CAIRN-INT.INFO : International Edition

1Though it is well known that healthcare is not the only factor that affects health, the economic imperative to provide healthcare in times of cost containment can only be justified by its capacity to affect health status. Cost-cutting has been introduced throughout Europe and the trend has been to compensate for budget reductions by increasing patients’ shares of health expenditure. These “cost sharing” policies are intended to minimalise or eliminate the inefficient or unjustified consumption of healthcare. They aim to establish the types of care or prescriptions that should not be paid for by the state (or social insurance). The identification of a “health basket” defines what should be left to individual responsibility and private finance.

2But the move to cost sharing policies raises problems of its own. Introducing a policy-driven demarcation between public and private expenditure on health presupposes that the inequalities that arise from its operation are legitimate. The ensuing debate about fairness in healthcare relies on a conception of need that opposes individual choices, modelled as preferences, and objective needs, expressed or constructed by society. Moral and political arguments designed to justify health policies in these terms are weakened by the lack of an in-depth analysis of the concept of need. Variable and inconsistent usage of the term allows nothing more than superficial agreement on the nature of the problems in this research area and actively hampers the search for solutions.

3Debates in health economics, though they pose philosophical problems, have developed without reference to the literature on the philosophy of need [Wiggins (1998), Reader (2005), Hamilton (2003)]. This literature permits the reformulation of the concept of health need. It can serve as both a guide and a justification for any particular health policy. Furthermore, it allows for a proper understanding of the specific nature of health over and above its economic aspects (externalities, asymmetric information, uncertainty, etc.).
In the first section, we discuss the problems raised by the attempt to reduce need to individual preference in health economics. These problems have led to a redefinition of need in terms of objective, quantifiable characteristics. But both the preference based approach and the objectivist alternative leave to one side the question of the moral justification of claims of need. In order to reintegrate moral justification, we present David Wiggins’ analysis of the concept of need in our second section. In our third section we build on Wiggins’ insights in an attempt to further develop health economics along institutionalist lines. Our contribution suggests that (against mainstream economics and the dominant trends imported from moral philosophy) needs cannot be read off a universal list nor derived from utility functions, but are instead the product of political processes of negotiation. The choices faced by different polities are constrained by existing institutions that generate specific, situated needs [1].

1 – Implicit and explicit conceptions of need in health economics

4It is widely accepted that individuals whose health status is severely compromised should not be excluded from care for financial reasons. It therefore makes sense to mitigate the effects of cost sharing policies according to some criterion that takes this relative deprivation into account: the obvious idea is to refer in some way to the health needs of the individual. In this sense, need serves as a guide to a policy of selective financing of medical consumption by reducing overall expenditure without sacrificing essential services.

5The concept of need has thus imposed itself as a central component of the mechanism that justifies inequalities in health provision in practice. It addresses the central dilemma of health policy: balancing the search for efficiency (in terms of cost-reduction) with the desire to reduce inequalities (in provision and access to health services), all in an environment of increasing costs [Williams et Cookson (2000), Cutler (2002)].

6Since it is not possible to equalise health status, economic policy adopts the role of rendering access to healthcare more equitable assuming a given set of needs. A presumptively equitable distribution of care can be insured in two ways [McIntyre et Mooney (2007)]: equal access for equal need, which corresponds to an equal opportunity to use the health service; or equal use for equal need, which takes into account actual use rather than opportunity.

7Hence need plays a crucial role in both the theory and policy that relates to healthcare. In an attempt to create horizontal equity (equal treatment for the same need) or vertical equity (unequal but equitable treatment for unequal needs), health economics has drawn on theories of social justice such as Rawlsian minimax and Dworkin’s concept of insurance [Fleurbaey (2006)]. At the same time, need still suffers from a lack of conceptual clarity in the sense that the health problems faced by any given patient can be defined in numerous ways. This fragility of the concept of need has led to serious examinations of its credentials as a theoretical tool within health economics [Culyer (1995), Wagstaff and Van Doorslaer (2000), Asadi-Lari et alii (2003)].

