The application of various ethical theories is inherent in health care. This forms the basis for the study of ethics. These theories inform the principles applied in health care in general, and are applied in particular issues. The commonly used principles in healthcare ethics include autonomy, justice, beneficence, and non-maleficence. Morrison (2009) argues that amongst these principles, justice is the most complex. According to the theories of justice, knowing that something is wrong aids in classifying is as morally wrong. For instance, unfairness in treatment is perceived as an injustice. Thus, injustice occurs when similar cases are treated differently. Decision theory is yet to influence theories of justice and in particular healthcare justice. All theories of justice start from a position that assumes the rational choice theory is correct ( Rawls, 2009; Scott, 2000; Hechter & Kanazawa, 1997 ). However, based on the current postulates of decision theory, the rational choice theory must be set aside. This paper proposes an alternative thesis, one of a theory of justice that is built upon decision theory in health care justice. First, an overview of healthcare justice will be given. Secondly, decision theory will be explored. This will be followed by an explanation of the rational choice theory, and its assumptions and criticism. Finally, the essay will present the suggested alternative theory of justice and its justified application together with the decision theory to remediate the rational choice theory.
Justice can be broken into two key categories. These are distributive and procedural. While the former is concerned with resource allocation, the latter pertains to the existence of fair procedures and their application. Despite their differences, the two principles are premised on the notion that in the distribution of benefits and burdens equality in allocation should be observed unless a material basis for discrimination exists. While procedural justice issues occur in health care, they are more common in the dealings with employees (Morrison, 2009). For instance, in case of an imminent termination, the procedures for determining those to be laid off ought to be followed without bias. Failures of due process are also likely to occur in the health policy sphere. With regard to distributive justice, resource allocation disparity is evident in health care spending and demand. For instance, Morrison (2009) argues that in the U.S, only 1% of the population consumes 23.7% of the total health care resources.
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Throughout most of the world, the distribution of health care is uneven. However, this maldistribution is more visible in the developing and less developed nations. In these countries, the majority of the people lack access to health care even though they desperately need it. Conversely, a significant number have access to care even when their needs are relatively minor (Morrison, 2009). Numerous reasons have been claimed to drive this phenomenon. One notable reason in this regard is that relative to the needs, health care resources are often limited. Due to inequities in the provision of healthcare services, many people who are in need end up not receiving care that would be vital in helping them to avoid such repercussions as disability, suffering or even death. Contrary to popular belief, these inequities are not solely driven by socio-economic underdevelopment and limited resources. Rather, they are, to a large extent, influenced by the uneven distribution of economic, social as well as political power. These disparities result in access and privilege for some people, and exclusion and oppression for others (Morrison, 2009; Rawls, 2009). The presence of these widespread, unnecessary and avoidable inequities, particularly those related to health care raises pertinent questions regarding social justice.
The understanding of equality for the majority entails the notion that all people ought to have the same quantity of certain natural rights that defined vaguely. Others reckon that all people should be made equal by getting access to various positive social or economic rights such as access to health care and education. While these might not be availed in equal quantities, they must be given in such sufficient quantities as to make people equal. This is articulated by Rawls (2009). In his book, Rawls (2009) reckons that “all social primary goods – liberty and opportunity, income and wealth, and the bases of self-respect - are to be distributed equally unless an unequal distribution of any or all of these goods is to the advantage of the least favored.” This concept of justice as articulated by Rawls is applicable, and has far-reaching implications for health care. Thus, the Rawlsian concept of justice can be directly translated into a principle of justice that applies to health care. Specifically, according to Rawls, the available health services, irrespective of extent, should be availed equally to all unless the resultant unequal distribution would be advantageous to the least favored.
An alternative view was offered by Nicholas Rescher. Rescher reckoned that distributive justice ought to embrace the entire economic dimension of social justice. This includes the concern of proper distribution of goods and service in the society. According to Rescher, the challenge of distribution was epitomized in the utilitarians’ historical positions. This group argued that utility ought to be distributed on the basis of the greatest good being assigned to the greatest number. In practice, this principle has proven to be unsatisfactory. This is because there lacks a standard scale for measuring quality against the quantity of good. Likewise, there is no scale for use when these factors oppose each other. Further, justice plays a role in the approach through which distribution is decided upon. This is especially the case when resource limitations necessitate inequities of distribution. This calls to attention the participation of members of the society in deciding what is just and the implementation of that justice.
