Justice in Oral Health Care

8/10/2019 Justice in Oral Health Care

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Te Preferential Option for the Poor 129

certain patients because of characteristics unrelated to their medicalcondition. In the article on patient selection, the Code reiterates thatdentists shall not refuse to accept patients into their practice or denydental service to patients because of the patients race, creed, color, sex ornational origin. Note that the patients nancial status is not includedin the list. Apparently, dentists may refuse to accept patients into theirpractice when and because the patients are poor.

Free-Market Liberalism

Te cited sections from the CDA and ADA ethics codes reect a liberalphilosophy of justice provided the term liberal is understood in theclassic sense of freedom-enhancing (and not as socialist as typicallhappens in the United States). Tis political philosophy of justice,when operationalized, generally results in free-market economics. Tefreedom of the trading partners is believed to be the best assurance

that the interests of all involved are maximized. Some freedom-limit-ing rules are necessary to assure that nobody is unfairly disadvantaged.For example, trading partners may not deceive, coerce, or negativelydiscriminate. But otherwise, the freedom of the trading partners shouldnot be restricted. Tus, patients should not be restricted in their choiceof dentist or treatments, and dentists may not be restricted in theirselection of patients or in their advertising strategies. From such a liberal free-market perspective, health disparities are most

denitely unfortunate. After all, the very purpose of the free market isthe maximization of the interests of all, not just part of society. How-ever, the disparities are not necessarily unfair. We are all responsible forthe many choices we make for ourselves each day, whether to labor orlinger, save or spend, invest or enjoy. Differences in affluence that resultovertime from these free choices are essentially of our own making andhence fair. Conversely, a duty imposed on dentists to give preferentialtreatment to any group, whether rich or poor, would constitute a viola-

tion of the dentists freedom and thus undermine the free market. Incontrast, volunteerism and charity, precisely because they arise from thefree will of the donors, support both the poor and the free market. Tis liberal theory of social justice may easily convince entrepreneursand politicians opposed to government imposed taxes. But in its purestform, the theory also has evident shortcomings. It is one thing to argue


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130 7 ~ Jos V.M. Welie

that poverty is the result of ones own free choices, but quite another toargue that ones gender, age, and race are. And yet, elderly black womenas a group have signicantly less access to health care than almost anyother population in the US. Te same would be true for congenital dis-abilities, epidemic illnesses, criminal trauma, or environmental diseasesEven if the causes of these health infractions can be blamed on someidentiable person(s), those who suffer the resulting illnesses generallyare blameless. Tey had no choice in the matter. Consequently, theirplight not only is unfortunate; it is also unfair. Justice requires that eachindividual at least has a fair starting chance, an equal opportunity atachieving and maintaining health and well-being.

Equal Opportunity Teories

Te theoretical problem now arises which differences in peoples stateof being are unfair and hence merit a corrective adjustment of the free

market, and which differences are merely unfortunate. Various argumen-tative strategies have been proposed, the best known of which probablyis the one developed by the American philosopher Rawls (1971). Hepoints out that in making these kinds of allocation decisions, it is virtu-ally impossible not to be biased by ones own state of being. Tus, anolder person will inevitably be tempted to safeguard the interests of theelderly, a rich person the interests of the affluent, a paraplegic personthose of the disabled. Te only way to protect against such biases is to

decide from behind the veil of ignorance. Tat is, one should ignoreall of owns personal characteristics and only then ask oneself the ques-tion: What conditions would I want to have adjusted if I did not knowwhere I would be born, from what parents and into what family; if I didnot yet know my gender or race, genetic make-up or nationality, my IQ,physical abilities or talents? According to Rawls, participants to such adebate would come to agree hence the term contractarian theory of justice that social and economic inequalities are unjust, unless they

are actually advantageous to all, and particularly those at the marginsof society. But advantageous in what way? According to Daniels (1985),having ample opportunities to realize ones life goals and to participatein society, is advantageous to all. From such an equal-opportunity perspective, diseases and traumasthat signicantly restrict peoples opportunities to function, warrant a


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distributive correction, particularly if the patients cannot be blamedthemselves for their conditions. Note, however, that this special care forthe poor and stricken does not really arise out of a concern for them.Rather, it results from a kind of enlightened self-interest: It could havebeen me! Tis kind of enlightened self-interest underlies all insuranceschemes. I buy insurance just in case some catastrophe befallsme. Othersshould also buy insurance, for elsemypremium will become too high.However,I only need as many other people to join me in the plan as arenecessary to keep the plan solvent; those who have a high probabilityof consuming more benets than they contribute in premiums shouldbe deselected from the plan. Evidently, such cherry-picking is only possible if we know who, becausof age, genetic make-up, or other factors, poses a greater risk. Rawls veiof ignorance is intended to prevent exactly that bias. But then again,can we ever shed such knowledge about ourselves? As long as we arehealthy, it is truly difficult to imagine life as a severely disabled personOnce a certain state of affluence has been gained, it is quite difficultto make do with less. Te very attractiveness of the equal opportunityapproach its appeal to rational self-interest also reduces its real-lifeapplicability.

Equal Rights

Tere are alternative theories of justice that do not build forth on indi-

vidual freedom and self-interest. Or more precisely, given each personstendency to foster his or her own freedom and interests, even at thepotential detriment of others, these theories of justice use a different,non-egoistic starting point. Most such theories assume a fundamentalequality of all human beings, out of which arise certain rights that eachperson is endowed with and that are inalienable. Te best-known cata-logue of such rights is the 1948Universal Declaration of Human Rights,issued by the United Nations. Te Declaration does not mention oral

health care, but it does list a right to medical care necessary to maintainhealth and well-being. As Chambers (in his contribution to this book) points out, such adeclaration of rights is generally a discussion stopper. And indeed,universal rights language is exactly intended to do this. Te very idea ofa fundamental human right is that it is not up for discussion. It is not


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conditional upon the maximization of the interests of some or even allindividuals. Tis is the very strength of rights language. But again, its strength is also its weakness. For there are few funda-mental rights that enjoy world-wide or even wide-spread consensus.Tose that do, either are phrased rather vaguely, or are negative. Tatis to say, they guarantee freedom from some kind of evil (such as thefreedom to practice ones religion without restrictions by third personsor government). Positive rights, also called entitlements, are rare. Teright (of all children) to basic education is one of the few entitlementsthat enjoys widespread consensus, but the right to basic health care doesnot. In this respect, the 1948 UN Declaration is the exception insteadof the rule. Undoubtedly, the hesitance to acknowledge positive rights is caused atleast in part by the fact that such rights entail a loss for those who haveto guarantee the entitlement, either in the form of labor by speciedindividuals or taxation income to be allocated by the government. Forexample, if we were to acknowledge a fundamental right to basic oralhealth care, dentists would automatically become obligated to providesuch care, possibly supported therein with public funds (predictably atlow reimbursement rates). Tis seems unfair to dentists, at least primafacie so. Moreover, in a world increasingly dominated by free marketeconomics, egalitarian theories generally are not persuasive. In theUnited States, even those who are less well-off, tend to shun such views,driven by the dream to still make it and the fear that this dream willbe squashed in any political system that merely reeks of socialism. But even in countries where social-democratic ideologies have gained astronger political foothold, any egalitarian theory that would require eachand every person to be provided with the best oral health care available,would be economically unfeasible. As Winslow (in his contribution tothis book) points out, it would not make much political sense to exertequality by prohibiting the more affluent from buying more expensivecare. Instead of a ceiling approach, Winslow therefore advocates a oorapproach beneath which nobody should sink. Te challenge then is

to reach agreement on the existence of a fundamental right tobasicoral health care. And this is not a challenge easily met. Te fact thatin a country with a decidedly social-democratic tradition such as TeNetherlands, the national commission established explicitly to studythe issue of basic health care excluded dental care does not bode wellfor any alleged right to basic oral health care (Dunning et al. 1991)