8A seemingly reasonable solution to this problem is to allow individuals to define their own health needs. This solution allows one to avoid endorsing a definition of need imposed from the top (by the state) that might constrain individual liberty [Fleurbaey (2007)]. Beginning with the individual in an attempt to define need in the context of healthcare has another advantage: it does not leave the determination of need in the sole hands of the medical profession. In other words, it does not reduce need to “clinical need” [Cookson and Dolan (2000)]. This move attempts to address a central weakness of the theory of health insurance with moral hazard which, in assuming that patients determine their own expenditure, forgets the discretionary power that doctors have to convert the morbidity of the patient into a pattern of healthcare consumption [2].

9This agent-based research programme (often called “welfarist” in the literature) relies on individual preferences to develop the idea of personal responsibility in health economics. Seen in these terms, personal responsibility provides a moral foundation for subsequent health inequalities. The welfarist approach posits that individual valuations of health status (i.e. of one’s own health) determine which health inequalities are legitimate and which are not [Powers and Faden (2006)]. Giving this theoretical role to preferences leaves it up to individuals to decide between competing needs and makes the patient the final judge of his or her health status.

10Health needs are thus measured by self-reported health status and variations in the level of coverage are justified by appeals to “needs”, which express differences in perceived health status. Accordingly, the distribution of healthcare is designed to correct inequalities and match patients’ needs with healthcare services. If preferences express individual needs, the health basket should take into account the differences between preferences by applying the principle of “equal treatment for the same need”. Instead, however, different individual preferences are used to justify unequal treatment. From this perspective, variations in the distribution of healthcare can be considered equitable if they are the result of heterogeneity in utility functions or differences in rational agents’ valuations of the importance of their own health [Huber (2008), Rochaix and Tubeuf (2009)].

11Reinterpreting need in terms of individual preference changes the range of legitimate inequalities within a health system and has a direct effect on public policy [3]. Considerations of equity now require attention to lifestyles and the extent to which each agent values their health. As Fleurbaey and Schokkaert [(2009)] show, health needs, conceptualised in terms of preferences, not only vary between socio-economic groups but also within them.

12The welfarist approach nevertheless suffers from a number of problems. Most obviously, it assumes that individuals are good judges of their own health status and that declared health corresponds to “real health”. The literature reveals systematic differences in reported health status for individuals who share the same diagnosis but belong to different social groups [Etilé and Milcent (2006)].

13The observed heterogeneity of declared health is a serious impediment to the measurement of health inequalities. Perception of health status and the aspiration to improve it are affected by social and demographic factors such as age, gender, profession and education. Biases and measurement problems lead to the over-reporting of chronic conditions amongst the aged, people with high incomes and those with degrees in higher education. Conversely, less educated segments of the population and students tend to underplay their perception of poor health [Devaux et alii (2008)].

14These empirical results demonstrate that preferences are an inadequate substitute for the notion of health need. They suggest that for any given “real” health status, individuals use different points of reference when responding to surveys. In this sense they lend credence to theoretical studies such as Sen’s [(1993)] analysis of adaptive preferences. For instance, the self-reported health status of poorer people can suffer from a bias towards under reporting health problems as a result of lower health expectations [Tessier (2009)]. The perception of health problems also varies in accordance with time and context. Preferences are influenced, even transformed, by culture and institutions [Bowles (1998), Jan (1998)]. They are also susceptible to cognitive biases [Kahneman, Slovic and Tversky (1984), Tessier (2005)]. These examples provide solid reason to believe that individuals can misidentify what is, in fact, good for them. This suggests the desirability of some sort of mechanism to correct the effects of individual judgment, thus leaving open the door for paternalistic policies. And indeed subjective assessments of health status are regularly supplemented by “objective” corrections through the intervention of experts (doctors or others) who use declared preferences as mere guides to underlying need.
These objections suggest that we should not conflate the notion of objective need and that of preference, as economists have done recently. The extra-welfarist school has challenged preference-based approaches and emphasised those aspects of well-being that are not picked out by expected utility [Culyer (1989), Brouwer et alii (2008)]. Need is instead understood in terms of objective, quantifiable characteristics that define the health status of agents. Whilst utility comes from preference satisfaction, extra-welfarists see need in terms of the objective characteristics that produce well-being in humans.
The objectivisation of need leads to the promotion of a criterion of efficiency linking needs to patients’ capacity to respond to treatment. The criterion of “capacity to benefit” [Culyer (1995)] privileges the consequences of treatment and measures need in terms of health gains. This approach leads naturally to the introduction of certain forms of cost-benefit analysis. In this way, the normatively charged question of how to define health status has been resolved by the introduction of general criteria such as Qalys [4].
But cost-benefit analysis raises a number of moral objections once applied widely within a health system. The consequentialist reasoning which it shares with the traditional welfarist approach fails to provide a satisfactory response to the issue of fairness and equity [Hurley (2000), Mooney (2005), Davis and McMaster (2007)]. Thus, economic analyses that objectify needs face a number of ethically motivated criticisms rooted in the idea that – when it comes to the distribution of care – health policy must reflect ethical values and considerations of social justice. One place to find inspiration for such a project is in recent work on need emanating from moral philosophy. David Wiggins, possibly the most influential modern exponent of the theory of needs, establishes a link between the nature of need and the type of justification that we require for any claim of need to be satisfied.