The principles of justice cannot be decoupled from healthcare. For instance, the Rawlsian concept of justice and Rescher’s perspective of distributive justice can be combined to form a series of principles of justice which are related to health care. The major principle in this regard is based on Rawls general theory of justice. In this case, the available health services should be availed equally to all. However, deviations from equality of distribution are only permissible when those that are worse off are made better off. Another notable view of equality was introduced by Dworkin and termed ‘option luck’ and its contrasting ‘brute lack.’ Their relationship with insurance was also articulated. According to Dworkin “option luck is a matter of how deliberate and calculated gambles turn out, whether someone gains or loses through accepting an isolated risk he or she should have anticipated and might have declined” ( Lippert-Rasmussen , 2001). In contrast, ‘brute lack’ is “a matter of how risks fall out that are not in that sense deliberate gambles” ( Lippert-Rasmussen , 2001). However, together the two forms of luck explain how risks fall out.
The availability of insurance offers a link between option and brute luck. According to Dworkin, “the decision to buy or reject insurance is a calculated gamble” ( Lippert-Rasmussen , 2001). This implies that an individual may face bad brute luck and as a result end up being worse off than others, yet the inequality that results might be characterized by differential option luck. This is particularly true if the individual who ends up being worse of could have insured against the back brute lack that he or she suffers yet failed to do so. Therefore, from Dworkin's perspective, the difference between brute luck and option luck matters fundamentally. This is because according to Dworkin, the fact that people cannot count on the ability of the private insurance to offer suitable insurance such as when someone is worse off, this exemplifies bad option luck. Thus, equality necessitates the state to distribute from the individuals with good brute luck to those with bad brute luck against which no suitable insurance existed. Further, equality does not need the state to tax individuals with good option luck so as to compensate those with bad option luck. It also does not need the state to compensate those with bad brute luck where a suitable insurance was available to them. Several reasons justify why the state, guided by the distribution policy, should not tax those with good option luck so as to compensate those with bad option luck. Firstly, by doing so, the state would deprive the people of the chance to gamble. Since some individuals prefer gambling, preventing them from doing so would be bad. Despite its importance in advancing the equality discourse, the idea of ‘option luck’ has been challenged, particularly due to the current understanding of the human decision-making process.
Decision Theory
Decision theory is a theory about decisions. There are diverse ways and traditions of theorizing about decisions. Theorizing about decisions is akin to theorizing about human activities. Human decisions are based on everyday happenings and on aspects of human nature, some of which scholars still lack a clear understanding of. However, not all human activities are pertinent to decision making. Mostly, the focus of decision making theories is on how freedom to make a decision is exercised ( Rawls, 2009 ). In the hypothetical situations theorized by decision theorists, normally there are options from which to choose. Often, the choice is random. Choices in the face of these theorized hypothetical situations have a character that is referred to by decision scientists as being ‘goal-directed’ ( Rawls, 2009 ). Therefore, decision theory concerns goal-directed behavior when one is faced with options.
Decision making is not a continuous activity. Rather, decisions are made at particular times. This is followed by a period in which the consequences of that choice are experienced or realized ( Rawls, 2009 ). The range of scientists who typically pursue decision theory research include economists, statisticians, psychologists, political and social scientists as well as philosophers. The different kinds of researchers are involved with their specialties, and there is some form of division of labor. However, in its totality, decision science is a blend of various decisions and is mainly multidisciplinary ( Rawls, 2009 ). The main theories and models of decision making include the bounded rationality model; the incrementalist view; the organizational procedure view; the garbage can model; and the individual differences perspective. Others are the naturalistic decision making perspective; the multiple perspectives approach; and the faster decision making approach.
The broad classification of decision making consists of two schools of thought. These are the analytic and the experiential ( Klaczynski, 2001; Kolb et al., 2001 ). The latter is also referred to as the incremental school of decision making. Both of these ways of thinking involve three main steps in decision making. These are problem definition, identification and evaluation of alternatives, and lastly implementation. The differences between these approaches lie in the weighting of the different steps. The analytic school relies more on the first two steps, with implementation consisting of the simple execution of the meticulously chosen alternative. The experiential school is an iterative improvement of a chosen alternative through a feedback mechanism.