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And yet it is also clear that these egalitarian theories of justice capturea basic moral sentiment. It may be unfortunate but not unfair that largesegments of society cannot afford orthodontic care. But it is decidedlyunfortunateand unfair that so many people do not have access even toprimary preventive oral health care and get to enjoy only extractions.Te signicant efforts on the part of individual dentists, local dentalsocieties and, increasingly, national dental associations to improve accessto basic oral health care, cannot be explained adequately by free-markettheories of justice or even a Rawlsian adjustment thereof. Self-interest,even rational and enlightened self-interest, cannot account for the wide-spread indignation about the staggering oral health disparities and themanifold efforts to provide for the most needy. In contrast, egalitariantheories of justice that emphasize the intrinsic dignity of each humanbeing can account for such indignation and the subsequent response. From an egalitarian perspective, people who are severely ill, in pain,or signicantly disabled must be provided with the necessary (oral)health care, not because we (who are lucky not to be so afflicted) couldhave ended up in their shoes, but simply because they are human likeus. Teir not-being-so-lucky does not reduce their humanness. Note,however, that the decisive principle, i.e., the level of basic health care, ia rather abstract and to some extent arbitrary principle of equality. Tepoor are only deserving of care because and to the extent that theyhave slipped under the agreed-upon level of basic oral health care. Te preferential option for the poor takes us yet a step further, thatis, further away from our own interests (as in libertarian theories of justice) and even past generic human interests (as in egalitarian theoriesof justice). Instead of sameness to us, it is the otherness of the poor thatinvokes moral obligations on our part. It is precisely because they areindigent (unlike us), vulnerable (unlike us), sick or disabled (unlike us)and powerless (unlike us) that we are called to act on their behalf. Butbefore we expand on this counter-cultural idea, let us rst examine thehistorical origins of the preferential option for the poor.

Historical Origins

Very little has been written about the preferential option for thepoor in health care. Te only comprehensive overview is the recent


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collection of papers entitled Jesuit Health Sciences and the Promotionof Justice. And even here, the editors felt it necessary to add the sub-titleAn Invitation to a Discussion, so as to emphasize the explorativenature of the book (Welie & Kissell 2004). In this collection, Mas-saro provides an excellent summary of the historical and theologicalfoundations of the preferential option for the poor, on which I relyheavily here. Te notion of a preferential option for the poor was rst proposedand contextualized by the Roman Catholic bishops from Latin Americaat their 1968 conference in Medellin. It captured the bishops concernabout the staggering economic disparities and economic injustices intheir respective countries. While the terms chosen were new, the concernwas not. Troughout the history of the church, a concern for the poorand socially marginalized is evident, most tangibly in saintly guressuch as St. Francis, St. Damian, and more recently, Mother Teresa. More structural efforts arose towards the end of the 19th centuryas the western world was rapidly being industrialized. In the 1891encyclicalRerum Novarum,Pope Leo XIII analyzed the new challengesof the industrial age and placed the church on the side of the workersin their struggle for decent working and living conditions (Massaro2004, p. 77). Tese developments accelerated during Vatican II. Pope John XXIII, one month before the opening of the Council, declared:In the face of the undeveloped countries, the church is, and wants tobe, the church of all, and especially the church of the poor (1988, p.xxvi). Among the documents resulting from this Council,Gaudium etSpes most explicitly addressed the issues of social justice, as evidencedalready by its opening statement: Te joys and hopes, the griefs andanxieties of the men and women of this age, especially those who arepoor or in any way afflicted, these too are the joys and hopes, the griefsand anxieties of the followers of Christ. Indeed, nothing genuinelyhuman fails to raise an echo in their hearts (Pope Paul VI 1992, par.1). Pope Paul VI offers this paraphrase: In teaching us charity, the Gospel

instructs us in the preferential respect due to the poor and the specialsituation they have in society: the more fortunate should renounce someof their rights so as to place their goods more generously at the serviceof others (1992, par 23). Massaros analysis of encyclicals written byPope Paul VI such asPopulorum Progressio (1967) andEvangelii Nun-tiandi (1975) leads him to conclude that the scope of his suggestions


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for rigorous corrective measures to benet the poor knew no bounds,reaching to the international economic system, political procedures, landreform and even the churchs own methods of evangelization (2004, p.78). And this concern for social justice was taken up yet again by Pope John Paul II during his lengthy ponticate. o be sure, John Paul II also expressed concerns about the possibilitythat the church fail in its mission as church if it would engage itself toodeeply in socio-political causes.

Emptied of its full content, the Kingdom of God is understood in arather secularist sense: i.e., we do not arrive at the Kingdom throughfaith and membership in the Church but rather merely by structuralchange and sociopolitical involvement. Where there is a certain kindof commitment and praxis for justice, there the Kingdom is alreadypresent. Tis view forgets that the Church receives the mission toproclaim and to establish among all peoples the kingdom of Christand of God. She becomes on earth the initial building forth of thatkingdom (Pope John Paul II, 1979, p. 62).

Specically, the church must always foster reconciliation, so it must notin any crass way take sides, whether with the rich or the poor hence thePopes opposition to any liberation theology that translates the optionfor the poor in a Marxist-type class struggle. Te option for the pooris not an adversarial slogan that pits one class or group against another(United States Catholic Bishops 1992, pars. 86-88). Pope John Paul IItherefore preferred alternative phrasings such as preferential yet not

exclusive love for the poor and option or love of preference for thepoor (Pope John Paul II, 1987, par. 42).

Te Great Reversal

Even if we grant that exclusive concern for the poor would constitutean injustice towards all others, Pope John Paul IIs modied expressionsignies the same moral core of the original adage, that is, the poorevoke a special moral obligation on the part of the well-off. And thequestion therefore remains why that is the case. None of the secularethical theories of justice presented above justies such favoritism of thpoor. At most, an egalitarian perspective would call for equal treatment


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of the poor. Tat perspective is itself already rather radical for the mostpopular contemporary theory of justice, that is, free-market liberalism,tends to consider poverty an unfortunate but not unfair side-effect ofan economic system that increases overall affluence so much so thatprobably even the poor are better off now. Te preferential option forthe poor thus constitutes the great reversal (Massaro 2004, p. 72). Indeed, the moral foundation for this perspective is not secularbut biblical. In the Judeo-Christian tradition, it is God himself whoappears to have a preferential option for the poor. It captures Godsspecial relationship with disadvantaged people (Massaro 2004, p. 69).Tere are ample references in both the Jewish Bible and the ChristianScriptures for this divine predilection (see also able 1). A continuous

strand in the biblical witness to Gods self-revelation highlights howdivine favor has been heaped time and again upon the poor, the lowlyand the outcast (Massaro 2004, p. 72). Winslow (in his contribution tothe book) already referenced the 8th c. BCE prophet Amos who scoldedthose who trample the heads of the weak into the dust of the earth

Table 1. Biblica l Se lections Sugg esting Gods Pre ferential Optionfor the Poor

God executes justice for the orphan and the widow and befriendsthe alien, feeding and c lothing him. So you too must befriend thealien, for you were once aliens yourselves in the land of Egypt(Deuteronomy 10: 18-19).

God has thrown down the rulers from their thrones but lifted upthe lowly. The hungry he has filled with good things; the rich he hassent away empty (Luke 1: 52-53).

God chose those the foolish of the world to shame the wise, andGod chose the weak of the world to shame the strong, and Godchose the lowly and despised of the world, those who count fornothing, to reduce to nothing those who are som ething, so that no

human being might boast before God (I Corinthians 1: 27-29).

Whatever you did for one of these least brothers of mine, you didfor me (Matthew 25: 40).

