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Social Responsibility and Healthcare in Finland

The Luck Egalitarian Challenge to Scandinavian Welfare Ideals

Published online by Cambridge University Press:  27 June 2016

JOHANNA AHOLA-LAUNONEN
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Abstract:

This article examines current trends and prospects in Finnish healthcare literature and discussion. The Finnish healthcare system was long considered to manifest an equal, universal, and solidaristic welfare scheme. However, recent data reveals structural inequalities in access to healthcare that result in health differences among socioeconomic groups. The political will aims at tackling these inequalities, but the ideological trend toward responsibilization of the individual taking place across political spheres elsewhere in Europe creates potential challenges to this goal. The applications of this trend have a theoretical background in the responsibility-sensitive egalitarian—or luck egalitarian—tradition. The theory, which is unfit for real-life policy applications, has explicit appeal in considerations aiming at the responsibilization of the individual within the healthcare sector. It remains to be seen in which direction the Finnish welfare schemes will continue to develop.

Keywords

social responsibilityhealthcare ethicsluck egalitarianismindividual responsibilitysocial determinants of healthegalitarianismwelfare statehealth policyreciprocity
Type
Special Section: Bioethics Beyond Borders
Information
Cambridge Quarterly of Healthcare Ethics , Volume 25 , Issue 3 , July 2016 , pp. 448 - 465
Copyright
Copyright © Cambridge University Press 2016 

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References

Notes

1. Esping-Andersen G. The Three Worlds of Welfare Capitalism. Cambridge: Polity; 1990.

2. For a description of Finnish welfare schemes, see, e.g., Mikkonen, J. Finnish experiences. In: Raphael, D, ed. Tackling Health Inequalities: Lessons from International Experiences. Toronto: Canadian Scholars’ Press; 2012:155–84.Google Scholar

3. Rawls, J. A Theory of Justice. Cambridge, MA: Belknap Press of Harvard University Press; 1971.Google Scholar

4. Holm S, Liss P-E, Norheim OF. Access to healthcare in Scandinavian countries: Ethical aspects. Healthcare Analysis 1999;7:321–30.

5. Takala, T. Justice for all? The Scandinavian approach. In: Battin, M, Rhodes, R, Silvers, A, eds. Medical and Social Justice: Essays on the Distribution of Healthcare. New York: Oxford University Press; 2002:183–90.Google Scholar

6. Nordlund A. Social policy in harsh times: Social security in Denmark, Finland, Norway and Sweden during the 1980s and 1990s. International Journal of Social Welfare 2000;9:31–42.

7. Keskimäki I. Socioeconomic differences and justice in Finnish healthcare [Sosioekonomiset erot ja oikeudenmukaisuus Suomen terveydenhuollossa]. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2010;47:201–7.

8. See, e.g., White, S. The Civic Minimum: On the Rights and Obligations of Economic Citizenship. Oxford: Oxford University Press; 2003.CrossRefGoogle Scholar

9. See note 5, Takala 2002, at 187.

10. Keskimäki I. How did Finland’s economic recession in the early 1990s affect socio-economic equity in the use of hospital care? Social Science and Medicine 2003;56:1517–30.

11. See note 7, Keskimäki 2010; Keskimäki I. Social Equity in the Use of Hospital Inpatient Care in Finland. Helsinki: Research Reports 84, STAKES National Research and Development Centre for Welfare and Health; 1997.

12. Keskimäki I, Koskinen S, Salinto M, Aro S. Socioeconomic and gender inequities in access to coronary artery bypass grafting in Finland. European Journal of Public Health 1997;7:392–7; Keskimäki I, Salinto M, Aro S. Private medicine and socioeconomic differences in the rates of common surgical procedures in Finland. Health Policy 1996;36:245–59; Keskimäki I, Salinto M, Aro S. Socioeconomic equity in Finnish hospital care in relation to need. Social Science and Medicine 1995;41(3):425–31.

