Justice – Medical Ethics

8th January 2020

MBBS Year 2
Academic Session: 2019 -2020
(Compiled by Dr. P Y Lee)
 The Principle of Justice
Learning Outcomes
At the end of this topic the student
should be able to
•define the term Justice.
•explain social justice.
•discuss distributive justice.
•explain the theory of a social
contract.
The Federal Court in Malaysia
The Palace of Justice houses the Malaysian Court of Appeal
and Federal Court
 The Term - Justice
Justice is a complex concept.
Concept is based on numerous fields; morality,
law, religion, theology, rationality, equity and
fairness.
It is made more complicated because each of the
contributing fields present differing viewpoints,
perspectives and ideas.

•
 Justice
Justice is at the heart of many legal,
political, philosophical and religious,
arguments.
Refers to the quality of being just;
•fairness, equality, rightfulness,
lawfulness ; getting what is your right,
•distribution of wealth, privileges and
opportunities, within a society.
 Justice
Common to think of a set of ideas when the word “justice” is
mentioned.
•in relation to the courts of law at different levels, and to the legal
system in the country.
•system of laws allow punishment of a guilty person or groups of
people.
The judge decides how the guilty
should be punished.

•a concern for fairness, peace, and

genuine respect for people
 Justice
• The courts concern themselves
with a large variety of matters
relating to criminal and civil
disputes, just behaviour, fairness
and peace, law and order and
respect for people.
 Justice
In medical ethics, justice is one of the four key
principles.
•referred to as
– The Traditional Principles
OR
– The Fundamental Values of Justice
Within the medical context , justice
refers to, the allocation or distribution of
resources amongst the population.
 Justice
The principle of Justice refers to
– the fair treatment of individuals
– the equitable allocation of healthcare
dollars and resources.
Summary: Justice is concerned with the
equitable
distribution of benefits and burdens to
individuals in social institutions, and how
the rights of various individuals are realized.
 Justice
Basically, the principle demands
the fair treatment of “equals” within
the health-care system.
•unfortunately,
– there is no single answer as to
what constitutes fair and equal
distribution.
 General Discussion of justice
Discussions on Justice
•The 4 types of justice:
•Common to discuss the four types of justice. But
in medical ethics, the stress is on the first two
types:
- social justice
- distributive justice
- procedural justice
- commutative justice**
 Social Justice
What is social justice?
A general definition of social justice
•difficult to arrive at,
•even more difficult to reach a
consensus,
•even harder to implement.
 Discussions on Justice
• Social justice
as found in religion,
philosophy, theology…
• based on the concepts
of human rights and equality,
– justice in terms of the distribution
of wealth, opportunities, and
privileges within a society.
 Social Justice
In essence, social justice is equal
justice for all,
-in the courts,
-in all aspects of society,
-demands that people have equal
rights and opportunities;
-an even playing field for everyone;
from the poorest to the wealthiest.
 Social Justice
Why are there many different definitions
given to social justice.
•a variety of factors;
political orientation, different cultures,
values, religious background, and
political and social philosophy.
•a modern, liberal concept
- not achievable in any society.
 Social Justice
What do the words “just”, “fair”, “equal”,
“liberty” mean?
•who should be responsible for creating “a
just and fair society?”
•how do you implement policies regarding
social justice?
•should you legislate for justice in society
•can you rely on the moral compass of
people to achieve a fair and just society?
 Social Justice
A summary…
•'social justice' implies fairness and
mutual obligation in society; that we
are responsible for one another, and
that we
should ensure that all have equal
rights and opportunities to
develop ourselves to the fullest.
 Social Justice and Medical Ethics
Doctors should concern themselves with
this complex topic because
•the functions of institutions and policies,
affect the way in which people fall ill and
the way in which they receive health care,
•essential in ethics to consider what these
institutions and policies owe to patients
and physicians alike.
 Medical and Social ethics
• appreciate the two
• difference between medical ethics and
social ethics ?……
• real or artificial
• medical ethics refers to immediate
patient concerns ,
• problems in society concerns people as
private citizens, not as patients.
 Procedural Justice
Procedural (legal) justice is
•the idea of fairness in the processes
that resolve disputes and allocate
resources.
•another aspect is related to
discussions of the administration of
justice and legal proceedings.
 Procedural (legal) justice
The Four Pillars are -
1) being fair in processes,
2) being transparent in actions,
3) providing opportunity for voice,
4) being impartial in decision
making.
 Commutative justice
• refers to that which is owed
between individuals, such as in
conducting business transactions. 
• calls for fundamental fairness in all
agreements and exchanges between
individuals or private social groups.
• (members of a group are treated
equally e.g. by the law)
Distributive justice
•concerns with the
equitable distribution
of scarce resources
among all
socio-economic
groups and
population sectors
•a key ethical issue in
medical care
 distributive justice
Chris Armstrong* School of Social Sciences
University of Southampton, Southampton, UK
Armstrong defines distributive justice --
•as the ways that the benefits and
burdens of our lives are shared between
members of a society or community.
•principles of distributive justice tell us
how these benefits and burdens ought to
be shared or distributed.
 Distributive Justice (cont.)
• in the fair allocation of resources to
members of a community
• commonly takes into account the
– total amount of goods to be
distributed
– distributing procedure
– pattern of distribution
 Distributive Justice
With limited amount of wealth and
resources, how do you distribute these
resources?
•common answer is that resources should be
distributed in “a reasonable manner”
rather
•“limited resources” ought to be distributed
“a reasonable manner”
– each individual receives a "fair share”.
•what constitutes a "fair share."
 Distributive justice
In other words,
• individuals have the right to
be treated equally regardless
of ethnic group, gender, age,
culture, marital status, diagnosis,
social standing, rich or poor,
political or religious beliefs,
or any other individual factor
 Principles -Distributive justice.
Various principles could be applied
•most common criteria:
equality, equity, and need
Equality - the ultimate criterion
•goods are distributed equally among all
persons - each person receives the same
amount ,
•but due to differences in levels of need,
this would not result in an equal
outcome
 Equity Principle – in distribution
According to the principle of equity,
•individual’s contribution
– those who make a greater contribution
to the society, deserve more benefits
– people who work harder in more
valuable jobs should earn more money
•this method is typically associated with an
economic system where there is equal
opportunity to compete
According to Need in Distribution
Distribute according to need
•those who need more of a benefit or
resource will receive more
•colleges offer needs-based
scholarships or
•states provide welfare payments to
the poor
 Distributive justice