Blessed are you who are poor, for the kingdom of God is yours(Luke 6: 20)

All biblical fragments in this chapter are taken from the Catholic Study Bible,Oxford University Press, 1990


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and force the lowly out of they way (Amos 2: 7). But best known isprobably Christs lists of Beatitudes which appears in slightly differentform in both the gospel of Matthew (5: 2-12) and of Luke (6: 20-26).As Massaro summarizes, each version in its own distinctive way singlesout the poor, weak, humble, meek, hungry and sorrowing as ndingfavor with God (2004, p. 73). And to make matters even worse forthe well-off, Luke follows his Beatitudes (Blessed are the . . .) with series of condemnations (But woe to you rich . . . ; you who are full . . ; you who laugh now . . .) (Massaro 2004, p. 73). At the risk of arrogantly trying the impossible, one may wonder whyGod imparts such favors on the poor. Te evangelist Mark remindsus that those who are well do not need a physician, but the sick do(2: 17). However, the subsequent verse shows that those in need of aphysician are not the poor but the sinners, and these evidently arenot synonyms although there was in biblical times and still is in ourmodern capitalist societies a denite tendency to equate socio-economicsuccess with moral quality. Burghardt explains that [b]iblical justice isdelity to relationships, especially those that stem from a covenant withGod. Gods intent in creating was not to fashion billions of monads,isolated individuals, who might at some point come together througha social contract. God had in view a family, a community, wherein noone could say to any other, I have no need of you. Te Jews were tofather the fatherless, mother the motherless, welcome the stranger, notbecause the orphan and the alien deserved it, but because this was theway God had acted with Israel (2004, p. 103). It is one thing to stipulate a divine predilection for the poor and societysmarginalized. It is quite another to clarify what that means in practicalterms for us humans. Massaro readily concedes that the Scriptures donot provide an economic blueprint (2004, p. 75). It is quite clear whichapproaches arenot consistent with the Judeo-Christian tradition. First,any economic theory that dehumanizes or otherwise lessens the intrinsicdignity and value of the poor is unacceptable. Massaro gives the exampleof Social Darwinism. Tis theory extrapolates Darwins biological rule

of the survival of the ttest to the social sphere: Supporting the poor,that is, the non-t, risks undermining human progress. Social Darwin-ism in this most radical form nowadays has few advocates. However,the sentiment that the poor are somehow less worthy or less deservingappears deeply rooted in humankind and has a way of inuencing manysocial policies. If we grant that the poor are of equal dignity and worth,


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if we grant that they too are created in the image of God, the secondunacceptable approach is apathy. But exactly how we must be involved,is not spelled out in the Scriptures. Unfortunately, there is very littlepositive structural advice to be found in the Bible, particularly advicethat is applicable to 21st century global economies.

Higher Educationn

ranslating the moral imperative of a preferential option for the poorinto practical strategies will yet require much visionary thinking andcreative experimenting in the many different domains that make upsociety, from engineering to trade, from war fare to social security, andfrom health care to the legal system. One area in which much visionarythinking and creative experimenting has already taken place, is highereducation, specically in the colleges and universities sponsored by theSociety of Jesus. Shortly after the founding of the order in 1556, the

Jesuits got involved in education. By the end of the 16th

century, theywere already running nearly 300 schools and colleges, earning them thenickname School Masters of Europe, even though that label fails toacknowledge that their school system was in fact global. After the papalabolishment of the order in 1773, virtually all of the existing schoolsand colleges had to be closed or turned over to secular authorities.Although the order was reestablished by a subsequent pope in 1814,the damage was already done. Still, with 202 institutions of higher

education worldwide, 79 technical and professional schools, 444 sec-ondary schools and 123 primary schools (2005 statistics), the presentnetwork is probably the single largest global educational system. Butwhat matters for the purposes of this chapter is not the number butthe nature of these schools. As Welie & Kissell already have pointed out, ever since the foundingof the Society of Jesus by the Basque soldier-convert Ignatius of Loyolain the mid-16th century, the Society has been engaged in social activ-

ism, caring for the poor and marginalized, striving to improve their lotthrough practical care, education and political engagement (2004, p.9). Te 1773-1814 abolishment of the order had caused its membersto become much more socially restraint. But the orders overall socialdirection changed yet again by the mid-20th century, instigated rstand foremost by the 28th Superior General of the Society. A former


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medical student, eye witness of the horrors of Hiroshima, Father Arrupe(1973) challenged:

Have we Jesuits educated our alumni for justice? We will have toanswer, in all sincerity, that we have not. Tis means that, in the future,we must make sure that the education imparted in Jesuit schoolswill be equal to the demands of justice in the world . . . . What kindof person is needed today by the world? My shorthand is men andwomen for others. . . . Only by being a man or woman for othersdoes a person become fully human. Only in this way can we live in

the Spirit of Jesus Christ, who gave of himself for the salvation ofthe world, who was, above all others, a man-for-others.

wo years later, the delegates to the Societys 32nd General Congregationaffirmed that the Societys mission was the service of faith, of whichthe promotion of justice is an absolute requirement(Decrees1977,p. 411). Daoust (1999) lists three ways in which Jesuit universitiescan promote justice. (1) Accompanying the poor and making services

available to them. (2) Political engagement towards a more just society.And (3) developing awareness of the demands of justice and the socialresponsibility to achieve it. But Daoust also warns the rst two arenot paradigmatic of higher education; these are the missions properof soup kitchens and political mobilization campaigns. Essential tohigher education is the third way: developing social consciousness andconscience, or conscientization. Indeed, the prototypical justice-oriented Jesuit university is in Latin

America, the Universidad Centroamericana Jos Simen Caas (UCAfor short) in San Salvador, the capital of El Salvador. Founded in 1965,its charter, bylaws and composition of the board of directors underscorethat the university seeks to transform social structures. As Massaro haspointed out, the universitys research projects that focused on issuesof justice, poverty and human rights were favored over merely techni-cal ones that did nothing to challenge the oppressive status quo of thenation. Even the architecture and layout of the campus was deliberately

selected to encourage a mingling of personnel and a cross-fertilizationof departments intended to overcome the tendency of faculty to isolatethemselves into quarreling academic efdoms (Massaro 2004, p. 86)UCAs social engagement, based on high level research and promotedthrough its scholarly journal,Estudios Centroamericanos, soon gainedit a reputation in the country and disrepute among the powerful elites.


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Menaces and military occupations of the campus were but a forebode.On November 16, 1989, six of UCAs Jesuits and two female employeeswere assassinated by the Atlacatl Battalion of the El Salvadoran army.

Dental Education

Even if most of the other Jesuit sponsored universities fortunately donot face such daunting dangers, it remains a difficult task to translate the

preferential option for the poor into an academic program. Te task iseven more challenging for health sciences degree programs. Some haveevaded the problem, arguing that health care, health sciences educationand biomedical research, when done well, already realize this justicemission. Te greatest service one can do for the marginalized andpoor is to simply educate the very best health care providers (see, forexample, Hrubetz 1993). But the staggering oral health disparities inthe US make clear that training truly excellent dentists and hygienists

simply does not suffice. Others have pointed out that Jesuit sponsored schools of dentistry,like other non-Jesuit Catholic institutions, have always been and stillare, heavily involved in indigent care. But the question remains whetherthis service to the poor constitutes so-called service-learning as wellIt is not at all clear that the health sciences students who treat indigentand other marginalized patients typically do so in the context of astructured course that specically focuses on the problems of indigent

and marginalized patients (see also the chapter on service-learning byHenshaw elswhere in this volume). For example, are dental studentstrained foremost to perform high-end dental procedures that theirindigent patients can only afford because the school has substantiallydiscounted the fees in order to attract patients? Or are they trained toefficiently provide the kind of effective basic oral health care that, upongraduation, they can offer those same patients in their private practicesat a price the patients can afford?

