The common good: reviving our social contract to improve healthcare

As a nation, we are becoming increasingly polarised into two philosophical groups, positions that are well described in a recent New Zealand Herald op-ed and an ensuing letter to the editor. The first describes how our government is simply allowing, even perhaps encouraging, privatisation to creep forwards through neglect of its philosophical and economic responsibilities for hospital healthcare.¹ A contrary brief response argues that the government is doing its best against an ever-growing demand for an increasingly expensive service.² We contend that the resurrection of the social contract between government and governed is a constructive way to bring these two positions together for better national health and wellbeing.

The social contract

The notion of a, sometimes implicit and sometimes explicit, social contract between groups or between sovereign/government and the people, to their mutual advantage, has ancient roots.^3,4 It rose to prominence in the seventeenth century, when it became a pledge from powerful monarchs or governments to protect the security and property of the governed, in return for payment in cash, kind, loyalty and service. It became established by habitual use and in statute, and developed along two separate philosophical lines: i) contractarianism—based on all involved parties being motivated to maximise self-interest,⁵ and ii) contractualism—based on morally constrained agreements between those who regard each other as equals, warranting respect.⁶ These two social arrangements have been diversely developed to include many types of human interactions and transactions. Across democratic countries, the choice between them is influenced by the prevailing political philosophies and economic policies of the participating parties.

In the commercial world, neoliberal philosophies declare “the market knows best”; thus, the contractarian line is followed with the intention of maximising profits for owners and investors. Here, time frames are largely determined by short-term strategic planning and profit. Conversely, in public healthcare, where altruistic service is central, and some health-education, prevention and early-intervention programmes might take years to complete, a contractualist social contract is justified,⁷ and can serve the current conception of “the common good”.⁸

Beginning of the welfare state in Aotearoa New Zealand

Until the inception of our universal-access secondary health system in 1938, healthcare was delivered by private providers and charitable institutions. The new system did not cover primary healthcare or adequately address inequitable health and welfare outcomes for Māori, Pacific peoples and all those living in poverty. However, clearly the government of the time was attempting to constructively address their philosophical and economic responsibility for the health and wellbeing of the population. For their part in the partnership with government, the people responded to this responsible contractualist-style leadership by strongly backing the Labour Government involved and by returning it to office at three subsequent elections.⁹

During the second half of the twentieth century, the mix of public and private healthcare here (as in the United Kingdom [UK] and Australia) could be categorised as a liberal health system, where income support and social and health services were only partially funded and were less comprehensive than some other national health systems.¹⁰ Contractarian and contractualist philosophies and economics existed side-by-side in relative harmony, but substantial inequities in wealth, healthcare and welfare outcomes persisted.

Subsequent developments

Since 1990, the social pendulum has swung towards greater contractarian, individualistic immediacy—“it’s all about me; it’s all about now”. Successive governments have followed this social trend and slowly abrogated their responsibility to provide the economic support necessary for the maintenance of the common good and an effectively functioning public healthcare system.¹¹ Supporters of such contractarian individualism claim that the cost of universal access is prohibitively high.² Large international studies have shown, on the contrary, that, in the long-term, universal access to healthcare is the cheapest and most cost-effective system.^12–15 Indeed, investing in healthcare resources across 25 European Union (EU) countries has been shown to yield substantive fiscal multipliers.¹² Unfortunately, it appears some governments either have not believed in such dividends or have erroneously assumed that they are not politically attractive because they would take too long to mature to address short-term political agendas.^12,13 Creeping privatisation in Aotearoa New Zealand is facilitating a decline in government responsibility for comprehensive secondary healthcare.¹⁶

Constructive policy changes can produce health-system improvement. One study has shown that integrating well accepted and appropriate contractualist philosophy and policy can create a more just and equitable health service.¹⁷ Another has suggested how political, philosophical and economic considerations can be combined to help appropriate healthcare policy making.¹⁸ To the surprise of many, data from both the United States (US) and the EU show that the private healthcare sector is not even more efficient than the public sector; indeed, the reverse is more generally true.^19,20 Nonetheless, it is important to acknowledge that an articulated philosophy to underpin our healthcare system is insufficent without also ensuring that this system is built and maintained at an appropriate level of technical and managerial excellence. The current accelerated trend to greater healthcare privatisation will not work to our long-term advantage and will ultimately benefit only an ever-smaller group of the wealthy and powerful, who simply do not care for the common good.^21,22

The solution

We suggest that a way forward for us is to again bring into the centre of our public life a positive, widely canvassed, ethically normative social contract—tailored to our local needs and regularly updated—that establishes:

• the philosophical and economic responsibilities of government that have been shown to be efficient and cost-effective elsewhere.^12,13
• a focus on equity of outcomes rather than equality of access.
• transparency at all clinical, commercial, administrative, managerial and political levels, especially ensuring that contractual details for public works are not kept secret on the grounds of commercial sensitivity.
• short-term political ambitions that are attuned to long-term social needs.
• the reciprocal responsibilities required of our people, particularly a revival of our former egalitarian spirit and, in pursuit of the common good, the necessary industry to increase mutual trust and to make the contract work. These reciprocal responsibilities are reflected in Te Ao Māori values of manaakitanga, kotahitanga, whanaungatanga and kaitiakitanga.

Because twenty-first century governments of all persuasions here have often reneged on their responsibility for leadership, the force for change will necessarily come from our community, our people. They can provide strong, resilient and well-informed advocacy via standing committees of relevant experts and community leaders, including all ethnic, cultural and socio-economically underprivileged groups.

The key challenge involves deciding as a society that we need to re-establish the social contract and to fund the duties and responsibilities that flow from that. The population being older, the non-communicable disease burden being greater and inequity being much more marked are reasons to respond with a system that aims at universal access, not a system that rations on the basis of the ability to pay. Just because tax revenue is constrained under the current income-tax–based system does not mean that there is insufficient wealth in the population to support the needs of an ageing population. A more progressive income tax, a wealth tax, a capital-gains tax or some judicious combination of these can ensure that the healthcare system remains viable into the foreseeable future. Like the social contract, a more equitable taxation system that provides sufficient funding for that social contract is a choice.

Conclusions

Our initial steps in 1938 towards a universal open-access health system were world-leading but imperfect. Subsequent reform should have been focussed on widening the contractualist vision and providing the political and economic support to achieve universal equitable health outcomes. Nearly a century later, we are regressing to an increasingly contractarian philosophy. This will lead us progressively to a US-style health system that is prohibitively expensive, highly inefficient and unacceptably inequitable, and from which we will be unable to extricate ourselves. Right now, we have the opportunity and the capacity to revive the social contract. Do we have the courage and persistence necessary to do so?