Healthcare, Rawls and Nozick
By John Spicer (Head of Primary Care Education and Development, Health Education England) and David Misselbrook (Senior Lecturer in Family Medicine, RCSI Bahrain)
John Rawls (left, 1921 – 2002) and Robert Nozick (right, 1938 – 2002) were Harvard philosophers, colleagues and friends. Their notions of justice and their political philosophies were starkly contrasting and arguably defined the liberal and libertarian political agendas for the later part of the 20th century.
In his hugely influential book A Theory of Justice Rawls argued for “justice as fairness”.1 His central argument is contractarian and derives from the thought experiment of “the veil of ignorance”. Rawls argues that if we were to be blinded to our actual position in society then we would want society to be so organized as to protect our interests, whatever our actual circumstances. From this he derives two principles. The liberty principle is that: “each person is to have an equal right to the most extensive basic liberty compatible with a similar liberty for others." So there is nothing wrong with working hard to get rich. The difference principle is that “social and economic inequalities are to be arranged so that … they are to be of the greatest benefit to the least-advantaged members of society”. So whilst the unsuccessful will be poorer than the successful they will never be destitute.
Nozick started from different principles. He stressed Kant’s teaching that persons are never to be considered merely as means to an end but always as ends in themselves, therefore goods should be redistributed only by mutual consent. He links this with a Lockean account of human rights. He acknowledges the need for taxation to fund a minimal state whose function would be to protect citizens against force, theft, fraud and to enforce freely entered contracts. Beyond this he concludes that it is unjust to take away rightful earnings via tax as a means to some other goal, such as a more equitable society. In his book Anarchy State and Utopia he argues that people should be free to form their own social groups to pursue their own favoured ways of life, with no one model imposed by a powerful state.2
These two books have had an immense impact on recent political thought. Perhaps though they both illustrate how one can retro-engineer convincing philosophical arguments from one’s final preferred position. Rawls was a left of centre political liberal, Nozick a right of centre libertarian. Rawls’ argument depends upon an ingenious, perhaps somewhat hypothetical and ahistorical thought experiment. It is not entirely certain that one can draw such clear and binding conclusions, although we may be in sympathy with his principles for other reasons. Nozick bases his argument on strong moral realist principles, but seems very blinkered as to what issues he is prepared to admit within his moral gaze. Do we really have nothing in common as humans that might make us feel that there is such a thing as society? Certainly Aristotle would not recognise Nozick’s account of the polis, or of the human good.
Perhaps the challenge for our philosophical and political debate is to progress beyond the armed stalemate that these two positions represent. In the debate we staged at the Royal Society of Medicine we sought to trace out the implications of these positions for healthcare and the NHS in particular. View the full debate in the top right video. The video below is of John Spicer commenting on the conference.
1 Rawls J. A Theory of Justice. Harvard: Harvard University Press, 1971.
2 Nozick R. Anarchy State and Utopia. Oxford: Blackwell, 1974.