Similar questions can be raised regarding the area of biomedicalresearch. Scientic programs heavily rely on the subsidies and grantsfrom the medical and pharmaceutical industries. Tese companies arenot primarily interested in the health care needs of the indigent andmarginalized in society. Tey are not the ones who spend fourteen percent of the national gross product on health care goods and services.


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Tey are certainly not the patients who can afford the latest implants,veneers, and orthodontics. A dental school desiring to help in the ght against injustices will rsthave to ask a similar question as did the UCA when it was founded:Who are the vulnerable and marginalized in the modern world thattend to be neglected by the oral health care system at large as well as byindividual dentists? We can distinguish two main categories of vulner-able patients. Tere are those who by virtue of social, economic or other non-medi-cal factors become vulnerable. Teir medical symptoms and conditionsmay not differ from those of patients in general, but because of thesenon-medical factors they are unable to reach the health care system,communicate with caregivers or afford the care they need. In order toaddress these needs, we must train health care providers to providebasic care, wherein the term basic has multiple connotations: basicas in low-tech; basic as in comprehensible; basic as in affordable; basicas in universal. Te second category of vulnerable patients are those whose verymedical condition causes them to be at risk for medical neglect. Tis isbecause the medical system tends to focus on certain diseases, treatmentmodalities and categories of patients while paying relatively little atten-tion to others. Tere are many reasons for this favoritism and it tendsto vary by historical period and country. At present, it would seem thatwestern medicine tends to focus on acute medical needs, curative care,interventions that are technologically advanced and elective treatmentsthat are commercially protable. Consequently, patients with incurableillnesses that demand a symptomatic palliative approach tend to bemarginalized. So are mentally disabled patients, elderly with chronicillnesses and children in need of preventive care. Te more difficult subsequent question is how dental schools canbest prepare graduates to meet the needs of these vulnerable patients.Pending a scientically supported proposal, I submit that the a dentalcurriculum for justice would place heavy emphasis on preventive and

community dentistry, basic dental care, dental care for patients withmental or physical disabilities, geriatric dentistry and nursing homeoral health care. Te courses in these disciplines, in addition to regularscientic and technical training, should be further enriched with service-learning projects.


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Evidently, it would not be possible to simply expand the time allottedto the aforementioned subjects without cutting into the curriculumelsewhere. Most dental curricula are already overlled, leaving studentslittle time to engage in extracurricular formation activities or even withtheir families. Tis condition of permanent stress does not favor anattitude of concern for the least among us (Stempsey 2005). But assoon as we begin to list disciplinary areas that are to be sacriced inorder to make time for justice-related subjects, the suggestion is madethat those disciplines fail to contribute to more justice in health care;or, even worse, they counteract justice. Te suggestion that certain health sciences courses could counteract justice is most certainly false. All of health care can contribute to thecare of the poor and vulnerable in society and when properly applied,no health care causes injustice. No specialty disqualies its practitionersof service for the poor and vulnerable. Even esthetic dentistry, thoughincreasingly used to cater to the vanity of patients who have money tospare, can also be practiced in the service of those whose deformities,traumas or tattoos have rendered them socially vulnerable. In fact,this discussion is not about the disciplines themselves but about thepatient populations on which they tend (not) to focus. It is about shift-ing emphases. Instead of focusing on the health care needs of peoplewho have a voice and are already being listened to by the many otherhealth sciences degree programs, schools subscribing to the preferentialoption for the poor must listen to the silent outcries of the voicelessin society.

Bibliography

Arrupe P.Address, International Congress of Jesuit Alumni in Valencia, Spain on July 31, 1973. Available on-line at http://www.sjweb.info/education/docu-ments/arr_men_en.doc

Burghardt W. Biblical Justice and the Cry of the Poor: Jesuit Medicine andthe Tird Millennium. In Welie JVM & Kissell JL (Eds.). Jesuit Health Sci-ences and the Promotion of Justice. An Invitation to a Discussion. Milwaukee:Marquette University Press, 2004; pp. 95-109

Daoust J.Faith and Justice at the Core of Jesuit Education: Of Kingshers andDragonies. Keynote address to the attendees of the Western RegionalConference on Justice Education, 1999. Available on-line at: http://cms.


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Decrees of the 31st and 32nd General Congregations of the Society of Jesus. St. Louis:Institute of Jesuit Sources, 1977Daniels N. Just Health Care. New York: Cambridge University Press, 1985Dunning AJ et al.Kiezen en Delen. Rapport Van De Commissie Keuzen in De

Zorg [in Dutch; Report of the National Commission on choices in healthcare]. Te Hague: Ministerie van Welzijn, Volksgezondheid en Cultuur,1991

Hrubetz J. Nursing education in Jesuit universities and colleges. Te art ofscience and caring.Conversations 1993, Spring: 18-19

Kolvenbach PH.Te Service of Faith and the Promotion of Justice in American Jesuit Higher Education. Address at Santa Clara University, 6 October 2000.Printed inStudies in the Spirituality of Jesuits 2001, 35(1): 13-29

Massaro . A Preferential Option for the Poor: Historian and TeologicalFoundations. In Welie JVM & Kissell JL (Eds.). Jesuit Health Sciences andthe Promotion of Justice. An Invitation to a Discussion. Milwaukee: MarquetteUniversity Press, 2004; pp. 70-92

Pellegrino ED & Tomasma DC.Helping and Healing: Religious Commitmentin Health Care. Washington DC: Georgetown University Press, 1977Pope John XXIII. Allocution of September 11, 1961. In Gutirrez G (Ed.).Introduction to the revised edition.A theology of liberation, fteenth anniver-sary edition. Maryknoll NY: Orbis Books, 1988

Pope John Paul II. Opening address at the Puebla conference, 28 January 1979.In Eagleson J & Scharper P (Eds.).Puebla and beyond: Documentation andcommentary. Maryknoll NY: Orbis Books, 1979

Pope John Paul II. Sollicitudo rei socialis. In OBrien DF & Shannon A (Eds.).Catholic Social Tought: Te Documentary Heritage.Maryknoll NY: OrbisBooks, 1992

Pope Paul VI.Gaudium et Spes. In OBrien DF & Shannon A (Eds.).CatholicSocial Tought: Te Documentary Heritage.Maryknoll NY: Orbis Books,1992

Pope Paul VI.Populorum progressio. In OBrien DF & Shannon A (Eds.).Catholic Social Tought: Te Documentary Heritage.Maryknoll NY: OrbisBooks, 1992

Rawls J.A Teory if Justice. Cambridge: Harvard University Press, 1971

Stempsey WE. Forming Physicians for the Poor: Te Role of Medical andPremedical Eductation. In Welie JVM & Kissell JL (Eds.). Jesuit Health Sci-ences and the Promotion of Justice. An Invitation to a Discussion. Milwaukee:Marquette University Press, 2004; pp. 131-151


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United States Catholic Bishops.Economic Justice for All. In OBrien DF &Shannon A (Eds.).Catholic Social Tought: Te Documentary Heritage.Maryknoll, NY: Orbis Books, 1992U.S. Public Health Service.Oral Health in America: a Report of the SurgeonGeneral. Washington DC 2000. Available on-line at http://www.surgeon-general.gov/library/oralhealth/(access veried on 11/3/05)

Welie JVM & Kissell JL. A Matter of Identity: Te Role of Jesuit Health Sci-ences Centers toward the Promotion of Justice. In Welie JVM & Kissell JL(Eds.). Jesuit Health Sciences and the Promotion of Justice. An Invitation to aDiscussion. Milwaukee: Marquette University Press, 2004; pp. 9-15

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David W. ChambersDistributive Justice