2 – In search of ethical foundations for need

15Wiggins [(1998), (2005), (2006)] explicitly rejects the welfarist approach described above, instead reconstructing a theory of need that cannot be translated into the language of preferences. His conception also breaks decisively with the extra-welfarists by founding the idea of need on moral justification. Building on the work of Wiggins allows the development of another notion of objective need based on ethical principles (section 2.1). The latter conception is played out in existing health systems that construct the health basket on the basis of general categories that identify needs through moral intuition (2.2).

2.1 – Moral justification

16Both the welfarist and the extra-welfarist approach treat the satisfaction of needs as entirely separable from questions of moral justification According to the latter approach, the objectivity of need is dependent on its detachment from value judgments. In contrast, the conception of an objective need developed by Wiggins is part of an overarching ethical point of view. This is why Wiggins is unsatisfied with the absence of moral criteria in the definitions of need provided by both welfarists and extra-welfarists. Instead, he builds the concept of need on two fundamental characteristics:

  1. Their objective dimension, which rests on the fact that needs refer to the world as it is rather than our beliefs about it (undermines the welfarist approach);
  2. Their necessity, based on the claims of an individual to avoid suffering and on the absence of alternatives such that he could truthfully assert that it is impossible for him to do without the object of his need (undermines the extra-welfarist approach).
The idea of lack or suffering is susceptible to multiple interpretations. But it can be broken down from a generic criterion (to avoiding suffering) into sub-criteria that depend on the characteristics of the state of the individual (degrees of suffering) and the object of need [Wiggins and Dermen (1987)]. These sub-criteria are necessary for the definition of need, but their high level of abstraction makes them unusable for deciding between competing needs. Thus, according to Wiggins, the justification for rules that fix priorities (and thereby access to the health system) should be determined by the best moral and political ideals available. We can seek out and compare these moral and political ideals as the expressions of different institutional configurations.

2.2 – From moral and political ideals to institutional configurations

17Whilst the moral notions that underpin health needs are diverse, we can nevertheless attempt to classify them by using Hasman et alii [(2006)] distinctions. The paper proposes three specifications of healthcare needs based on three criteria of justice that are regularly employed to justify the distribution of care.

  • The criterion of the “poor initial state”, which relies on an ordinal ranking of health states and a threshold intensity for the illness or handicap in question. The more degraded the initial health state is, the greater the need. The application of this criterion generates a moral obligation based on the common desire to prevent death for as long as the patient wishes. On the basis of this obligation it is possible to fix a threshold that distinguishes the worst off patients from those who do not need care.
  • The criterion of minimum normal functioning range. The objective is to improve the health state of the patient to a predefined level, which is deemed necessary for “normal” participation in the life of the community. This criterion relies on the belief that participation in social life is the ultimate goal of human existence.
  • The criterion of significant gain. A required intervention is deemed to be “needed” if it results in an improvement in the health state of the patient that passes some quantitative and arbitrarily defined threshold. This type of reasoning in terms of “degree of healthcare” relies on the notion of relative (and non-absolute) improvement in the health state of the patient. It presupposes a cardinal rather than ordinal measure of health states. This criterion relies on the intuition that individuals must have the capacity to benefit in some significant sense from the improvement of their health states in order to assert a claim of need.
These criteria can be used to illustrate the definition and priorities of public policy. They are combined differently in different European health systems. The cases of France and the UK, which have very different health systems [5], provide an interesting comparative illustration (Table 1).

