problem with my specific application

Norman Daniels, Ph.D., Professor, Department of Philosophy, Tufts University,

Medford, Massachusetts 02155, U.S.A.

The Journal of Medicine and Philosophy 14:677-680,1989.

© 1989 Kluwer Academic Publishers. Printed in the Netherlands.
678 Norman Daniels

of it to health care, using the fair-equality-of-opportunity account.

Her central arguments are aimed entirely at my use of the biomedi-
cal model of disease and disability and its implications for an
account of our social obligations to meet health care needs, and
she offers no criticism of the Prudential Lifespan Account itself. I
turn now to these criticisms in her Sections in and IV.2
Some philosophers of medicine have criticized the biomedical
model on which I draw (Daniels 1985, Ch. 2) on the grounds that

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the notion of disease is a value-laden concept, not the objective,
theoretical notion presupposed by the biomedical model, and
Jecker seems to agree with these criticisms. But whatever the
merits of those criticisms, they are different from Professor
Jecker's complaint. Professor Jecker's central argument is that my
appeal to the biomedical model smuggles in particular concep-
tions of what is good in life, whereas the choice situation in which
people agree on principles of justice should use a thin conception
of the good that is neutral, not biased in this way. She also sug-
gests that the results of prudent choice under my constraints fail
to match our considered moral judgments in reflective equi-
librium. I think neither criticism is successful.
There are uses of medical technology which may be important
to some individuals, or even to society, but which will not be
thought of as meeting health care or medical needs. Cosmetic
surgery and non-therapeutic abortion are two examples (noted in
Daniels 1985: 30-31). The biomedical model draws some distinc-
tions here which capture distinctions we generally make and
accept: insurance companies do not reimburse for purely cosmetic
surgery (or hair transplants), though they do for reconstructive
plastic surgery. Most people, including most feminists, do not
conceive of a pregnancy, even an unwanted pregnancy, as a
disease or as manifestation of a disability. If we allow every
matter of mere taste or preference that requires a use of medical
technology for it to be satisfied to be something which counts as a
"health care need/' then we open the door to a very general
problem in the theory of justice, the problem of expensive tastes.
Not every expensive preference of an individual, even if the
individual thinks satisfying the preference is important to her
well-being, gives rise to claims on social resources. If the
biomedical model draws a line where we have some good reason
to draw it, at the same time closing the door on one aspect of the
expensive taste problem, then so much the better for it. In any
 The Biomedical Model and just Health Care 679

case, if it is correct philosophical analysis of the concept of disease,

then there can be no objection merely because it has a greater
effect on some views of what is good in life than on others.3
Where we think that meeting a non-health care need with
medical technology is of considerable moral importance, as I think
it is in the case of publicly funded abortions for Medicaid patients,
we should have other reasons available than merely saying that an
unwanted pregnancy is a disease. If we agree that women should

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have effective control over their lives, including over the timing of
pregnancy, then we have compelling reasons for publicly funded
family planning and abortion services. But that is not because
some pregnancies are diseases (Daniels: 1985:32). Similarly,
keeping such abortions legal may be a very important preventive
health measure, since women will otherwise die from back-alley
abortions; but here too it is not the unwanted pregnancy that is
the disease, but the effects of unsafe abortions.
Professor Jecker argues that the results of choices made by my
prudent deliberators would not match our considered judgments.
Her key example is the suggestion that, because it is "normal" to
lose some memory in old age, a drug that improved memory late
in life would not really meet a medical need on my account. In
fact, I think it is important to draw some line between tech-
nologies which change the baseline of normal species functioning
and those which keep people up to it. But this may not even be
what is at stake in Jecker's example. Loss of memory may be
statistically frequent without it counting as normal, for normality
as I use it is not just a statistical notion (indeed, dental caries may
be nearly universal but still be diseases). How normality is to be
distinguished from a merely statistical notion is a complex issue in
the philosophy of biology, but the biomedical model does not rest
on simple errors about the nature of species-design, as Jecker
suggests.4 I believe the notion of species normal function can be
made compatible with any evolutionary picture that is reasonable
to accept about genetic drift, speciation, etc.5
One last point: I take great pains to suggest that the fair equality
of opportunity account does not imply that every technology that
meets a health care need is of comparable importance. First,
impact on opportunity range is a rough measure of the impor-
tance of a particular medical technology. Second, many high-cost
technologies whose "opportunity costs" are too high are not
things which people can claim entitlements to on grounds of
680 Norman Daniels

opportunity. I never argue that meeting a health care need is a

sufficient ground for something being included in a properly
designed health care system. So the point of the argument about
artificial hearts escapes me.6

NOTES
1
The prudent reasoning I think is appropriate for the task of solving the age-

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group problem rests in information restrictions that are similar to Rawls', but the
justification for these restrictions derives from considerations of prudence and
not from the construction involving "free" and "equal" moral agents that is at the
center of Rawls' liberalism. Jecker does not note this important difference, and
much of her description of the methodological restrictions on my account is
therefore inappropriately imported from discussions of Rawls.
2
I caution the reader against a misstatement of my position in her Section II. I
never offer a "principle of age rationing," as Jecker implies, and certainly do not
accept one that says age rationing is permissible "whenever we can accomplish
an increase in our chances of living a longer-than-normal lifespan only at the cost
of reducing our chances of reaching a normal lifespan."
3
The notion of neutrality that Jecker appeals to is clearly too strong. The laws of
physics may have a different effect on some plans of life than on others, but that
does not mean they cannot be used by Rawlsian contractors because they are not
neutral in effect. Liberalism does not require that we turn the world upside down
in order to be neutral in effect. Rawls (1988) clearly rejects this notion of
neutrality. In any case, as I noted earlier, my argument for the fair equality of
opportunity account does not presuppose Rawls' theory; nor does the Prudential
Lifespan Account.
4
In fact, Jecker seems to confuse genotype and phenotype when she suggests
that tooth decay may be part of the "innate design of the species"; in an environ-
ment containing fluoride, caries are not even frequent.
5
I am also puzzled by Jecker's unwarranted inference that, if reproductive
organs have a species-typical function, homosexuality is a disease.
6
Jecker is way off the mark when she suggests that I automatically would prefer
funding artificial hearts to developing safe contraceptives or preventing teen-age
pregnancy. Since my theory emphasizes preventive health measures, it gives
clear priorities in the opposite direction.

REFERENCES
Daniels, Norman: 1985, Just Health Care, Cambridge University Press.
Daniels, Norman: 1988, Ami My Parents' Keeper? An Essay On Justice Between The
Young and the Old, Oxford University Press, New York.
Rawls, John: 1988, 'The priority of right and ideas of the good', Philosophy and
Public Affairs 17,251-276.