Distributive justice is concerned with the way common benetsshould be distributed within the group to which they arecommon bluntly put, who gets what from the common

stock (Audi 1999; Edwards 1967)? Te question has two parts: Whichbenets are common (as opposed to private) and how is the allocationto be made? Tis paper will not address issues of retributive justice (fairpunishment), substantive justice (what is fair to ask for), or formal orprocedural justice (fair procedures) although there is some evidencethat such questions are regarded as more telling for the publics senseof satisfaction (Alexander & Ruderman 1987; Folger 1977). Issues of distributive justice can be raised with regard to oral health.For example, are dental treatment (or certain kinds of dental treatment),a specic level of oral health, or information about or diagnostic andother public health measures community goods and should action betaken to distribute them differently from what results from forces cur-rently in place? In addition to voluntary contributions from industryand donated services by dentists (which the ADA estimates to beapproximately $10,000 per dentist, or 0.5 percent of dental services),

the U. S. government purchases about 4 or 4.5 percent of all dental carefor redistribution through Medicaid, the uniform services, the IndianHealth Services, prisons, etc. In addition, the government funds, to asmall extent, public health measures such as public water uoridation,oral health promotion, and research. Some of the questions that ariseinclude: Is this the right amount? Are the resources optimally distrib-uted? Are the allocation mechanisms meaningful, clear, and efficient? Te plan for this paper is to mention briey the shortcomings of

individual and universal solutions to problems in social justice and tofocus on game theory, including Pareto optimality and six alternativerational approaches for discovering the justice criterion the fair way todistribute resources. In the end, it will appear that this task is complex,and more importantly, necessarily possible only in limited ways. Such a


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146 8 ~ David W. Chambers

conclusion points to the value of discursive ethics the creation of ethicalcommunities through mutual promises as the best way forward.

Te Sense of Justice

Just is different from other adjectives such as big or benign. It imorally suasive. One could not say, I prefer to be unjust but it isacceptable to strive to be small or even have a deadly jump shot. If on

is accused of injustice there is a social obligation to defend ones actionor change them. Tere is a corresponding obligation for anyone whomakes such an accusation to place his or her differing views in the listsBecause the term should is admitted to discussions of justice theybecome moral questions. Discussions of justice take the form of comparisons among alternativefuture world views that are believed to be feasible and possibly attain-able. When the dentist says Medicaid insurance should reimburse for

crowns on lesions covering multiple cusps, he or she is taking the positionthat the world would be better (for some group of individuals) if thiswere the case. Because the insurance carrier takes a contrary position,we can assume that some others would prefer a different world. Boththe dentist and the insurance company are willing to take action toincrease the chances of their world becoming the future reality. Oftenthe action is low-grade complaining; sometimes more resources areattached (as in lobbying or marketing); or there may be escalation to

research or litigation. Te point is that ethical conict over issues ofdistributive justice are collisions between future world views that are atleast partially incompatible and which call forth some level of responseon the part of those who hold these different alternatives. Tere are four general approaches for addressing such conicts overcompeting world views of distributive justice.

1. A Personal Approach.A strictly individual view is really onlyworkable when there is no cost in taking a position. Te dentist who

eschews Medicaid patients could proceed along these lines. One writingan editorial or even a journal article or making a speech to an audi-ence holding friendly views could work this angle. Tere may be somepersonal reward to be harvested, but no views of justice are likely to bechanged.


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Distributive Justice 147

A variation is to argue from a superior position. Teoretical justi-cations, such as philosophers and academic writers might take, andrights language are examples (Brandt 1979). Claims that one partyis coming into the discussion with a universally appropriate positiontypify a centurys-old quest that has so far produced only contendersand no champions (Kane 1996). 2.Oral Health As Right.With the exception of a recent presidentialcommission of the American Dental Education Association (Haden etal. 2003), arguably the United Nations, and possibly a few others, noone has held that oral health or oral health care are rights. Rights area special class of ethical assertion that apply to individuals by virtue ofwho they are and not what they have done (Edwards 1967). Humanrights (such as life and liberty) apply to all people without qualication,civil rights (such ashabeas corpusand adult suffrage) apply to citizensof the country in question different countries, different rights. Terights and privileges of membership in a group (such as using the initialsFACD in certain contexts if one is a fellow of the American Collegeof Dentists) are specic community rights. Rights imply an obligationon the part of the community as a whole (the human race, the country,or the organization) to ensure that its members rights are redeemable.Almost all rights are negative, such as freedom from unlawful searchand seizure, or opportunities (the pursuit of happiness), rather thanpositive, as perhaps a right to a specic income. Evoking rights tends to be a discussion stopper. We hold these truthsto be self-evident . . . , boldly stated in the US Declaration of Indepen-dence was not intended to invite analysis or debate. As Norman Danielsremarks, One problem with this somewhat pragmatic appeal to rightsis that is does not carry us past our disagreements and uncertaintiesabout the scope and limits of such rights claims (Daniels 1985, p. 5).Both Daniels and John Rawls (1971; 1993) are explicit that healthcareis not a right. (Daniels suggests that prudent deliberators would seekhealth care as a social benet to the extent that it protected individualsnormal opportunity range at each stage in life (1985, p. 103). Te 1948

United Nations Universal Declaration of Human Rights mentions thateveryone has the right to a standard of living adequate for health andwell being of himself and his family, including food, clothing, housingmedical care, necessary social services, and the right to security in theevent of unemployment, sickness, disability, widowhood, old age, orlack of livelihood in circumstances beyond his control. It also states in


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Article 23-3 that everyone who works has the right to just and favorableremuneration ensuring for himself and his family an existence worthyof human dignity.

Comprehensive philosophical positions on justice, such as thoseadvanced by Plato in theRepublic (1983), Ren Descartes (1979), Jean Jacques Rousseau (1978), John Locke (1988), David Hume (1966), orImmanuel Kant (1958) are no longer fashionable. Current thought leansto clarifying specic issues such as property rights, conicting interests ofnudists and communities, and various welfare policies (Aday, Andersen& Fleming 1980; Bayer, Caplan & Daniels 1983; Sandel 1983; Sterba1980; Veatch & Brayson 1976). Some rights are held to be prima facie they are in effect to the extent that other rights dont trump them.Because rights are unqualied and beyond discussion, this view resultsin a standoff between arbitrary positions. 3.Discursive Approaches.Te discursive view of ethics lies betweenthe individual and the universal approaches. Ethics is a reection ofcommunities (MacIntyre 1984). In fact, the discursive or rhetoricalprocess of searching for generally meaningful world views and makingpromises to other members of the community to behave in predictablefashion is intrinsic to creating community. Tis method will be takenup at the end of this paper. 4.Game Teory. A fourth approach has gained popularity amongacademics and offers an advantage of being content neutral. About theonly assumptions necessary in game theory are that the question can bereasonably well structured and that people will act in ways that maximizetheir self interests (Luce & Raiffa 1957). Game theory can be used toreveal the structure of a very large number of situations because it canbe shown that, generally speaking, issues involving many individualscan be converted into two-person games (one party vs. all others as agroup) and that complex courses of action involving many steps can beconverted into decisions involving one strategy vs. all others. (Tere aredifferences among games that do and do not have equilibrium pointssuch that one strategy always dominates, whether a zero-sum game is

being played a person can only win what others lose, and whethercommunication among players takes place, but such nuances are beyondthis paper.) Writing in the ethics of distributive justice generally proceeds alongone of two lines: (1) a characteristic of the current distribution thatannoys a writer is documented and a principle is presented that justi-


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es the teleological position of the writer or (2) a principle is selectedand its implications are worked out. Tis paper differs in addressingwhat it means to evaluate alternative distributions of social goods. Inthe sections on game theory and the justice criterion that follow, it isdemonstrated that no universally appropriate standards exist and thusthere will always be valid reasons for and against individually favoredpositions. Tese are difficult arguments to follow and difficult for someto accept. Te reader who is willing to concede this point may want toskip to the section on on Making Resources Common.

