Distributive justice and rural healthcare: a case for e-health

Abstract

People living in rural areas make up 20 percent of the U.S. population, but only 9 percent of physicians practice there. This uneven distribution is significant because rural areas have higher percentages of people in poverty, elderly people, people lacking health insurance coverage, and people with chronic diseases. As a way of ameliorating these disparities, e-health initiatives are being implemented. But the rural e-health movement raises its own set of distributive justice concerns about the digital divide. Moreover, even if the digital divide is overcome, e-health services may be of an inferior quality compared to face-to-face medical encounters. In this paper, I argue that before we can fully understand the distributive justice implications of e-health, we must first understand what distributive justice means. I argue that five elements--fairness, quality, accessibility, availability, and efficiency--constitute a general conception of justice and that all of these elements must be considered when evaluating e-health for rural health profession shortage areas. In doing so, it may be necessary to make important tradeoffs among these elements. I then examine the development of e-health programs in light of Rawls's principle of equal opportunity and Daniel's notion of species-typical functioning. I conclude that in the context of e-health, Rawls's principle should be expanded to include geography as a prima facie morally relevant criterion for allocating healthcare benefits. I also conclude that Daniel's notion of species-typical functioning provides grounds for thinking of health and some healthcare services as special goods.