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In defence of our model for just healthcare systems: why an explicit philosophy is needed in addition to the law, and how Scanlon helps derive just policies
  1. Caitríona L Cox1,
  2. Zoë Fritz1,2
  1. 1 The Healthcare Improvement Studies (THIS) Institute, University of Cambridge School of Clinical Medicine, Cambridge, UK
  2. 2 Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  1. Correspondence to Dr Caitríona L Cox, The Healthcare Improvement Studies (THIS) Institute, University of Cambridge School of Clinical Medicine, Cambridge, UK; caitriona.cox{at}


In a recent response to our paper on developing a philosophical framework to guide the design and delivery of a just health service, Sarela raises several objections. We feel that although Sarela makes points which are worthy of discussion, his critique does not undermine either the need for, or the worth of, our proposed model. First, the law does not negate the need for ethics in determining just healthcare policy. Reliance on legal processes can drive inappropriate focus on ensuring policies avoid judicial review, as opposed to ensuring they are truly just; the law affords protection against unjust policies but does not put a commitment to avoiding them at the heart of policy-making. We defend the need for Scanlonian supplementation by emphasising the practical value of adding a step based on reasonable rejection, particularly in ensuring that the views of vulnerable stakeholders are robustly considered. We discuss the similarities and differences between the work of Daniels and Sen in considering the relationship between health and opportunity, concluding that Sen’s capability approach is both valuable and compatible with our proposed model. Finally, the practical use of our model requires consideration of what constitutes a reasonable person. Our model is explicitly intended to help develop a healthcare system which is just to all its users. With this in mind, we suggest that those involved in decision-making should meet Scanlon’s definition of reasonable: they should be motivated to justify their actions to, and seek agreement with, others.

  • philosophy
  • ethics
  • policy
  • quality of healthcare

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  • Twitter @drzoefritz

  • Contributors ZF and CLC contributed equally to this work: together they conceived and refined the arguments. CLC produced the first draft, and ZF reviewed and made edits. The final piece is a result of their close collaboration.

  • Funding This study was funded by Wellcome Trust (Grant number: 208213/Z/17/Z).

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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