Game Teory

1.Outcomes Envelope. Consider a very improbable world view that dis-tributes oral health resources in lavish ways to all individuals. Anyonewho wants it is entitled, at no fee, to any dental procedure deemedbenecial by a panel of dentists, including all elective procedures such

as orthodontics, veneers, and whiting. Further, users are compensatedfor lost income while receiving care, and transportation and childcareare reimbursed. Tis unrealistic distribution gives all the benets to thepatient and places heavy burdens on others, such as dentists and thepublic. Te opposite extreme would involve some form of guaranteedbenets to dentists, with prohibitions against some people receiving care(even if it could be paid for personally as would happen if treatmentwere denied to undocumented aliens) and patients could be required to

spend time waiting and be embarrassed with bureaucratic work. Tiscosts the government or the public nothing. Some might argue that aworse alternative would be this scenario with patients receiving iatrogeniccare, and that in fact such examples currently exist. Tis system offersnothing for the patient and everything for others. Tese extremes areindicated in Figure 1 as Points P and O. Between the extremes of Points P and O there is a vast array ofalternatives, each involving some better balance between the patient

and others. Not every one of these combinations of outcome makessense, however. For example, it is not possible to support everythingthe patient wants and everything everyone else wants at the same time,the utopian Point U. Te dashed line on the left indicates a boundaryof economic infeasibility for the public or the profession. Anything tothe left of the line could not be sustained. Te dotted line represents


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the standard of care. Outcomes below this point are unacceptable, anda pattern of practice that makes such outcomes probable requires theintervention of society.

Generally, any outcome within the envelop would not cause concernsof a policy nature. Naturally, an outcome at point N would be seen asan opportunity for the patient that something more toward the topwould be preferred; while the dentist or public might like to see some-thing nearer the right. Tese are non-zero-sum opportunities becauseimprovements can be made that do not require a sacrice from others.Te possibility of such outcome signals an inefficient system. Tedentist could use better materials or be educated in more up-to-date

approaches; the patient could nd a dentist closer to home or use betterpersonal hygiene. 2.Pareto Optimality. Te upper-right border is of special signicance.Tese are the expected outcomes that leave nothing on the table foreither party. Tese are zero-sum combinations any advantage for

Figure 1. Outcomes Envelope relating Joint Potential Benefits toPatients and Others; Pareto Optimal Set is Depicted by the HavyLine.


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patient or dentist and the public comes at the expense of the other.Tis upper-right boundary is called the Pareto optimal set, named foran Italian economist who rst discussed it extensively (he also inventedthe 80:20 rule). wo things are important about Pareto optimality.First it is an operational denition of a maximally mutually benecialstrategy in a game situation. Second, it is not a single point; it is a setof strategies depicted in Figure 1 by the heavy line from points Athrough E which meet the mutually optimal strategic criterion. 3. Interpretation of the Outcome Envelop.Te gure represents atheoretical abstraction rather than the actual American oral health-care system or any part of it. It is important to realize that there hasbeen virtually no research designed to draw this picture in reality. Tequestion of scale has been begged. We do not know whether these aredollar or personal satisfaction units; but it is theoretically sufficient tohold that something like relative value units are assumed to be involved.Changes in scale (to reect personal preferences) will have the effect oftwisting the envelope to some extent. Tere will still be an economicand a standard of care boundary and a Pareto optimal boundary, andthey will be in the same general positions. It is appropriate to note thatthe diagram achieves a two-person game structure by combining theinterests of dentists and the public in opposition to patients interests. Itwould be equally appropriate to combine the public and patient interestsin opposition to dentists. Tis would most likely twist the envelop, butthe landmarks would probably retain their relative positions. It should be noted that there is lack of closure in the lower right-handside of the diagram. Tis is intentional. Te benets and burdens ofproviding care to the historically underserved are not well understood;nor do we well understand the value these individuals place on theservices they do not use. Despite rhetoric regarding a single standardof care, a multiple standard exists now and may make excellent sense. Ifthis were not the case, differences along the Pareto optimal line in thevertical dimension would be nonsense. Isnt orthodontic care for thosewho can afford it and no care for those who cannot afford it a differenti-

ated standard of care? Equally, the possibility must be considered thattypical dental care represents a net negative value for some individuals.Even when care is provided at affordable costs (free), many individualsavoid it. Equating pain control (emergency room visits for extractions)with oral care is a distortion. Such individuals are not using the oralhealth care system; they are using the medical system. At the very least,


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it is risky beyond responsibility to extrapolate from one part of thediagram to others. o assume that individuals in the lower right-handsegment of the diagram have the same values as patients in the upperleft or the same values that dentists have is irresponsible.

Te Justice Criterion

We have not yet identied a just distribution of benets and burdens

among parties even though we have described the set of possible out-comes and explored in a general way which are impossible, which areundesirable, which are too poorly understood to work with, and whichare most efficient (the Pareto optimal set). Although the Pareto optimalset offers the most promise for nding a point of just distribution, itnormally includes many alternatives, and nothing has been said thatfavored one point over another. For example, no one has proposed100 percent fee coverage for all dental needs. Te welfare economist

Amartya Sen makes the case against the other extreme: An economycan be optimal in [the Pareto sense] even when some people are rollingin luxury and others are near starvation as long as the starvers cannotbe made better off without cutting into the pleasure of the rich (Sen1970, p. 121). We must investigate various alternatives on and near thePareto optimal set to see what is entailed in various criteria for settingthe justice point. However, there is no generally accepted solution tothis problem.

1. Te Utilitarian Principle. English social philosophers such as John Stuart Mill and Jeremy Bentham proposed, beginning in the lateeighteenth century, a general approach that society thrives when, oreven exists for the purpose of, maximizing the utility of its members(Bentham 1970; Mill 1956, 1972; Sidgwick 1907). Te utilitarianprinciple states that social justice is the greatest good for the greatestnumber. Te power of this formulation rests in its appeal to individu-als determining their own values and the possibility of using factual

data to inform policy. It should be remembered that Utilitarianismwas born in the formation of the great principles of liberalism, such asthe French 1789 Declaration of the Rights of Man and of the Citizen(Liberty consists in the freedom to do everything which injures noone else; hence the exercise of the natural rights of each man has nolimits except those which assure to the other members of society the


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enjoyment of the same rights). Adam Smiths contemporary theory ofmarkets required only an invisible hand.

Its strengths are also the vulnerabilities of the Utilitarian approach.Philosophers have long enjoyed giving examples of anti-social individuautilities. Should we, for example, count in establishing policy for thedistribution of common benets, the law-breaking personal prefer-ences of counterfeiters or those who engage in civil disobedience? Teutilitarian advice given by the dental establishment to its new recruits,All you need to know about ethics is that you should treat every patientas though he or she were your mother fails on the grounds that somepeoples mothers are sociopaths, or at least have uncomplimentaryviews about poor people. Te troublesome side of the Utilitarian basein fact is the possibility it raises that justice is an empirical rather than aphilosophical question. Are we to decide what is just by counting actuautility preferences rather than thinking about what they should be? Inphilosophy this is known as the Naturalistic Fallacy the mistakenbelief that what ought to be can be determined from an examinationof what is. Te result of several hundred years of work with the Utilitariancriterion for determining just distribution of resources has been itsacceptance as a general guideline only. No one proposes to resolve dis-putes over justice with opinion polls, but references to the benet ofthe many over the privileges of a few carry weight in debates. Te pureform of Utilitarianism is indefensible people are not to be trusted asindividuals or collectively (other than in political speeches) so legis-lators, bureaucrats, academics, and pundits have arisen and organizedfor the purpose of making a few necessary adjustments in the system.Modern politics can be largely understood in terms of the amount ofimprovement in human nature necessary through law and regulation with the right referring to those that favor small corrections and theleft referring to those who see greater opportunities to improve humannature through greater intervention.