The Rational Choice Theory
The rational choice theory is used to explain social phenomena by assuming the existence of a rational stance on the part of the actor ( Rawls, 2009; Hayward, 2007; Hechter & Kanazawa, 1997) . In theory, however, it should explain the actions of the actor. The rational choice theory assumes that an actor chooses an alternative that they believe will result in a social outcome that will optimize their preference under subjective constraints (Sato, 2013; Rawls, 2009 ). The concept of payoff or utility is employed to act as a surrogate for preference to ease mathematical modeling. Hence, the assumption under this theory can be expressed in the following terms: The actor chooses an alternative that they believe will bring about a social outcome which maximizes their utility or payoff under constraints that have been envisaged subjectively.
The initial structures of the decision processes are divided into three parts. The first stage acts as the basis for decisions concerning an issue. The second stage is an examination of the opinions at a personal level without attempts at forming a majority. A second discussion follows in which questions are clarified, and the coalescing of opinions to a few general manageable opinions made. The last stage involves the actual choice between the different alternatives.This theory is also referred to as the ‘choice theory’ or ‘rational action theory.’ It offers the theoretical construct through which the understanding of and modeling of social and economic behavior is realized. This theory is premised upon the belief that aggregate social behavior is the sum of the decision making behavior of individual actors ( Rawls, 2009; Hechter & Kanazawa, 1997) . In addition to this, the theoretical framework also focuses on the determinants of these individual choices.
Five critical elements are included in the assumption under the rational choice theory. These include alternatives, social outcomes, constraints, belief, and utility. The theory assumes that an individual has preferences among an array of available choices or alternatives, among which he or she can make a choice ( Hechter & Kanazawa, 1997 ). There is the assumption of the completeness and transitiveness of the preferences. In this case, an actor can express the preference for one over the other alternative and that several alternatives can be ranked in order of preference. It is assumed that rationality or rational behavior takes account of the available information, probabilities, events and potential costs or benefits in selecting a preference as well as maintaining consistency. Behavior is said to be rational if it is goal-directed, reflective, and consistent (Lee et al., 2009). Specifically, the actor engages in an evaluative process that is unvarying as opposed to random impulsive behavior.
Previously, there was an assumption that a consumptive choice is made to maximize happiness and utility. However, current theory bases rational choice on a set of choice tenets which should be fulfilled. Pertinently, a consistent ranking of preference alternatives is needful regardless of the goal. Choices are made based on personal preferences and the prevailing constraints. This theoretical framework is predictive of outcome and choice pattern. Individual preferences are viewed to be self-centered under this theoretical framework. This aspect is often perceived as an additional assumption. Hence, under this framework an individual is assumed to be ‘homo economicus,’ a state in which an individual balances costs and benefits before arriving at a preference that maximizes personal advantage (Lee et al., 2009; Anderson, 2000). Assumptions are often considered as theoretical depictions which aid in the formulation of a clear, testable or falsifiable hypothesis.
The Use of Preference and Utility in Decision Making
In decision making, preferences are used to identify the best choice amongst alternatives. Therefore, an alternative is found to be uniquely the best option if it is better than all the other choices among the alternatives ( Levin & Milgrom, 2004 ). Hence, when a uniquely excellent alternative is present, a choice is made in favor of it. However, there are cases in which none of the alternatives is considered as being uniquely the finest. This phenomenon is characterized by the highest position being shared by two or more alternatives. In this case, if there are alternatives that are best, one of them is picked.
Utilities are used in decision making as numerically represented values and are easy to use in decision making. In this case, the basic decision-rule is both simple and obvious, where, choice amongst alternatives consists of choosing the alternative with the highest utility ( Levin & Milgrom, 2004) . However, this rule cannot be directly applied if there are more than two alternatives with maximal value. When this happens, the rule has to be supplemented, with a choice between alternatives consisting of choosing the alternative that bears the highest utility. If more than one alternative has the highest utility, one of the alternatives is picked without regard for which one is selected. This approach is referred to as the rule of maximization. It is upon this rule that most of the economic theory is based. Central to this is the idea that individuals maximize their holdings as measured in money. The utilitarian moral theory postulates that individuals should maximize the utility resulting from their actions (Greene et al., 2008). Some critics of utilitarianism maintain that this equals to demanding too much, arguing that only ‘saints’ are capable of always doing the best.
