Journal of medical ethics, 1978, 4, 3-4

Editorial

In search of justice
Over the first three years of publication of this
Journal the issue of justice in the provision of health
care has been discussed regularly, though perhaps
with less frequency than it merits. In an early issue
Ivan Illich claimed that there was an 'expropriation
of health' by the medical profession - a theme now
fully elaborated in his recent books Limits to
Medicine' and The Disabling Professions.2 In our
second volume Elizabeth Telfer, of the Department
of Moral Philosophy in Glasgow University,
explored the moral implications of different systems
of health care provision ranging from 'laissez-faire'
to 'pure socialist'. 3 Telfer's survey of possible
systems was subsequently questioned by Hillel
Steiner of Manchester University. 4 In our last
issue (December I977) a former Conservative
Minister of Health, Enoch Powell MP, declared
that the UN Declaration of Human Rights makes
statements about health care which are 'both non-
sensical and pernicious' - an opinion subjected to
critical scrutiny by Robin Downie, Professor of
Moral Philosophy at Glasgow University. Finally in
the present issue (and in the preceding one) Raymond
Plant has provided an exhaustive analysis of the
late Richard Titmuss's celebrated attack on the
market approach to medicine in his essay on blood
donation, The Gift Relationship.
These articles, although very different in many

respects, have all been concerned with two major
themes: the safe-guarding of individual freedom
and the achievement of a fair distribution of health
care resources. Within the tension between these
two moral values there lies the problem of justice in
health care policy. Too great a stress on individual
liberty leads quickly to a philosophy of 'weakest to
the wall': too heavy an enforcement of health care
standards leads, at best, to paternalism and, at
worst, to the horror of 'final solutions'. Individual
responsibility and initiative must be protected and
fostered, but never at the cost of disregarding the
vulnerability created by illness and social dis-
advantage.
The achievement of the required balance in moral

values is much more than merely a challenge to the
ingenuity of moral philosophers. The issues to be
faced demand political solutions of one kind or
another. In the USA commentators have been
describing for many years a 'crisis in health care
delivery', yet the enactment of legislation which will

make any real difference to the maldistribution of
medical manpower and resources seems to be as far
away as ever. In Britain the debate about the
effectiveness of the National Health Service,
provoked by the recent financial crisis, is beginning
to die down as public confidence in some kind of
economic kingdom of heaven on earth is restored.
Yet the health care problems in Britain, and in other
nations, will not be solved by increasing prosperity.
Indeed on both a national and an international scale
all the evidence points in the opposite direction:
economic expansion brings with it the twin problems
of an ever widening gap between the living condi-
tions of the advantaged and the disadvantaged, and,
for those who profit from the prosperity, the penalty
of the 'diseases of affluence'.
Thus, in adversity or prosperity, the moral issue

for health care legislators remains the same: how is
a society to cope with the recurrent problem of ill-
health in a way that enhances equally the life
prospects of all its members? We believe that no
quick answers should be offered to that question.
There is no short cut through the maze of arguments
by economists, political theorists, sociologists and
philosophers about the design of social institutions.
We see our task to be one of keeping all the
questions open by continuing to publish articles,
from a range of disciplines and viewpoints, on the
political reality of justice in health care.

References
'Penguin Books, Harmondsworth, I976.
"Boyars, London, I977.
3Journal of Medical Ethics, 2, 107-III.
4Journal of Medical Ethics, 2, I85-I89.

Screening for Spina Bifida
The Health Departments in the United Kingdom
are now considering the wisdom of performing tests
on all pregnant women in order to forestall the
birth of infants with open spina bifida by selective
abortion.

Alpha-feto-protein is normally present in the
bloodstream of the human fetus. In cases of open
neural tube defect (open spina bifida, anencephaly)
this protein is found in a higher-than-normal
concentration in the amniotic fluid, and also in the

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