Tere is also an argument against Utilitarianism on the ground

that it is impractical. It would be extremely cumbersome to measurethe preferences of a large number of people, denitions of the unitsof preference (known to decision scientists as utiles) are still beingdebated, and people change their minds. Te mathematics of utilitydecisions can become too complex for the typical person to performor even understand. In fairness, these criticisms can be leveled against


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all attempts to nd the justice criterion (with the possible exception ofthe voting method). 2.Majority Vote. Under certain conditions, simple vote is an excellentmethod for determining the just will of a group. It is assumed that thepreference of each person should be given the same weight. Electionof the American President and senators approximates this model. Tisapproach is simple. Some chafe at the constraint that all are assumed equal when thereare clear differences in political qualications. For example, idiots andbigots get the same consideration as those who are civically engagedand have studied the issues. Machine politics is an obvious abuse. So isthe concern that senior citizens can vote benets for themselves whilechildren cannot. Majority vote works well when there are two choices; but problemsarise when there are three or more alternatives (Bodily 1985). Forexample, A might be preferable to B and B preferable to C, but it some-times happens that C would be preferred over A. After all, comparisonsare made among alternatives that have many features. Or A might bemore desirable than B, except when C is present. Tis is known amongdecision scientists as the transitivity problem (Kenney & Raiffa 1993).Te outcome of a vote or other system for establishing group prefer-ence depends on which options are presented, with the possibility thatoptions not chosen determine the outcome selected. Recently, this wasseen in the Oregon presidential primaries where Republicans petitioned(unsuccessfully) to place Ralph Nader on the ballot in hopes thatenough liberal Democrats would vote for him to give the RepublicanBush the plurality over Democrat Kerry. An analogous argument iscurrently circulating in the debate over patient access to care. Advocatesare attempting to shift the balance of opinion in the profession towardmore open access by raising the prospect that a third party, the politicalprocess is prepared to weight in. A principal shortcoming of majority vote as a method for determiningthe justice criterion is that appropriate groups simply do not vote on

such matters. Perhaps the board of an insurance company could vote, ora large group practice might vote concerning policy within its purview,but almost all decisions that might collectively be taken as the expres-sion of social justice are at best representative democracy, where a groupelected for general purposes is asked to decide a test case rather than a


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comprehensive principle. Tere are no plebiscites on dentistry; decisionsabout oral health are not referred to all the people with teeth. 3.Maximin ( John Rawls). Te recently deceased American social justice philosopher John Rawls (1971, 1993; see also Moskop 1983)was concerned that efficiency in a social system (Pareto optimality) doesnot dene justice. In fact, he argues that justice is a higher principle thanefficiency, so the justice point might not even be in the Pareto optimalset (even though that is where the search begins). Rawls Difference Principle his key to dening social equality states: Te social order is not to establish and secure the more attrac-tive prospects of those better off unless doing so is to the advantage ofthose less fortunate. Among decision theorists, this position is knownas the maximin principle changes should be made in the distributionof multi-party strategies until no further improvement can be expectedin the prospects of the group that begins in the least favored position.Te argument is more complicated than it may appear at rst. Forexample, it is not proposed that those with many benets should givethem away so everyone has the same level (communism). Successfuldentists are necessary to maintain a successful oral healthcare system.Boris Pasternaks novelDr. Zhivagois a study in what happens when aprofession is stripped of its prerogatives. Rawls analysis focuses on the question, What is the proper levelof superior benet for the more privileged? His answer is that justicecan be achieved by establishing systems that benet privileged classesif those increases benets also result in greater benets for the leastadvantaged in society, and systems should be established that reducebenets for privileged groups when their benets are not translatedinto advantages for those groups worst off. Rawls proposes a trickledown theory of social justice, one where social advantages are valued tothe extent that they benet others. States use something like Rawlsianlogic when deciding whether to establish dental schools (Lightner &Zwemer 1999). Oral health is a social benet and the tax base providedby professionals is attractive. Rawls would imagine (there is no evidence

in his writings that he actually proposes this specic test) that legislaturesdebate whether it is more advantageous for the long-term oral health ofthe state for those with the worst oral health to fund programs for theunderserved or to invest in more dentists (through schools or throughtransfer systems such as WICHE) or to improve the lot of the poorthrough food stamps, education, job training, etc.


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It is possible to argue that Rawls would have had little concern withthe American fee-for-service dental system based on the fact that den-tists as a group pay approximately twice the annual amount of federalincome taxes as the government spends on all oral healthcare programs.Te current concern over access to dental care is not straightforward.Te oral health status of the poorer segments of America is roughly thesame (in absolute and relative terms) as it was twenty years ago, as isutilization of services. If we have an access issue now, we had one twdecades ago, and probably a worse one still fty years ago. What haschanged during this time is the proportion of dentists income derivedfrom services that are not health-related bleaching, orthodontics,veneers, and other cosmetic services. Tese do not benet the leastadvantaged in society. For the past twenty years, the income of den-tists has increased at 150 percent of the American economy generally(Guay 2005), and the amount of oral health care provided to the poorhas remained a constant proportion of the healthcare budget. Rawlswould probably favor policies to curb the recent shift of a privilegedgroup beneting from serving another privileged group. A peculiarity in Rawls maximin approach is his insistence on treat-ing levels in society as classes, represented by single individuals, therepresentative man. Lawyers equal members of the working class equalthe unemployed; each class having the same weight in his analysis. Onthis framing of the issues, Rawls suggests that his maximin principleis more liberal (kindly to the least advantaged) than the position of hisarchrivals, the Utilitarians (Rawls 1993). Weighting classes by theirnumbers or their economic impact seems defensible and certainlychanges the order of the rules for nding the justice criterion. In fact,among all the rules to be considered in this paper, Rawls maximin ruleor Difference Principle is the most conservative his view of justiceallows the greatest range across benets and burdens. 4.Harsanyis Additive Utility. A much more liberal denition of the justice criterion is offered by John Harsanyi (1955), who proposes anelaboration of Utilitarianism to allow for the possibility that all indi-

viduals are not of the same value or importance to society. His formulais simple: the preferences (utilities) of each involved individual are tobe weighted by some factor that reects each individuals signicancein the decision. Te weighted preferences are then tallied. For example,a consortium of organizations that funds healthcare clinics for theunderserved would vote on several alternatives for the distribution of


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their common benet, but each organizations vote would be weighted bythe dollar contribution it has made to the common fund. Alternatively,the directors of the programs that might receive such funds would votebased on the number of patients they could deliver. Te American Asso-ciation of Retired Persons is exactly an example of Haranyi principle.It is a self-dened lobbying group that actively recruits members forthe purpose of gaining weight in the political arena (Putnam 2000).A similar process is involved in organizations such as the AmericanDental Education Association, the American Dental Association, andso forth when policy positions on social issues are taken, along withrepresentations about their numbers or the inuence of their members,to decision makers in other settings, such as legislatures. Te liberal bias of the Haranyi (weighted utility) rule for nding the justice criterion is made more apparent by considering another ruledeveloped by Vilfredo Pareto. It is no joke that he developed the 80:20rule (80% of the problems are caused by 20% of the people, etc.). As aneconomist, he studied the distribution of wealth in Europe at the end ofthe nineteenth century and discovered that it was a severely positivelyskewed distribution (Pareto 1909). Small numbers of people have largeamounts of resources. Such distributions are known as Matthew curves(a misinterpretation of the verse in Matthew 13:12 about those who havebeen given more). Later work in the eld has shown that such distribu-tions develop spontaneously in systems where the benets accrued at

ime 1 can be carried over in same way to ime 2. Such multiplicativerelationships as compound interest, education, or health always resultin positively skewed distributions over time. Any weighting of positionsthat does not exactly match the criteria that created the skewed distri-bution in the rst place will tend (by the rule of regression toward themean) toward a more uniform distribution reallocation of resourcestoward those who do not have them now. (Tis is a characteristic ofnumbers, not of social benets and burdens.)

