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Conflicting demands on a modern healthcare service: Can Rawlsian justice provide a guiding philosophy for the NHS and other socialised health services?

Published in:

Fritz Z, Cox C. Conflicting demands on a modern healthcare service: Can Rawlsian justice provide a guiding philosophy for the NHS and other socialized health services?. Bioethics. 2019;00:1–8.

Why it matters

Healthcare systems face a number of challenges, but many of them boil down to competing demands. How do you weigh clinical needs versus financial constraints? Do you invest in current patients or plan for the future?

In situations of competing or conflicting priorities and interests, it’s difficult to design health system that balances everyone’s needs. But philosopher John Rawls’s theory of justice could help.

Rawls suggests that people will make rational, impartial decisions if they are separated from their vested interests. Behind a theoretical ‘veil of ignorance’, they don’t know what role they’re going to play in a society (or system). This frees them to design that system based on just and equitable principles.

This paper looks at how Rawls’ theory could apply to health system design. It asks what the NHS might look like if the people making policies didn’t know whether they were going to be a patient, clinician, or manager now or in the future.

Our approach

This analysis applies Rawls’ theory of justice to specific areas of conflict in healthcare, including staff training, work conditions, finances, and broader health policy. It explores how a Rawlsian approach could help design just and sustainable healthcare systems, and how it could help address some of the current challenges facing the NHS.

What we found

  • Though Rawls’ theories have often been criticised as tools for making specific healthcare decisions, applying some of Rawls’ principles could help guide how health services should be run.
  • A just healthcare system designed using Rawls’ principles should:
    • Promote staff recruitment, retention and training
    • Invest in long-term, sustainable infrastructure, and not be tied to the five-year cycles of political party control
    • Give more power to the people who work in the system, and the people who use it
  • To apply this theory practically, healthcare managers, clinicians, patients and carers could come together and debate conflicting issues behind a hypothetical ‘veil or ignorance’.

Related content from our open-access series, Elements of Improving Quality and Safety in Healthcare

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