Criticism of the Rational Choice Theory
The rational theory is criticised mostly for explaining individual behavior assuming that the actors will be rational in their decision making. This is because the theoretical construct ignores non-rational human behavior such as the influences of emotional, pathological and moral aspects. However, according to Sato (2013), this criticism is unfounded since it is based on the principle of falsifiability. This principle argues that from the viewpoint of scientific methodology, it is the hypotheses derived from assumptions and not the assumptions themselves that should be empirically tested. Overall, critiques of the rational choice theory are categorized into three groups ( Rawls, 2009; Whitford, 2002; Scott, 2000) . The first criticizes the assumptions about preference and utility. The second attacks the empirical validity of the assumption of rationality. The third, on the other hand, questions the explanatory power of the theory.
The critics of assumptions about preference and utility argue that this theoretical framework does not interrogate the origin of preferences of actors (Sato, 2013). In particular, one of the critics argues that this theory does not hold up when different cultural contexts are being examined and that the cultural contexts in which preferences are constructed are indeed a part of the focus of cultural theory. This critic is particularly of value due to the exploratory nature of prior conditions. Nevertheless, it falls short of specifying the kinds of social phenomena that have not been explained by the rational choice theory and are explained by examining the cultural contexts of preference. The critic is therefore insufficient as it only points out the observation that preference depends on culture. There is no attempt to show the superiority of the alternative viewpoint in contrast to the rational choice theory. Further, the critic is self-defeatist and does not strengthen the argument for the new paradigm. This is due to the retort that although preference is forged in cultural contexts, the choice process can be studied by rational choice theory once the preference is formed. This argument only serves to enrich the content of rational choice.
Doubt has likewise been cast on the assumption of the maximization of expected utility. In this case, it is assumed that an actor computes and compares expected utilities of alternative choices using utilities of all the possible outcomes with probabilities as weights. A choice is then made amongst the alternatives that would produce the highest expected utility. In this critic, it is argued that actors use ‘prospect’ rather than expected utility when they choose alternatives, with prospect being computed using decision weights rather than probabilities (Sato, 2013). Decision weights are not independent of probabilities. Rather, they are a function of probabilities, which implies that the prospect theory implied here covers a wide variety of decision making processes than the expected utility theory. Hence it is argued that the former generalizes the latter, which enriches rational choice theory. Therefore, the relative explanatory power of the expected utility theory and the prospect theory should be used to decide which one ought to be used in explaining social phenomena.
The second group of critiques focuses on the empirical validity of the assumption of rationality. The assumption does not perfectly reflect the decision-making of actors. Hence, several psychological mechanisms need to be added to the assumption to better ‘explain' the
decision-making. There is a risk of this line of thought confounding the objective of rational choice theory, which is used to explain social phenomena. In rational choice theory, actors are assumed to be rational, and theory attempts to explain a target social phenomenon based on the assumption and the analysis of the actors’ interactions. Failing this, the assumptions that constitute the theory should be revised, including the need to revise the assumption of rationality. For instance, social identity may need to be incorporated into the theory to enrich the concept of rationality and to enhance its explanatory power. However, criticism of the assumptions without regard to the explanatory power of the theory is fruitless.
In contrast to the focus by the first and second groups of critiques of rational choice theory on the theory’s assumptions, the third group questions the explanatory power of the theory. All of these critiques are important as they argue that rational choice theory fails to explain the target social phenomena. For instance, the rational choice theory has been criticized regarding the accounts of the American politics. These politics focus on political phenomena such as voter turnout, the free-rider problem in political collective action, legislative behavior and spatial theories of electoral competition. At the end of which there is a harsh indictment of the failure of rational choice theories to explain these phenomena. In Sato (2013) future directions for the rational choice theory are given. The first direction is a more comprehensive understanding of the interaction between actors and institutions. A second direction is to advance applications of evolutionary game theory and agent-based modeling. Although it has shown steady analytical power in studying micro-to-macro transitions, conventional game theory finds it difficult to deal with a society with a large population. A third direction is to incorporate the concept of social identity into rational choice theory.