Te second great principle of social justice proposed by Rawls (besidesthe Difference Principle) was that social and economic inequities are

to be arranged so that they are attached to offices and positions opento all under conditions of fair equality of opportunity (Rawls 1993).In a word, Rawls urges that no systems or structures should be createdthat codify or prevent the reversal of gains in benets through exerciseof the multplicative principle of the Matthew curve.


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Te problem with the Harsanyi approach is determining how weightsshould be assigned in a fair manner. Naturally occurring mechanisms such as larger population groups among those on the left and moremoney to buy media and closer personal connections with inuentialindividuals on the right are at play in American politics. Haranyideveloped his ideas originally in the limited context of small groups(such as committees), and he proposed the generally unworkable solu-tion of having a third party determine the allocation of weights. Tecourt system does on occasion play this role, but it is not regarded as asatisfactory sufficient approach. 5.Nash Bargaining Solution. A useful and intuitive approach for xingthe justice criterion was suggested in the 1950s for the two-person caseby John Nash (1950) and subsequently generalized by a number of deci-sion theorists (see Luce and Raiffa 1957). Nashs insight was that thosewho have the most must give up the most to maintain a relationship.Consider the metaphor of a Caribbean hurricane. Te same unfortunateevent costs many times as much in Florida as it does in Haiti. What isthe likelihood that a dentist will sue a patient compared to the likeli-hood of a patient suing the dentist?

o implement a Nash solution (or to capture the power of this viewwithout formally solving specic problems) we need to know what eachparty stands to gain (or to lose if the transaction does not take place).A dentist with empty chair time looks at a capitation plan differentlyfrom a dentist who has a full schedule. Te economic analysis of mar-ginal utility for the plan is not the same there is no intrinsic value inoutcomes independent of what they add to the utilities of others. (Tispoint will become critical in discussions below). Writers in the theoryof negotiation refer to the baseline position as the BA NA the bestalternative to a negotiated solution (Fisher & Ury 1991). Tose withlarge relative BA NAs have a strong negotiating position. As the situ-ation with international terrorism demonstrates, those with nothingto lose are in the strongest position. Formally, the Nash solution is tomaximize the product of the potential gains for each strategy under

consideration. Te Nash solution to dening the justice criterion introduces threenew ideas. First, the marginal utility perspective (gain rather thanoutcome) is important. It matters where each party is at the beginningof any considered change in strategy. Te Nash approach is the bestknown of this class of decision rules called von Neumann-Morgenstern


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bargaining solutions (von Neumann & Morgenstern 1944). Tese twomathematicians demonstrated that there is no need to consider theentire range of potential outcomes or even the entire Pareto optimalityset when searching for fair solutions. Each party can be presumed torule out all alternatives that are worse then their current position. Tenegotiation set, shown in Figure 1 as the area N, B, D describes theoutcomes that are mutually no worse than the current joint situation,N, presumably the only outcomes that should be considered. Te Nashsolution will always be in the von Neumann-Morgenstern negationset. Second, Nashs view is described as a bargaining solution because ilends itself to iterative approximations of a mutually optimal resolution.Tis is in contrast to theoretical positions such as Rawls or Harsanyisviews where a one-time insight into the optimal solution (usually by athird party) is desired. Te view of social policy formation as a give andtake, extending over time and even into the future, is intuitive. Teoristshave correctly noted that the iterative nature of a bargaining approachcontains the inherent potential for reaching only local maxima (Luce& Raiffa 1957). Tat is a valid criticism and one that explains whyrevolutions occur from time to time. Te third unique characteristic of the Nash approach is that it dependson an understanding of what others stand to gain or lose. echnically,the Nash maximization of utility gains is calculated over all other par-ties, holding ones own position constant. Tis is a shift in perspectivefrom choosing what is good for oneself in the abstract to nding whatis best for oneself by considering the impact of ones position in termsof its effect on all others. Te Nash approach might be avoided pre-cisely because of this characteristic. A faux Nash solution is typicallyadvanced instead, where individuals decide what they think is best forother parties. In thirty years of attending meetings on the allocation oforal health resources, the author has never met anyone who was presentonly in the capacity of a patient, let alone an individual who had notregularly received dental care. Tere has been no shortage of individu-

als, however, who have been willing to explain what they thought theseabsent Americans needed. Te Nash solution applies only in those cases where the parties valuecontinued participation in the group. Bodily (1997) has demonstratedthat, for any common set circumstances about a decision, the Nash


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solution will always lie between the conservative Rawls solution andthe liberal Harsanyi solution. 6.Tird-Party Solutions.Te nal alternative approach for nding the justice criterion on the distribution of benets and burdens partiallyabandons the two-party game structure assumed until now. Especiallyin situations were outcomes are uncertain or where there is substan-tial ambiguity, parties may agree to submit the determination of a fairdecision to a third party. Te courts are often thus engaged. In othercircumstances, third-parties insert themselves into differences regarding just distribution without being invited, as in the case of regulators. Except, perhaps, in the case of last best offer arbitration (where thearbitrator is constrained to choose only between the two nal offers madeby the parties and is not free to introduce any alternatives), a third-partysolution will never be found in the Pareto optimal set (French 1990). Afair resolution is some point on a straight line between two positions onthe Pareto curve offered by the two parties. In splitting the differenceas some sense of justice, the arbitrator sacrices efficiency for justice(Chambers 1995). Tird-party solutions to the issue of justice have the important char-acteristic of sacricing efficiency. Mutually, the parties to an arbitratedsolution enjoy less than they would have mutually in a two-party solu-tion. Although either party might get more or less in the two-partysolution to justice, cumulatively they receive less. Tird parties takebenets out of the social system always. Tere are two costs: one isthe direct costs of keeping the third-party in business, the other is thelost opportunity of unrealized benets. It is always better in the longrun to settle; the short run is what costs. It is not always the case thata third-party solution to the distribution of social benets falls in thevon Neumann-Morgenstern negation set. Imagine a tangent betweenpoints A and E on Figure 1. All arbitrated solutions represent lossesfor one or both parties. Te collapse of communism and the UnitedStates governments sometimes attempts to drive down healthcare costsby increasing supply are examples. Charles Dickenss novelBleak House

describes the tragedy of a court ght between two parts of a family thatentirely consumed the disputed inheritance and destroyed lives.


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Making Resources Common

Most of the attention devoted to questions of social justice is focusedon the fair division of the pie; there is less concern with how big thepie should be (Daniels 1985; Sen 1973, 1982). Te public purchaseof oral health is almost entirely from undifferentiated sources taxes.Tere is no requirement that specic groups within society contributedirectly to oral health as there is in medicine where the residencysystem provides subsidized care. Also unlike medicine, there are nodirect obligations for patients to participate in pro-health behaviors.Te public is required, for example, to show proof of certain inocula-tions to enter school or to wear motorcycle helmets or automobile seatbelts in order to reduce the general health burden. Most rights begin in the common domain (Audi 1999; Edwards1967). Liberty, the pursuit of this or that, and freedom of somethingelse need not be taken from one person to be given to another. Free-dom to follow healthy lifestyles involving such behaviors as dietary

choices, exercise, and ossing are possibly of this category. But oralhealth treatment is not in the common domain, it must be brought infrom various private sectors. Robert Nozick (1974) develops a theoryof social justice that has as its rst principle the ownership of personalproperty. Society has three primary means for converting personal resourcesto common ones. Tese include (1) agreement, (2) em

Justice in Oral Health Care

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