DISTRIBUTIVE JUSTICE AND THE ALLOCATIONS OF ADDITIONAL RESOURCES TO THE FUNCTIONALLY DISABLED ELDERLY

This thesis examines the particular question of expanding Medicare- or Medicaid-financed community-based long term care services for the functionally disabled elderly in terms of the underlying distributive justice issues. It shows that this public policy debate, when examined from this perspective, has important implications for the more general questions of controlling health care costs, of rationing health care and the high cost user, and of what would constitute a just health care system. This debate occurs in the context of changing demographics and patterns of morbidity and mortality where there is increasing demand for these services, even as the elderly already consume a disproportionate share of health care resources. How this is a question of distributive justice is addressed, and the material principles of need and desert are discussed. The notions of rationing and scarcity are analyzed as they bear on this issue. The objections to providing community-based long term care services to the functionally disabled elderly, and more generally, of meeting the needs of the high cost user, are summarized and addressed under four headings: (1) the elderly already are responsible for a disproportionate share of health care resources; (2) we cannot afford any additional spending for this purpose; (3) meeting the health care needs of the functionally disabled is a private, individual matter, not a public concern; (4) other needs or claims for public resources have greater priority. Each of these objections is analyzed in terms of its underlying distributive justice concerns. The thesis concludes with a discussion of the implications of several questions raised in the paper: whether age is a morally relevant criterion for resource allocation; costs and who will bear those costs; costs that result from the free choices and voluntary risks of individuals; what constitutes a decent minimum; and the distinction between private and public responsibility