13. See note 7, Keskimäki 2010.

14. Van Doorslaer E, Masseria C, OECD Health Equity Research Group. Income-related inequality in the use of medical care in 21 OECD countries. In: The OECD Health Project: Towards High-Performing Health Systems. Paris: OECD; 2004:109–66.

15. Koolman X. Unmet need for health care in Europe. In: Comparative EU Statistics on Income and Living Conditions: Issues and Challenges. Proceedings of the EU-SILC conference. Helsinki: Eurostat; 2007.

16. McCallum AK, Manderbacka K, Arffman M, Leyland AH, Keskimäki I. Socioeconomic differences in mortality amenable to health care in Finland 1992–2003: 12 year follow up using individual level linked population register data. BMC Health Services Research 2013;13(3). doi:10.1186/1472-6963-13-3.

17. Linna M, Häkkinen U, Peltola M, Magnussen J, Anthun KS, Kittelsen S, et al. Measuring cost efficiency in the Nordic hospitals—a cross-sectional comparison of public hospitals in 2002. Health Care Management Science 2010;13(4):346–57.

18. See note 7, Keskimäki 2010.

19. See note 7, Keskimäki 2010.

20. See note 5, Takala 2002.

21. The National Advisory Board on Social Welfare and Health Care Ethics ETENE. Ethical Grounds for the Social and Health Care Field. Helsinki: ETENE-Publications 34, Ministry of Social Affairs and Health; 2012; Socially Sustainable Finland 2020: Strategy for Social and Health Policy. Helsinki: Publications of the Ministry of Social Affairs and Health; 2011.

22. A policy document evaluating possibilities to dismantle the multilayered funding structure of social- and healthcare [Sosiaali-ja terveydenhuollon monikanavarahoituksen purkamisen vaihtoehtoja koskeva selvitys]. Publications of the Ministry of Social Affairs and Health 2015;19.

23. Helen I. The fate of citizenship of health: Notes from new health policy and high-tech medicine [Terveyskansalaisuuden kohtalot: Huomioita uudesta terveyspolitiikasta ja huipputeknologisesta lääketieteestä]. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2008;45:146–54.

24. Walters W. The “active society”: New designs for social policy. Policy & Politics 1997;25(3):221−34.

25. World Health Organization. The World Health Report: Reducing Risks, Promoting Healthy Life. Geneva: WHO; 2002.Google Scholar

26. Clarke J. New Labour’s citizens: Activated, empowered, responsibilized, abandoned? Critical Social Policy 2005;25(4):447−63.

27. Feiring E. Lifestyle, responsibility and justice. Journal of Medical Ethics 2008;34(1):33−6.

28. Smith KE, Hunter DJ, Blackman T, Elliott E, Greene A, Harrington BE, et al. Divergence or convergence? Health inequalities and policy in a devolved Britain. Critical Social Policy 2009;29(2):216−42; Hunter DJ. Choosing or losing health? Journal of Epidemiology and Community Health 2005;59(12):1010−12; Ter Meulen R, Jotterand F. Individual responsibility and solidarity in European healthcare: Further down the road to two-tier system of healthcare. Journal of Medicine and Philosophy 2008;33(3):191−7; Ter Meulen R, Maarse H. Increasing individual responsibility in Dutch healthcare: Is solidarity losing ground? Journal of Medicine and Philosophy 2008;33(3):262−79.

29. See note 5, Takala 2002.

30. The publications surveyed include Duodecim, the leading Finnish general medical journal concentrating on clinical issues, and Journal of Social Medicine (Sosiaalilääketieteellinen aikakauslehti). I surveyed contributions related to lifestyle and individual responsibility from 2007 to 2015.

31. Valkendorff T. Fatness as a self-inflicted problem: Arguments from the Internet discussion forum. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2014;51:4–17.

32. See note 31, Valkendorff 2014.

33. Mustajoki P. Obesogenic food environment explains most of the obesity epidemic [Ruokaympäristön muutos selittää pääosan väestöjen lihomisesta]. Duodecim 2015;131:1345–52.

