Inequalities in health, inequalities in health care: Four generations of discussion about justice and cost-effectiveness analysis

The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed the philosophical landscape and encouraged some in bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice.