Justice, objectivity and disability assessment within social insurance medicine. An ethical and scientific-philosophical analysis of three disability models, seen in a historical perspective.
BACKGROUND: Since the middle of the 1990’s, there has been a paradigmatic debate within Norwegian social insurance medicine concerning the biomedical concept of disease and the social function of social insurance medicine.
AIMS: To analyse 1) central criteria of social justice, 2) central criteria of objectivity and 3) to what extent three models of disability assessment fulfil the criteria of social justice as well as the criteria of objectivity within the context of Norwegian social insurance medicine. The three models of disability assessment are: The scale model, which describes a quantitative relationship between a medical condition and the accompanying work disability by means of a scale. The biomedical unifactorial model, which describes disease as the cause of a permanent reduced ability to obtain income under a certain limit. The functional ability model, which, according to WHO’s ICF, utilizes three basic categories for finding descriptions: body functions and structures, activities and social participation.
MATERIAL: The material consists of 1) literature of social and medical history and history of philosophy, 2) Norwegian law texts on disability pension and their preparatory works, written material from administrative practice of The National Insurance Administration and from The Social Security Tribunal, social medical and social insurance medical articles, doctoral dissertations and excerpts from books and The Norwegian Medical Association’s Code of Ethics, all from the period of 1950 to 2005, and 3) a few sources from German medicine and social insurance medicine around 1900.
METHODOLOGY: Text analysis with philosophical methodology, where conceptual analysis has been combined with some aspects of the philosophical hermeneutics of Hans-Georg Gadamer, has been used. Central analytical concepts are the following: Concerning the concept of justice, two kinds of conditions are both necessary and sufficient: the formal principle of justice and one or more material criteria of justice. A sharp distinction is made between the concept of ontological objectivity and that of epistemological objectivity. Ontological objectivity is defined as that which exists independent of knowledge or consciousness. Epistemological objec- tivity is defined as a cognitive performance with a content that is supposed to be valid for all human beings. Ontological subjectivity is defined as that which exists only dependent on the consciousness. A complex medical model of health and disease is constructed on the basis of a pluralistic-holistic ontology. This ontology describes person in nature and society on a physical- chemical, psycho-organic and a human level. The functional ability model is interpreted on an action theoretical basis.
RESULTS: Central criteria of justice within social insurance medicine: Two forms of justice are found fundamental for the disability pension of The National Insurance. The first one is compensatory justice with injury to person as the central criterion of justice. This should continue to be a central criterion. Sickness, injury or defect is the prevailing refinement of this criterion in the disability pension chapter of The National Insurance Act. The second one is distributive/redistributive justice with need, equality and achievement as the material criteria of justice. It is argued that real equality of opportunity for everybody should become a central criterion of redistributive justice of The National Insurance. This is defined in the following way. Various groups in the society should have provable equal possibilities of flourishing and participating in society, included working life. This criterion requires an accurate description of the person’s needs in his or her current environment.
Central criteria of objectivity within social insurance medicine: The central criterion of ontological objectivity is objective findings. This concept is considered to be a sufficient condition for the concept of justice. Based on the distinction between ontological and epistemological objectivity a holistic concept of objectivity is construed. This concept recognizes both an ontological objective and an ontological subjective aspect of the human being. It also requires epistemological objectivity when both these aspects are described. This concept is considered to be a necessary condition for the concept of justice. A criterion of this concept of objectivity is designated the medical holistic criterion of objectivity. It is characterized as a professional description and assessment of the patient’s experience, of body and environment according to a complex medical model of health and disease. The following criteria of epistemological objectivity are proposed: impartiality, intersubjective validity, accuracy and correctness. Attestation should not be misleading. Arbitrariness should be avoided. These are necessary conditions for the concept of justice.
Analysis of the three models of disability assessment: The three models of disability assessment are found to be used to a greater or lesser extent when disability pension claimants are assessed within The National Insur- ance of Norway. There are no problems with the criteria of epistemological objectivity presented above in relation to the three models. The scale model is considered, to a certain extent, to be consistent with the criterion injury to person. The biomedical unicausal model is presently based on a biomedical ad hoc model in Norway, that is, a classical biomedical model that also recognizes ontological subjectivity (illness without disease). This model is also, to a certain extent, considered consistent with the criterion injury to person. According to these two models the claimant of disability pension is not looked upon as an acting person with needs in his or her environment. Therefore they are neither consistent with the criterion real equality of opportunity nor with the medical holistic criterion of objectivity.
A complex functional ability model is proposed which modifies and completes the biomedical model within WHO’s ICF, using the proposed complex medical model for health and disease. Significant activity limitation is proposed as a new refinement of the criterion injury to person. It should replace sickness, injury or defect. The complex functional ability model is considered consistent both with the criterion real equality of opportunity for everybody and the medical holistic criterion of objectivity.
CONCLUSION: Both the scale model and the biomedical unicausal model are considered unsuitable for a medical disability pension assessment in a society aiming at human flourishing and participation. A complex functional ability model is proposed as the best alternative. Significant activity limitation is proposed as the preferential refinement of the criterion injury to person.