34. Sarlio-Lähteenkorva S, Prättälä R. Nutrition policies and nutritional inequalities? [Voidaanko ravitsemuspolitiikalla kaventaa väestön ravitsemuksen sosioekonomisia eroja?]. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2012;49:180–8.

35. Poskiparta M, Kasila K, Vähäsarja K, Kettunen T, Karhila P. Dietary counseling in diabetes within primary care [Diabetesta sairastavien ravintorasvojen käytön neuvonta perusterveydenhuollossa]. Sosiaalilääketieteellinen Aikakauslehti—Journal of Social Medicine 2007;44:20–8; Salmela SM, Kettunen T, Poskiparta M. Planning of effective lifestyle guidance intervention—easier said than done? [Vaikuttavan elintapaohjausintervention suunnittelu—helpommin sanottu kuin tehty?]. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2010;47:201–8.

36. The National Advisory Board on Social Welfare and Health Care Ethics ETENE. Borderline between Autonomy and Abandonment from the Ethical Point of View. Helsinki: ETENE-Publications 10, Ministry of Social Affairs and Health; 2004.

37. As argued in Daniels N. Just Healthcare. Cambridge: Cambridge University Press; 1985.

38. Luoto R, Hilakivi-Clarke R, Tomás E. The long shadow of an obese mother [Lihavan äidin pitkä varjo]. Duodecim 2014;130(2):101–2.

39. Vuori I. Health effects of living habits [Elintapojen terveysvaikutukset]. Duodecim 2015;131(8):729–36.

40. Ronald Dworkin put forward the original systematic formulation of a responsibility-sensitive egalitarian position—equality of resources—in which the currency of equality is resources, and redistributive institutions operate to compensate the outcomes of brute luck that people face concerning their resources: Dworkin R. What is equality? Part 2: Equality of resources. Philosophy and Public Affairs 1981;10:283−345. Later luck egalitarian theorists have focused especially on developing the currency of egalitarianism—e.g., G. A. Cohen stated that the proper currency to be distributed is access to advantage (Cohen GA. On the currency of egalitarian justice. Ethics 1989;99:906−44), and Richard Arneson advocated equality of opportunity for welfare, and later, responsibility-catering prioritarianism (Arneson R. Equality and equal opportunity for welfare. Philosophical Studies 1989;56:77−93).

41. See note 27, Feiring 2008; Cappelen AW, Norheim OF. Responsibility in healthcare: A liberal egalitarian approach. Journal of Medical Ethics 2005;31(8):476−80; Cappelen AW, Norheim OF. Responsibility, fairness and rationing in healthcare. Health Policy 2006;76(3):312−19; Buyx AM. Personal responsibility for health as a rationing criterion: Why we don’t like it and why maybe we should. Journal of Medical Ethics 2008;34(12):871−4. For a review of the constructive potential of luck egalitarian applications for taking into account personal responsibility in healthcare policy, see Voigt K. Appeals to individual responsibility for health: Reconsidering the luck egalitarian perspective. Cambridge Quarterly of Healthcare Ethics 2013;22(2):146−58. For a critical review of the issue, see Daniels N. Individual and social responsibility for health. In: Knight C, Stemplowska Z, eds. Responsibility and Distributive Justice. Oxford: Oxford University Press; 2011:266−86.

42. See note 5, Takala 2002.

43. The criticism is extensively considered by Scheffler S. Responsibility, reactive attitudes, and liberalism in philosophy and politics. Philosophy and Public Affairs 1992;21(4):299−323; see also Scheffler S. Choice, circumstance and the value of equality. Politics, Philosophy and Economics 2005;4(5):5−28.

