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From Needs to Health Care Needs

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Abstract

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything.

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Notes

  1. See [2] for a thorough discussion of sufficiency principles and [4] for an interesting account.

  2. A need is sometimes understood as a tension in the organism, examples being the alcoholic’s need for a drink or the heroin addict’s need for heroin. This version of a need does not seem to fit well with an understanding of a health care need and will be ignored throughout this paper.

  3. Needs of this type are sometimes referred to as fundamental or basic needs. However, I shall refer to them as dispositional in order to distinguish them from categorical needs terminologically and also since the property of being dispositional is, I believe, their relevant feature.

  4. Whether needs are best understood in terms of y being a necessary condition for z is discussed below.

  5. Crisp writes “instrumental or constructive”. To say that y is instrumental to z is to say that y is a pure mean to z but to say that y is constructive to z means that y partly constitutes z. This difference plays no important role in Crisp’s discussion and neither in the following text.

  6. Happiness, life satisfaction, welfare, well-being, quality of life and utility can all be said to fall into this category. In this paper I will refer to well-being, by which I mean to signify, in accordance with Sumner [25], “how well it is going for the individual whose life it is” [25:20; italics in original].

  7. It may be argued that DN could be understood as a sub-category of CN (perhaps a very important such category). Furthermore one may ask whether the dispositional needs really are non-circumstantial in the sense that Thomson suggests. However, my aim in this paper is not to make a general conclusion about theories of need but rather to investigate how each and one of them relate to health care needs. Therefore, I will for the sake of the discussion, at this point, relate to them as if they were three distinct ideas.

  8. It may be disputable whether it really is true of all x that they need water in order to avoid harm. In certain end-of-life situations some x may even be harmed by the intake of fluid. I shall ignore this difficulty here.

  9. Liss [15] employs the instrumental idea to characterize the notion of health care need. On Liss’s account a health care need is a gap or a difference between an actual state of health and (his version of z) a desired state of health. His view of health is strongly influenced by Nordenfelt [18], for whom health is, roughly, having the (second-order) ability to achieve one’s vital goals; however, with some minor refinements on the notion of second-order abilities. [See 15: 92–93].

  10. Current needs are sometimes further distinguished, as is done in the Swedish guidelines for priority setting [23], into two categories, health related needs and quality of life related needs. The former category has to do with states which may be restored in some sense, the latter has to do with ones where there is no evident prospect of such restoration but it is rather a question of, for instance, palliative care.

  11. Note that this does not seem to be a question of y being necessary for z but rather of y offering some probability of a more positive prognosis regarding Jack’s condition. This distinction will be further discussed below.

  12. Well-being as well as harm may also be understood in relation to life-span. However, I will for the sake of simplicity not discuss that possibility here.

  13. Wiggins says about this issue that “[w]hat constitute suffering or wretchedness or harm is an essentially contestable matter, and it is to some extent relative to people’s conceptions of suffering of wretchedness and harm. Obviously there is much more to be said about that…but instead let us hurry on” [29:11]. Hope et al. do not take a stand on exactly what it would be for a person to be harmed but it is discussed within the framework of [8] where it is understood in terms of one’s pursuing one’s “vision of the good” or “plan of life”. There are two preconditions for achieving that: first that the person survives, second that he or she is autonomous. [11:471].

  14. Smart is here discussing what he refers to as “Negative Utilitarianism.” However, this issue (as recognized by Griffin [9]) does not concern only Utilitarians but also anyone else who gives weight to people’s well-being.

  15. [E.g. 3, and to some extent 12] Sometimes it is argued that “health” should be the obvious goal here [e.g. 7, 15; cf. 17].

  16. This categorization is rough. All three kinds of theory come in different versions with different refinements. For more extensive discussion of these views, [see e.g. 1, 5, 20, 25; for an alternative framework see 13].

  17. [See e.g. 3] when it comes to the former, e.g. Juth (unpublished) when it comes to the latter.

  18. See e.g. [28]. See also [19] for a discussion of this topic regarding needs.

  19. It may be argued here that x in such a case has a health care need but for some y which then do exist. In this case, for example, a need for palliative care (compare with health related needs versus quality of life related needs in Fn 10), however, this is not the point which is stressed here. The intention here is to capture the need for certain y’s which do not yet exist.

  20. Liss develops his view of necessity in terms of irreplaceability [see 15:53].

  21. Not surprisingly, the reasons for moving from necessity to some weaker condition with regard to health care need seem to apply equally well to many needs for just anything. I shall, however, leave this issue with this observation and restrict the following discussion to health care needs.

  22. The variety of interpretations of Kant’s formula is vast [see e.g. 24].

  23. Sometimes there is a distinction drawn between ability as a competence or capacity and opportunity in terms of the presence or not of external obstacles. For the sake of simplicity I shall assume that ability entails some kind of opportunity.

  24. That y can benefit x means that y is a part of a sufficient condition for x to achieve z.

  25. A further question which needs to be answered is how one should weigh needs where there are interventions available now against needs where there are no interventions available now. This question, however, together with other delicate normative issues falls outside the scope of this essay.

Abbreviations

IN:

Instrumental need

CN:

Categorical need

DN:

Dispositional need

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Acknowledgments

For helpful comments on earlier drafts of this paper I would like to thank Niklas Juth, Lennart Nordenfelt, Ingemar Nordin, Lars Sandman and Stellan Welin.

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Authors and Affiliations

  1. Division of Health and Society, Department of Medical and Health Sciences, Linköping University, 581 83, Linköping, Sweden

    Erik Gustavsson

  2. The National Center for Priority Setting in Health Care, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

    Erik Gustavsson

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Gustavsson, E. From Needs to Health Care Needs. Health Care Anal 22, 22–35 (2014). https://doi.org/10.1007/s10728-013-0241-8

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