What does it mean for something to be right? Or fair? Or just? These ideas—and other concepts within the principle of justice—are challenging, as first we need to answer how we define these terms before we can apply them to clinical scenarios.

As stated by Basil Varkey:

Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Of the several categories of justice, the one that is most pertinent to clinical ethics is distributive justice. Distributive justice refers to the fair, equitable, and appropriate distribution of healthcare resources determined by justified norms that structure the terms of social cooperation… How can this be accomplished? There are different valid principles of distributive justice. These are distribution to each person (i) an equal share, (ii) according to need, (iii) according to effort, (iv) according to contribution, (v) according to merit, and (vi) according to free-market exchanges.

It is understood that these are some of the goals of medical ethics: to establish a system that is fair and just. But the reality of their application is not always as ideal.

A patient in his early 40s recently came to the U.S. to visit family and collapsed. He was taken to the hospital and received an early diagnosis of cancer. The patient is not a legal resident and does not have a “path to insurance”—not through Medicare, Medicaid, private insurance, or otherwise. The cost of treatment is well over $5 million, though the hospital is unable to give an exact amount. Because of this, the patient cannot pay out of pocket.

With treatment, there is a 90% chance of full recovery. Without treatment, death is likely in the near future. The patient would like to pursue treatment.

Does this patient deserve to receive the treatment?

This situation challenges several concepts within the idea of justice. Should this patient receive an equal share? Or receive according to his need? How do we ensure we treat this patient fairly?

If we decide to provide the treatment without any expectation of payment, what about the next patient in a similar situation? Should that person also receive treatment without payment? Is that fair? Is that justice?

Justice and fairness do not always mean unilateral distribution or guaranteed patient satisfaction. Sometimes, in order to uphold justice, some patients might see their access limited. But how can that be a just system—one that expects some to suffer for the benefit of others?

This situation shows how complicated it can truly be to uphold justice.