44. Dworkin explicitly offers his theory of equality of resources as a response to the requirements of personal responsibility in the welfare strategy posed by the nonegalitarian critique, by claiming that egalitarian policies maintain a “culture of dependency” (Dworkin R. Sovereign Virtue: The Theory and Practice of Equality. Cambridge, MA: Harvard University Press; 2000:325−8). Also, Cohen points out that one of the achievements of luck egalitarianism is that it succeeded to demonstrate that egalitarians can incorporate “the most powerful idea in the arsenal of the anti-egalitarian right: the idea of choice and responsibility” (see note 40, Cohen 1989, at 933).

45. See note 44, Dworkin 2000, at 323.

46. See note 43, Scheffler 2005; Scheffler S. What is egalitarianism? Philosophy and Public Affairs 2003;31(1):5−39; Anderson E. What is the point of equality? Ethics 1999;109:287−337.

47. According to Rawls, in order to be able to participate in society and to have the capacity to develop and pursue a rational plan of life, which is constitutive of one’s good, society must distribute certain primary goods that are needed independent of a person’s rational plan of life, viz., basic rights, liberties and opportunities, income and wealth, and the social bases of self-respect. These goods are essential elements that citizens need in order to be free and equal persons. See note 3, Rawls 1971.

48. See note 37, Daniels 1985; Daniels, N. Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press; 2008.Google Scholar

49. See note 44, Dworkin 2000, at 73–4, 322–4.

50. See note 40, Arneson 1989.

51. See note 40, Cohen 1989.

52. Mason, A. Leveling the Playing Field: The Idea of Equal Opportunity and Its Place in Egalitarian Thought. Oxford: Oxford University Press; 2006.CrossRefGoogle Scholar

53. See note 46, Anderson 1999.

54. The “moralism of responsibility” is discussed by Scheffler as a way of placing the focus of the reasons for poverty directly on the poor themselves, which enables the well-off to feel that they can take credit for their own success without needing to be troubled for the less fortunate. The moralism of responsibility entails that there is something immoral about being poor (see note 43, Scheffler 2005). A similar moralism can be seen in a moralism of health. As Joel Feinberg notes, if the surveillance of morality is extended to the private sphere of life, the detecting authorities will insult individual privacy by monitoring the citizen’s private life. Feinberg J. Social Philosophy. Englewood Cliffs, NJ: Prentice-Hall; 1973, at 40.

55. Mäki-Kuutti A-M. Health discipline in medical television shows [Terveyskuri television lääkärisarjoissa]. Sosiaalilääketieteellinen aikakauslehti—Journal of Social Medicine 2012;49:44–59.

56. The CEO of the Hospital District of Helsinki and Uusimaa, Aki Lindén, comments on a study that indicated that the costs of social and healthcare services accumulate to a small minority of the population—e.g., the elderly, the disabled, child welfare recipients, substance abuse patients, psychiatric service customers, diabetics, and heart and vascular disease patients. See Leskelä RL, Komssi V, Sandström S, Pikkujämsä S, Haverinen A, Olli SL, et al. Social and health service users in the city of Oulu [Paljon sosiaali- ja terveyspalveluja käyttävät asukkaat Oulussa]. Suomen Lääkärilehti—The Finnish Medical Journal 2013;48:3163–9. Lindén questions the rhetoric of the “heavy user” used in discussing the results by pointing out the magnitude of costs brought by, e.g., premature infants, cancer patients, and victims of serious accidents, none of whom are, however, labeled as heavy users. See Lindén A. Opinions. Helsingin sanomat—Helsinki Times 2015 Mar 15.

57. Saarni SI, Anttila H, Saarni SE, Mustajoki P, Koivukangas V, Ikonen TS, Malmivaara A. Ethical aspects of bariatric surgery [Lihavuuden leikkaushoitoon liittyviä eettisiä näkökohtia]. Duodecim 2009;125(20):2280–6.

58. See note 41, Daniels 2011.

59. See note 43, Scheffler 2005.

60. Knight C. Luck egalitarianism. Philosophy Compass 2013;8(10):924–34.

61. See note 41, Voigt 2013.

62. See note 41, Voigt 2013, at 153.