30 May 2013


There are four potential theories of distribution justice.

The feudal or caste system is the most unjust. Whether a person ends up being a prince or a slave depends solely on the luck at birth but not what he does.

The libertarian system or free market appears to offer equal opportunities, but this is not entirely so. If children from rich families are more likely to receive good education and job opportunities, they still have a huge advantage over poorer people.

In some countries, this potential flaw is tackled by the meritocratic approach. This attempts to offer fair equality of opportunity. For example, the government may provide equal educational opportunities for both the rich and the poor. In USA and China, children of ethnic minorities are even preferentially admitted to the college. (Of course, ethnic minorities are not necessarily poorer. That would be another topic.)

However, John Rawls (1921-2002) argued that even the meritocratic approach cannot totally eliminate inequality. You may provide opportunities to the disadvantaged, but you cannot prevent the fastest runners from winning a race and the cleverest students from entering college. To a certain degree, being fast or clever is also a matter of luck similar to being born in a rich family. The society still produces the retired professor who found no problem in charging his patient an outrageous sum.

Now, you may argue that your success is not the sole result of talent and upbringing; you have worked very hard to achieve what you have today. Rawls would counter by saying that even effort may be the product of a favorable upbringing. Besides, the society pays for your achievements, not your hard work. In this world, there must be soccer players who practise even harder than David Beckham and remain unheard of, but you probably would not advocate that they should be the richest soccer players instead.

Rawls is not saying that successful people should not earn more. This would take away the incentives to work hard and excel. Instead, he wants us to understand that while we are entitled to what we have, we should remain humble and not to think we deserve everything. Instead, earning more is justifiable only if we at the same time help less fortunate people.

23 May 2013


For libertarians, the question is quite unworthy for discussion. So far as the patient is willing to pay and there is no coercion or deceit, charging dearly is not wrong. For instance, you would not object to Lionel Messi’s salary however high it may be. Libertarians favor free market. People should be free to decide what to do with their money. Taxation is unjust because it jeopardizes the ownership. To go one step further, libertarians also believe that people own their bodies and their lives, and therefore do not support moral laws such as those against prostitution.

In contrast, the utilitarian philosophy considers how we may maximize happiness and minimize pain. For example, Jeremy Bentham proposed building beggar workhouses in the 18th century. According to the scheme, beggars in the streets were to be locked up. They would then have to work to pay for the expenses of the workhouses. Bentham reasoned that other citizens would be happier with no beggars in the streets, at a small cost of a few beggars who might be forced to live in places they did not like. The overall happiness, or utility, of the society would nevertheless increase.

At first glance, we may think that utilitarians must support low doctor fees. Patients would be happier, or at least feel less pain, if they can pay less for the same service. However, utilitarians would point out that it depends on whether lowering doctor fees would result in fewer competent doctors joining the profession and deteriorating health care. In the latter case, the utility of the society would actually decrease.

Utilitarian principles are difficult to apply. Above all, happiness cannot be quantified but utilitarians try to measure everything in the same scale. Even if measurement is possible, a popular policy among the majority does not mean it is right. In the era of the Roman Empire, prisoners were forced to fight with tigers and die a brutal death for the entertainment of Roman citizens. Tens of thousands of people were enchanted at the expense of a few prisoners who would die from other punishments anyway, but yet we find the practice hard to accept. Surely overall or average happiness cannot be the sole yardstick we go after.

16 May 2013


Most of us cannot accept what Chopper did. Doctors should not earn money by doing unnecessary and harmful procedures.

In that case, let me tell you another story.

A retired professor performed a 5-minute procedure for a rich man. The accounting clerk saw the bill and was astonished. That was the price of a brand new car. Summoning her courage, the clerk called the professor and asked if he might have added an extra zero by mistake. (She wanted to say two zeroes but thought better of it.)

The professor answered, “I am a famous doctor and he is a rich man. What is the problem with that?”

Now, is this acceptable? This time, the professor did a legitimate albeit simple procedure. Money did not bias his clinical decision. In fact, one may even argue that if he can charge whatever he likes for such minor tasks, the chance for him to offer unnecessary interventions would be lower.

9 May 2013


Recently, my friend told me a story about Chopper.

Chopper, as you may imagine, chops things. As far as the patient can pay, he can chop off anything. Over the years, he has chopped many cancers, but he has also chopped off countless normal body parts. Now, if you persuaded a patient to undergo surgery but the resection specimen turned out to be normal, you would probably blush and wonder how to explain. But not Chopper. He would just knock on the door with a radiant smile and trumpet with his baritone voice, “Congratulations, madam! There was nothing but normal tissue. It was not cancer. You don’t need to worry now.” Time and again, the patient would thank him wholeheartedly, eyes filled with tears.

Last year, a high-ranking official from the Whirlpool Galaxy travelled to Earth. He had cancers spread everywhere. No healer from his galaxy could offer any cure. Chopper was undeterred. “I can chop off your airbags and the oncologists can then take care of the smaller tumors,” he explained.

The official could not live without airbags and died shortly after the chopping procedure. Furious, a group of Whirlpoolers grabbed Chopper and planned to burn him in M51. As luck would have it, Charles Messier learned about the operation and rescued Chopper from the Whirlpoolers. That said, Chopper’s eyes were burnt by the scorching flame of the Sun. If you come across him, you may still see him wearing a pair of extra-large sunglasses.

2 May 2013


What, then, is equality?

According to our young student, equality means rich and poor people should receive the same medical service. Allowing some patients to pay for earlier treatment is discrimination against the poor and jeopardizes their welfare. You may argue that the problem only exists when an institute practises private and public services at the same time. In a broader sense, however, unless the supply of healthcare workers is unlimited, the private market drags manpower away from the public system and affects the waiting time and service quality similarly.

Many people would object to the student’s idea of equality. It violates the freedom of choice. If people are not allowed to buy what they want, there will be limited incentives for working. As my co-interviewer said, this would be the path to communism.

Nevertheless, in the case of medical care, freedom of choice is not the only issue. Most of us would not mind the rich buying a Porsche while the sports cars are inaccessible to people less well-off. In contrast, it would be unacceptable if firefighters would only come after payment by victims. Therefore, the root of the problem is what we consider as essential care.