• distribution in this manner

ensures that everyone's basic and
essential needs are met
• which is good for the individual,
also,
• makes criminal and political
violence less likely as well.
 distribute resources according to
social utility
• (what is in the best interests of society
as a whole) 
• argument frequently made by highly
paid executives
• argue that they deserve their high
salaries because of their contributions to
their businesses,
• thus paying "job creators," highly
benefits society as a whole.
 Distributive justice
In general, for a society to function
effectively, each member of a group must
be motivated to operate productively and
satisfactorily.
•equal distribution is thought to give
people the responsibility of full
membership and partnership
•equity fosters the drive to produce and to
be rewarded for one's productivity.
 ..principles of distributive justice..
Uses a variety of factors as criteria..
•To each person an equal share
•To each person according to need
•To each person according to effort
•To each person according to contribution
•To each person according to merit
•To each person according to free-market
exchanges
Distributive justice
 Violations of Distributive Justice
• violations in the fair distribution of
limited resources in healthcare
• rich using more of the healthcare
services than the poor who have the
greatest needs
• this can be seen in both health
promotion and the treatment of illness
and disease - e.g. -- cancer treatment
 Violations of Distributive Justice
Pharmaceuticals and cancer treatment.
Classic example of violations of
distributive justice ---
•these drugs typically are expensive
•in 2009 a new drug
Folotyn (treatment of lymphoma)
•cost about US $30,000 per month
 Violations of Distributive Justice
• Erbitux (treatment of colon cancer)
costs approximately
$10,000 per month.
• Avastin (treatment of
lung cancer
or breast cancer)
costs almost $100,000 per year
 Violations of Distributive Justice
• nation helps to maintain the profit
margins of pharmaceutical companies
• society bears the burden of payment
• in terms of distributive justice, cancer
medications are simply not available to
the poor
• treatment for HIV/AIDS presents
another classical example of ongoing
violations of distributive justice
distributive justice
doctor and surgeon
Doctor:
What did you operate on
Jones
for?
Surgeon:
A hundred pounds
Doctor:
No, what did he have?
Surgeon:
A hundred pounds

(Punch cartoon1925)
 Social Contract
In moral and political philosophy;
•a theory or model; an enormously
influential theory, 
•concerns the legitimacy of the authority
of the state over the individual,
•Age of Enlightenment (Age of Reason)
the 18th century that dominated the
world of ideas in Europe,
 Social Contract
• the typical argument
• presumes that “individuals have
consented, either explicitly or tacitly, to
surrender some of their freedoms and
submit to the authority” (of the ruler, or
to the decision of a majority) in
exchange
• for “protection of their remaining rights
or maintenance of the social order”.
 Rawls Theory of Social Contract
In the twentieth century,
•moral and political theory regained
philosophical momentum as a result of
John Rawls’ Kantian version of social
contract theory. 
•Proponents of social contract: Thomas
Hobbes (1651), John Locke (1689), Jean-
Jacques Rousseau (1762) and Immanuel
Kant (1797)
 Rawls Theory of Social Contract
For Rawls a social contract 
•is a hypothetical not an
historical contract. 
•does not claim that people actually agree
to a particular set of morally defensible
principles of justice,
•Rawls describes his theory as
“justice as fairness.”
 Concepts of "Rationality"
Rationality
•the quality or state of being rational - that is,
being based on or agreeable to reason.
•implies the conformity of one's beliefs with one's
reasons to believe, and of one's actions with
one's reasons for action.
•has different specialized meanings in philosophy,
economics, sociology, psychology, evolutionary
biology and political science.
(Optional slide)