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How should medical services be distributed within society? Who should pay for them? Is it right that large amounts should be spent on sophisticated technology and expensive operations, or would the resources be better employed in, for instance, less costly preventive measures? These and others are the questions addreses in this book. Norman Daniels examines some of the dilemmas thrown up by conflicting demands for medical attention, and goes on to advance a theory of justice in the distribution of health care. The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services. Access to care, preventive measures, treatment of the elderly, and the obligations of doctors and medical administrations are fully discussed, and the theory is shown to underwrite various practical policies in the area.

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In this essay we examine three competing causal interpretations of racial disparities in health. The first approach views race as a biologically meaningful category and racial disparities in health as reflecting inherited susceptibility to disease. The second approach treats race as a proxy for class and views socioeconomic stratification as the real culprit behind racial disparities. The third approach treats race as neither a biological category nor a proxy for class, but as a distinct construct, akin to caste. We point to historical, political, and ideological obstacles that have hindered the analysis of race and class as codeterminants of disparities in health.

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No country in the world can afford all of the medical care that providers can render to populations. Thus, in every nation governments and private-sector organizations design mechanisms that ration resources in ways that seem compatible with the values of a particular society. For the most part, governments establish these mechanisms, and most of the resources flow through public budgets or at least publicly fashioned funding channels. But in the United States the purchasers of medical care have increasingly favored the allocation of resources through marketlike mechanisms rather than by government regulation. Consumers and providers have found many of these strictures objectionable and have argued that private health plans must be called to greater accountability for their allocation decisions.In this paper Norman Daniels, a philosopher, and James Sabin, a physician, argue that the basis for assuring accountability in a democratic society is through the use of processes that accentuate fairness and openness. In the current political climate, neither party seems prepared to leave the development of these processes to the private marketplace, but whether Congress can achieve consensus on these contentious issues before the end of the 105th session is debatable.Daniels is Goldthwaite Professor and former chair of the Philosophy Department at Tufts University. He has written widely on ethics and public policy, and he recently coauthored a book on the ethical implications of the human genome project. Sabin is an associate clinical professor of psychiatry at the Harvard Medical School and codirects the Center for Ethics in Managed Care sponsored by Harvard Pilgrim Health Care Center and the Division of Medical Ethics at Harvard.

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Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health and healthcare with an account of fair process for setting limits of rationing care. This account is provided by three conditions that comprise "accountability for reasonableness."