Table 1

Specifications of Need. The cases of France and the UK

Table 1
Prioritise according to United Kingdom National Health Service France Insurance system The criterion of the “poor initial state” Defining emergency care, when admission is unpredictable, fix the obligations of NHS (no waiting list) Exemption of co payment for (elderly) people with serious diseases The criterion of minimum normal functioning range Socioeconomic criteria like average income and level of education in the weighted capitation allocations to regional health authorities Free supplementary health insurance plan (household income less than 606 in 2008 for a single person) The criterion of significant gain National negatives list of drugs. Local complementary positive list “guidances” and economic evaluation of the gain Positive list of pharmaceutical specialties reimbursable (Evaluation by the improvement in therapeutic value of the drug) Regulatory praticed guidelines

Specifications of Need. The cases of France and the UK

18The application of these different criteria represents an attempt to address the numerous ethical dilemmas that arise in the management of a public health system [6]. In each case, the criteria that justify a particular intervention depend solely on the health of the patient or the group of patients concerned and not on comparisons, trade-offs or calculations of individual expected utility. But the application of these criteria simply reintroduces the dilemmas in the sense that the trade-offs are made implicitly when the thresholds for relevant classificatory variables (whether an illness is long-term or serious, or considerations of income, residential status, education, etc.) are decided. This type of problem does not seem to be resolvable without considering processes of social negotiation and consensus building in the discussion of healthcare needs [Baertschi (2002)].

3 – An institutionalist approach to need

19Though there are notable modern precursors in the philosophy of economics [Lawson (1997), Pratten (1997)], institutionalists have been the main proponents of an objective conception of need in health economics whilst maintaining a critical stance towards extra-welfarism [Davis (2001), Mooney (2005), Batifoulier and Gadreau (2005), McMaster (2007), Hodgson (2008)]. The institutionalist approach takes into consideration the central importance of ethical considerations in identifying health needs without conflating them with preferences and without reducing need to the maximisation of health gains. In section 3.1 we show how this approach, rooted in moral philosophy, defends the concept of objective need in health economics and avoids the problems of the positions discussed above. In the following section (3.2), we present and develop a dynamic theory of healthcare needs that complements existing approaches by focussing attention on the political process. Our emphasis in the final section (3.3) is on the emergence and consolidation of situated healthcare needs, and on the mechanisms that permit them to be framed as legitimate claims on the health system.

3.1 – Institutionalism in health economics and the problem of universal needs‑lists

20Institutionalists seek meta-theoretical support for their position in moral philosophy and in particular in the systematic and prescriptive accounts of human need that have been articulated as lists during the last twenty-five years [Braybrooke (1987), Doyal and Gough (1991)]. These accounts consist of comprehensive and ordered rankings of needs that are judged to be universally applicable and rooted in human biology and psychology. The need for physical health or some conception of tolerable physical functioning is unsurprisingly a key feature of needs-lists [Doyal and Gough (1991), p. 56-59, Braybrooke (1987), p. 32]. Lists tend to rely on the identification of needs and their invocation in policy-making as entitlements. Consequently, once a need can be identified and included in the list, provision for it is not a matter of political negotiation. Every member of the population has a claim to his need being met, regardless of cost or practical implications.

21The universal scope of needs lists has important consequences. When they address healthcare directly, needs lists place overriding emphasis on the provision of preventative public health measures and basic primary care [Doyal and Gough (1991), p. 201-204]. This is based on the realisation that if comprehensive medical coverage were required – for example by admitting the imperative to extend life indefinitely as a basic human need – healthcare would become a “bottomless pit” into which financial resources are poured at the expense of other needs [Braybrooke (1987), p. 293-295]. The problem of healthcare is so acute that, according to Braybrooke, it constitutes a “breakdown of the concept of needs” to which lists provide no obvious answer [ibid., p. 301]. It is therefore difficult to see how needs lists could be effectively translated into guidance for health policy.

