In a democracy, what should a healthcare system do?

  • Malcolm Oswald

Student thesis: Phd


In a democracy, what should a healthcare system do? It is a question of relevance to many disciplines. In this thesis, I examine that question, and add something original to the existing debate by drawing on, and synthesizing, thinking from several disciplines, and especially philosophical ethics, economics and systems theory. Paper 6 in this thesis, entitled "In a democracy, what should a healthcare system do?", tackles the thesis question directly. The central conclusion of that paper, and of this thesis, is that a healthcare system in a democracy should do as much good as possible, although sometimes some overall good should be sacrificed for the sake of fairness, as John Broome has argued. However, what counts as the good of healthcare, and when good should be traded off for fairness, depend on your weltanschauung (or worldview). Political pluralism is normal, and every democracy has institutions and processes for making policy when people disagree because their worldviews differ. Ultimately, elected policymakers are accountable for making decisions.This analysis is complemented by paper 5, entitled "Accountability for reasonableness - as unfair as QALYs?". It assesses the vulnerability of three theories of resource allocation to injustice. It concludes that Daniels and Sabins' accountability for reasonableness approach is vulnerable because it does not require evidence of costs and benefits. Maximising quality-adjusted life years can also lead to large-scale injustice because it is concerned only with health gain, and not with fairness. I conclude that a "good and fairness framework", which is drawn from the writing of John Broome, is the least vulnerable to large-scale injustice. There are four other papers in this thesis. "What has the state got to do with healthcare?" (paper 3) makes the case for an important assumption underpinning this thesis, namely that the question of what a healthcare system should do is a question of public policy. Paper 1, entitled "It's time for rational rationing" argues that efficiency gains are not inexhaustible, and to continue with its austerity programme, policymakers should assess whether the NHS in England could do more good with the same money by doing different things. I explore how philosophical ethics can contribute to policy, and the importance of context when writing papers about policy, in: "Should policy ethics come in one of two colours: green or white?" (paper 2) and "How can one be both a philosophical ethicist and a democrat?" (paper 4).These latter two papers, and much of the narrative within this thesis, explain how my thinking has developed during the course of my PhD, and why I have looked within and beyond philosophical ethics for an answer to my central research question.
Date of Award31 Dec 2013
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorSoren Holm (Supervisor) & Catherine Stanton (Supervisor)


  • rationing
  • healthcare prioritisation
  • resource allocation
  • democracy
  • good
  • healthcare system
  • fairness

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