The Need for an Alternative Theory of Justice
The imperfections of the rational choice theory described thus far can be summarized as failure to acknowledge that other aspects other than the rational nature of actors are responsible for decisions on choices between alternatives. There are criticisms of preference and utility, the empirical validity of the assumption of rationality, and the question of the explanatory power of the theory. The main ideas of the theory of justice are predicated upon fairness, and different aspects are referred to as being just or unjust. These include laws; social institutions; social systems; and actions of many kinds, including decisions, judgments, and imputations. Also, attitudes and dispositions of persons and the persons themselves can be just and unjust (Rawls, 2009). The theory of justice concerns itself with social justice, and the main subject of justice is the basic structure of society. More specifically, this entails the way in which the major social institutions distribute fundamental rights and duties and the way they determine the division of advantages from social cooperation.
The majority of institutions are included in this context to mean the political constitution and the principal economic and social arrangements. Hence, examples of issues include the legal protection of the liberty of conscience and freedom of thought; private property in the means of production; competitive markets; and the monogamous family. Taken together as one scheme, the major institutions define men's rights and duties and influence their life prospects, what they can expect to be and how well they can hope to achieve. The basic structure forms the principal subject of justice. This is because its effects are not only profound but are also present from the start. The intuitive notion, in this case, is that this structure contains numerous social positions. Further, the idea is that people born into different positions boast different expectations of life. This is determined, partly by the prevailing political system as well as by social and economic environments. As a result, the societal institutions favor some people over others (Rawls, 2009). These are especially deep inequalities. Not only are they pervasive, but they affect men's initial chances in life. Despite this, these inequalities are unjustified by an appeal to the notions of merit or rationality. It is these inequalities, to which the principles of social justice must apply in the first instance. Subsequently, these principles regulate the choice of a political constitution as well as the main elements of the social and economic system.
How fundamental duties and rights are assigned determine the level of justice in a social scheme. It also determines the social conditions and economic opportunities in the various sectors of society. Social justice, thus, can be regarded as providing in the first instance a standard via which the distributive aspects of the society's basic structure are assessed. However, this standard is not to be confused with the principles defining the other virtues. This is because the basic structure and social arrangements generally, may be efficient or inefficient, liberal or illiberal, as well as just or unjust. A complete understanding of the defining principles for all the virtues of the basic structure, together with their respective weights when they conflict, is more than a conception of justice. Rather, it is a social ideal. Likewise, the principles of justice are but a part of such a conception. A social ideal in turn is connected with a conception of society, a vision of the way in which the aims and purposes of social cooperation can be understood. The various conceptions of justice are the outgrowths of various notions of the society against the backdrop of opposing views of the natural necessities as well as opportunities of human life. In order to fully understand the concept of justice, individuals must make explicit the concept of social cooperation from which it derives. But in doing this, they should not lose sight of the special role of the principles of justice or of the primary subject to which they apply.
A Superimposed Theory of Justice Built Upon Decision Theory Construct
The main aim is to propose a blend of a theory of justice with decision theory with the aim of producing a hybrid framework, which represents a different paradigm from the rational choice theory. The main idea is to ensure that it has structures to ensure the right order and as a result of this a just society. This is especially the case when major institutions are arranged and structured in a way that they achieve the greatest net balance taking cognizant of all the individuals in it. Each person in realizing their interest is certainly free to balance his or her losses against the gains. However, the decision theory has to take center-stage. Further, individuals may opt to sacrifice various aspects of their lives for the sake of a more significant advantage in the future. This is because an individual quite often acts, at least when others are not affected, to achieve his or her own greatest good, to advance his rational ends as far as possible. However, this has to be reversed.
Just like the well-being of an individual is constructed based on numerous satisfactions that are attained at different periods in the course of his or her life, the same can be applied to the well-being of society. This is by building upon the fulfillment of the systems of desires of the many individuals who make it up. Since the principal aim of an individual is to advance as far as possible his or her welfare and system of desires, the principal aim of the society ought to be to advance the welfare of the group. Also, the aim should be to realize the comprehensive system of desire derived from the desires of its members. Moreover, just as an individual balances present and future gains against present and future losses, a society may balance satisfactions and dissatisfactions between different individuals. In this regard, the society would be properly arranged when its institutions maximize the net balance of satisfaction. Social justice would be the principle of rational prudence applied to an aggregative conception of the welfare of the group. This idea would be strengthened by the two main concepts of ethics which are right and the good. This is because the concept of a morally worthy person is, undoubtedly, derived from them.
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