22So, whilst we have proposed that a closer understanding of the concept of need will help to advance debates in health economics, most philosophical theories of need do not provide a method for doing so. The strain on public health services that forms the central policy problem of health economics is not principally caused by a decline in the provision for basic primary care (this care tends to be provided as a matter of course in modern socialised health systems); rather, it is a direct consequence of the increased range and effectiveness of modern medicine. Many diseases and conditions that were untreatable can now be treated (often at great expense) and there is a public expectation that they should be.

23An important reason for the breakdown of this conception of need is that the category of “health needs” articulated in needs-lists is too broad to serve as a guide for framing policy [7]. Some institutionalists attempt to redress this problem by recognising that health economics is better understood as being concerned with the provision and distribution of medical services to meet healthcare needs rather than health needs. The literature does not appear to have converged on a definition of the latter, but it is clear that healthcare needs are different in important respects. First, they are subject to re-evaluation due to demographic and environmental factors as well as the complexity and diversity of institutional frameworks. Second, there is a powerful link between the identification of healthcare needs and the development of their satisfiers (medical technology, treatment and diagnostic techniques and medication). This focus on healthcare needs has caused institutionalists to question health economists’ search for principles of distribution that would lead to social optima in favour of a process of democratically informed institutional design [Hodgson (2008), p. 248] [8].
We wish to add to this proposal by further investigating the political dimension of healthcare needs. Thus far, the two main elements of institutionalist health economics – the advocacy of the concept of objective need and the reform of health economics – are relatively independent of each other. There is no explicit connection between the recognition of the objective basis of healthcare needs and a specific normative basis for institutional design. In other words, the recognition of healthcare needs does not lead to a hierarchy of essential services, or a mechanism for determining what this might look like. As with Hasman et al’s approach, intuitions about the distinction between human need and preference offer limited practical help in fixing a hierarchy to facilitate the allocation of resources. In the following section, we argue that the needs lists developed by philosophers can be replaced by a practically orientated theory of need that recognises the institutional element of healthcare provision and proposes a dynamic method for determining need.

3.2 – The political dimension of needs

24The limits of needs lists are much discussed. Two general challenges to the idea of a universally applicable list relate to its presumption of universality. Even on the most sophisticated construal of what needs are, contingent factors relating to time and location play a constitutive role in the determination of which needs are (or are not) included in any particular list [9]. Would it make sense, for instance, to consider human needs to be completely invariant over time such that our current needs are the same as those of mesolithic hunter-gatherers? Even within a given historical period, is it not imperialistic to assume that lists conceived in Western universities should apply transculturally? These challenges are motivated by the view that a comprehensive list a) would include needs that do not relate directly to facts about human biology; and b) would not be static [10].

25Since we can safely assume that some connection between specific healthcare needs and human biology can be established, it is (b) (the dynamic element of need) that will concern us here. In an original and wide-ranging book, Lawrence Hamilton [(2003)] provides an outline of what a dynamic political theory of needs might look like. Hamilton’s stated aim is to bring the accounts of needs emerging from moral philosophy into line with the practice of politics. The originality of his account lies in the links he attempts to re-establish between need and want and their consequences for the development of a viable institutionalist conception of healthcare needs [11].

