Allen Buchanan is a rare beast: a philosopher whose work crosses disciplinary boundaries to enhance understanding rather than to highlight difference. Nowhere is his talent for translating professional tribalism into meaningful debate more evident than in this collection of 10 essays spanning three decades of his academic career.
The essays encompass a more diverse range of problems than the book's title would suggest: for example, healthcare as a human right, the nature of professional discretion and the value of trust are deftly analysed. It is fitting that an author who concentrates as much on process as on content in bioethical reasoning has chosen to abandon the usual chronological format in favour of thematic order. However, the breadth of subjects does not preclude coherence.
At the book's core is the question of the moral significance of responsibilities and incentives, particularly with regard to the institutions and organisations charged with devising and delivering healthcare. Buchanan is unafraid of ambiguity and complexity. He simultaneously offers a meta-level theoretical perspective on healthcare while demonstrating how the micro-level realities of clinicians, managers and policymakers frequently challenge - and even undermine - the received wisdom of the ivory tower.
He engages with, interrogates and develops the work of an astonishing range of bioethicists and political philosophers while never losing sight of the routine business of healthcare delivery (and, with the emphasis on incentives, the word "business" is often apt). To achieve such scholarly rigour while addressing fundamental questions about what it means, in practice, to deliver morally defensible healthcare is remarkable.
For Buchanan, "justice" is not merely concerned with matters of access or resource allocation, but instead imbues all of healthcare. It is simultaneously a political choice, a systemic ambition and a normative value. Moreover, Buchanan exposes how even the most sophisticated theories of justice are found wanting when the realities of providing healthcare, nationally or globally, are considered. Theories of justice may arguably be necessary, but are rarely sufficient in bioethics.
While the author's nationality might lead one to suppose that the book largely focuses on healthcare in the US, it is a title of interest to an international audience. Two final essays in the collection specifically address global health and justice. However, those essays that concentrate on systems and approaches that are most familiar in the US serve an international readership via the demonstration of the significance of organisational structures in achieving justice in healthcare.
Buchanan's arguments about the distribution of responsibility, the equitable balance of costs and fair treatment, and the implementation of effective accountability in healthcare have applications to jurisdictions well beyond the shores of the US.
Like Howard Brody's The Future of Bioethics (2009), Buchanan reminds bioethicists, policymakers, clinicians and patients that moral choices in healthcare are inherently political. The source and scope of perceived rights to healthcare, the extent of responsibilities and the appropriateness of incentives are predicated on collective and individual judgements and decisions that are a complex mixture of politics, philosophy, economics and pragmatism.
If politics is unduly preoccupied with the art of the possible, this book reminds us that bioethics is too often unduly preoccupied with the impossible. Difficult questions are to be celebrated, not avoided. Theories that purport to offer complete explanations are to be interrogated, not unquestioningly cited. Perennial problems and partial solutions are inevitable, not signs of scholarly failure. Bioethicists who fail to address the inescapable empirical demands of healthcare risk marginalisation and redundancy.
Buchanan serves as an inspirational role model for all bioethicists seeking to make a meaningful contribution to the fundamental questions in the healthcare debate.
Justice and Health Care: Selected Essays
By Allen Buchanan
Oxford University Press
Published 12 November 2009