Thoughts about the value “justice” usually pertain to the field of political phi- losophy, whereby they fall outside the scope of this study. We have selected some of the most common meanings of the term adopting it to the subject we are looking at. We will examine four of them:
4.1. “To each person, the same”
According to this formulation, everyone should receive the same amount, so an action would be just if no one receives more than anyone else.
Despite its apparent innocuousness, it is an axiom that basically corre- sponds to a liberal model, since it is based on formal equality. If we all receive
24 Although referring to confidentiality, it is interesting to point out that article 51.2 establishes that “in
the event of genetic analyses of several members of a family the results will be filed and each of them will be informed individually”.
the same, the possible differences between different groups are not taken into account (for example, ethnic minorities, underprivileged social classes, the dis- crimination of women as opposed to men, and so on).
Thus, this meaning of justice is useful for avoiding negative discrimination (everyone has the right to vote, for example), but it prevents positive discrim- ination (for example, gender quotas in a bioethics committee to prevent it from being made up of men only).
An example of the dreadful consequences of the literal application of this principle was the famous “baby cheque” during the term of office of Presi- dent Zapatero’s socialist government. Every woman who gave birth while this subsidy was in effect would receive 2,500 euros per year. On the face of it, it seems a just measure (every woman receives the same), but in practice it is absurd for a millionaire to receive the same help as someone who may be on the threshold of poverty. It was more reasonable to concentrate financial ef- forts on those who really needed it rather than share out the scant financial aid equally.
4.2. “To each according to his work”
This formula first appeared in the New Testament (“he who does not work, neither shall he eat”, Saint Paul) and, by a paradox of history, it ended up in the Soviet Constitution of 1936:
In the USSR work is a duty and a matter of honour for every able-bodied citizen, in accordance with the principle: “he who does not work, neither shall he eat.” The principle applied in the USSR is that of socialism: “From each according to his ability; to each according to his work” (art. 12).
In the Marxist paradigm, this would be the criterion to follow during the existence of the socialist state, as a first step to its disappearance and entry in communist society.
Indeed, at this stage the state is still necessary (there are still capitalist states, so a socialist state is useful for upholding and spreading the achievements of the revolution). For that reason, some bourgeois reminiscences must still be maintained, such as everyone receiving according to what they bring to the revolution, according to their labour, and not according to their need.
If we transfer this idea to today’s world, we can observe what criterion is followed for the pensions systems in economies in countries such as the USA.
Indeed, the retirement pension in a capitalization pension system (Spain’s is for the moment, and with qualifications, a system based on sharing out the funds) implies that everyone receives according to what they contribute, so if they do not contribute anything, they receive no pension whatsoever.
The same is the case with private healthcare, which attends only to those who pay, regardless of social needs or other criteria of justice.
4.3. “From each according to his ability, to each according to his needs”
This principle was envisaged in the Marxist worldview for when capitalism had disappeared and all the countries in the world were socialist. At this stage, the socialist state would no longer be necessary and would be dissolved, giving rise to a society in which, without private property, police, army, laws, Church or bourgeois order, everyone would contribute what he could to the group ac- cording to his ability, but he would receive, not for what he contributed, but for what he really needed. Thus, a person could receive food, healthcare, and so on, even though he did not contribute with his strength to society, simply because his personal situation made him deserving of such attention.
Despite being an apparently utopian rule, envisaged for anarchist societies, it does in practice just about function in countries like Spain. In the Spanish public health system a person receives the treatment he needs (criterion of need) regardless of what he contributes in the form of social security payments or taxes (criterion of contribution).25 A person earning a high income may be
paying taxes and Social Security contributions for years without being given any healthcare attention if he does not need it. Conversely, a long-term unem- ployed person may receive the maximum possible medical care that the system can provide just because it is necessary.
25 The Spanish health service is funded through taxes, paid only by those who earn a certain amount of
money. Moreover, the percentage that must be paid varies according to the income obtained (crite- rion of progressivity, not proportionality). Moreover, those who are paid a salary must pay a certain percentage applicable to their salary in Social Security payments, and so the amount also depends on the size of their salary.
4.4. “To each according to his worth”
The concept of worth in this context means market value. In a wholly neolib- eral system, people’s value is determined by the correlation between supply and demand, regardless of the (real) social value of a commodity or service.
This would explain why a state hospital’s budget can be smaller than a top footballer’s signing-on fee. Our society, which votes through the consumption of advertising and the election of politicians who satisfy its preferences, gener- ally chooses (demands, prioritizes, etc.) the latter.
The priorities of biomedical research, for example, are very often estab- lished by the market, and not social needs. This means that research into rare diseases (they are not rare, they just affect a tiny minority), or research that is unprofitable, gets no attention whatsoever. The value of the research depends in these cases on the possibility of obtaining short-term gains, which condi- tions the market value of the research.
4.5. Justice as “social justice”26
The fifth meaning of this value establishes an antagonism between the princi- ple of autonomy and that of justice, understood as social justice.
Indeed, from this perspective, the principle of autonomy is the key value in a market economy context where the patient, and in reality, the citizenry as a whole, acts as a customer. For this reason, their interaction with healthcare personnel has given rise to a contractual relationship, not too different to what is established with a bank when you take out a mortgage, or even to mere con- sumerism, where healthcare products are just like any other good or service.
According to Daniels’s classic,27 there are three main criteria for allocating
healthcare resources: the market, rights and needs. For those who defend the first one, goods, including medical services, must be distributed according to supply and demand, because as individuals are the main actors in this model, they will seek the appropriate means to achieve their goals. The second model, which is enshrined in the Spanish Constitution, in the European Union and in many countries in our cultural ambit, comes up against the problem of cuts, the
26 Casado, M. (2016). “¿Gratuidad o precio? Sobre el cuerpo humano como recurso.” In: Casado,
María (coord.). De la solidaridad al mercado. El cuerpo humano y el comercio biotecnológico. Mexico City: Fontamara, pp.15-32.
breakdown of economic and social rights in the face of the global crisis. The last criterion argues with regard to basic needs, about which there has been much debate in the spheres of philosophy, law and economics in recent dec- ades. It has even been used as a basis for human rights, since if these needs are not met it is impossible for people to personally or socially achieve any pur- pose or goal in life.28
The economic crisis has provided the conditions for a rapid process of privatization of public services and an increase in inequality, and so countries, instead of protecting the citizens, give in to the private financial systems that govern the world’s economy. In countries that had a good health service, like Spain for example, the increasing privatization of medicine is an attempt to ap- propriate public resources by private interests that notably increases inequality and erodes values, because commercialization — the market — corrupts cer- tain values and practices, the core aspect of Sandel’s ideas on this issue.29
The State must meet certain moral standards to enjoy legitimacy and hold coercive power; for this it must treat all its citizens with equal consideration — not just consideration.30 Therefore, the gap between rich and poor — and
the existence of extreme poverty — is indefensible and a market society must be rejected, as must a “night-watchman” state that simply guarantees transac- tions, and a state at the service of powerful private interests that dictate its rules. All this in a context of the commercialization of life, in which there seems to be no remedy for inequality and which is particularly ominous in matters of health.
5. Prohibition of financial gain