26The construction of the dynamic approach turns on a reappraisal of the ontology of needs. Hamilton relates needs to our capacities for human functioning from two perspectives. His first category, vital needs, reflects a concern with physical survival; these needs must be satisfied in order to create the necessary conditions for healthy human functioning. His second category, agency needs, relates to the psychological and social conditions necessary for survival; these needs must be satisfied in order to create the conditions for full human functioning. These two abstract categories of needs are manifested through the wants and aspirations of individuals and groups. Hamilton refers to these more concrete and visible goals as particular social needs. The importance of his final move is paramount in identifying Hamilton’s approach as a departure from standard philosophical approaches. His intention is to retain Wiggins’ distinction between wants and needs whilst introducing a new dynamic element: needs and wants are synchronically distinct, but diachronically, specific wants can become needs. Needs should not be seen as static because they respond to the changing social and physical environment. In particular they are central to the functioning of political processes:


Needs emerge out of wants because the repeated satisfaction of a specific want, given the right conditions and the commonality of the want, transforms the felt want into a common requirement, into a sine qua non of normal existence.
[Hamilton (2003), p. 67]

28The dynamic theory emphasises the role of legitimation in transforming the objects of desire into necessities through mimetic processes, technological advances and political interventions [12].

29Hamilton outlines three ways in which particular social needs can be generated [ibid., p. 66-71]. Typically, abstract needs become political once they are expressed as claims against some centralised authority such as the state; usually using the formula “A needs X in order to Y”. The historical process that enshrines some such claim as a claim of need as opposed to a simple desire or request can be charted through the growth of institutions that act as satisfiers. In some cases, this may be traceable by historical analysis. The agencies that satisfy needs are usually created following public debate and legislation, as is the case with national health services [13].
The second case is more difficult to identify. Here non-verbal behaviour (attitudes, norms, etc.) acts as the legitimating force behind a particular claim. In these cases the standard formula may not be usable and the claim may be harder to circumscribe. But these informal cases are also potential need generators.
The third case is when a need claim is instigated as a radical reform. This case is substantially different because, instead of reflecting a commonly held perception about the way the world is, needs claims can be made with the intention of deliberately changing it. Radical need claims are absent from much of the literature on needs because they violate the powerful conceptual link established between need and lack: radical need claims cannot correspond to a lack since they identify a new need that had no satisfiers before the claim was made [14]. These arguments challenge the simplistic dichotomy between preferences and objective needs.

3.3 – The justification of healthcare needs and the political process

30Early needs theorists were at pains to establish and defend the distinction between need and desire and the inadequacies of the concept of preference are well documented. Once needs are treated in the above manner, do we not run the risk of re-introducing the conflation between preference and need? We believe that this is not the case. To see why this is so, it will be useful to locate Hamilton’s dynamic theory in a tradition of institutionalist theorising that emphasises needs whilst at the same time recognising the importance of social context.

31Thorstein Veblen’s [(1914)] famous inversion of the proverb “necessity is the mother of invention” was not merely a clever play on words; it was an astute description of a process that affects commodity-producing economies. Whilst at the time standard economics presupposed that the production of goods must correspond to pre-existing preferences in the form of demand, Veblen demonstrated that this is often not the case. The causal process can be reversed. The production and distribution of satisfiers can create a need for them. This is perhaps easiest seen in the case of a new technology where satisfiers (commodities such as computers) are generally produced before they correspond to any felt need in the population of potential users. Once available, they become causally implicated in the generation of new needs (for instance, the needs for information, connectivity, communication, etc.).

32This poses a threat to the traditional economic perspective when applied to healthcare, because economists make little allowance for the special characteristics of health. Insofar as healthcare is treated as a commodity, it is valued in the same manner as any other: through the market [McMaster (2007), p. 14]. But whilst on the institutionalist account all goods and services can generate preferences, only some can act as satisfiers and generate needs.

33How does the institutionalist perspective relate to the framing of healthcare needs? Medical conditions are related to some form of physiological lack or deficiency. This appears to support the view that they are independent of our knowledge and social arrangements and that they pre-exist any solutions or remedies. However, healthcare needs – those needs that relate directly to the provision of healthcare services – are not so straightforward. In the context of the institutionalist theory discussed above, healthcare needs can be seen as particular social needs that arise from the vital needs of individuals. The physiological condition of the patient is a necessary, but not a sufficient condition for the legitimacy of his claim of need. This provides a way of distinguishing between need and preference that does not assert the existence of a necessary connection between the identification of a specific condition and an obligation to satisfy it. The invocation of particular social needs helps in two ways. First it accounts for the time-sensitive aspects of healthcare needs by emphasising the importance of the creation and provision of satisfiers. Second it recognises the importance of social processes of legitimation and incorporates them into the conceptualisation of need. In addition, the rejection of the open-ended obligation to satisfy a need is a desirable feature for any viable theory of health economics, because the framing of any claim on the healthcare system as a claim of need (rather than a desire) is intricately bound up with changing conceptions of healthy and full human functioning.

34It is worth noting that empirical studies in health economics [Nguyen-Kim et alii (2005)] clearly demonstrate that implicit conceptions of healthy and full human functioning in fact vary across health systems and vary with changes in medical knowledge and social mores [15]. This is explained in part by the fact that the assessment of healthcare needs cannot be dissociated from clinical attitudes and developments in diagnostic and treatment techniques. In this way, “different” healthcare systems rely asymmetrically on different social processes that legitimate provision for some conditions and exclude others. An adequate conception of healthcare needs should take into account this tangible connection between needs and the specific institutional fabric that satisfies them [McMaster (2007), p. 16].
An ontological focus on the nature of needs and the mechanisms that can generate them reveals problems associated with the universalising tendency of modern needs theory. A claim of need is not equivalent to a desire, yet within health economics a nuanced view of the relationship between want and need is essential. What we have called the diachronic transformation of wants into needs – over time and with the mediation of institutions – is a common occurrence in modern welfare states. A theory of need that can recognise this political process and incorporate it is crucial for the development of a successful institutionalist health economics. It suggests that if healthcare needs emerge as a consequence of social, political and technological transformations, then the analysis of healthcare needs must become more empirically focussed and more explicitly normative. Debates should centre on why we consider some claims on the healthcare system to be claims of need rather than matters of personal choice. This implies a focus on processes of public and professional legitimation and the institutions that support and frame them. The current approach to health economics does not allow this.


35This article develops the institutionalist contribution to health economics by bringing out the importance of social processes and moral and political ideals in guiding health policy. In much the same way as the “communitarian claims” approach [Mooney (1998), (2005)], we emphasise the importance of claims of need, the values expressed by citizens, and the political processes that fix priorities in determining health policy. We do not, however, find inspiration for our arguments in Sen’s capability approach, but rather in a literature that is generally ignored by economists: the philosophy of need.

36We attempt to rehabilitate a conception of objective need that is both distinct and opposed to that of the extra-welfarists in health economics. In so doing, we investigate two related avenues for conceptualising need. First we discuss Wiggins’ approach, which is rooted in a conception of objectivity that relates need to our best moral theories. His conception is crucial for driving a wedge between need and preference, and for understanding health needs as rooted in the vital needs of human agents. The second avenue for conceptualising needs in health economics is inspired by Hamilton’s political theory of needs. This approach emphasises the emergence of objective healthcare needs as particular social needs expressed in specific institutional contexts.


  • [*]
    Draft versions of this paper were presented at the “Séminaire Conventions” (University of Paris Ouest Nanterre La Défense) and the “Cambridge Realist Workshop”, where we received insightful comments and criticisms. We would also like to thank Bernard Baertschi, Louise Braddock, Robert McMaster, Tony Lawson and two referees of this journal for detailed comments and suggestions.
    Philippe Batifoulier: EconomiX-Paris Ouest.
    John Latsis: Balliol College, Oxford University.
    Jacques Merchiers: EconomiX-Paris Ouest.
  • [1]
    The recognition of the contingent features of some needs does not entail that they are matters of personal choice or whim.
  • [2]
    Hence the notion of supplier induced demand, which is a common feature of models in health economists [Evans (1974), Rice (1983)].
  • [3]
    The “ordinary” challenge of healthy policy in European countries is to fill the gap between the unmet needs of the poor and the care (in particular the access to specialist doctors) that the rich receive. This inequality index (along with Lorenz curves and a Gini concentration coefficient) is used by the international network Ecuity.
  • [4]
    Qalys are discussed by other papers in this special issue.
  • [5]
    The French National Health Insurance System (social security) is preparing a targeted withdrawal of basic insurance. The construction of a health basket has been used to limit the rising co-payments. In the British system, the health budget is allocated centrally. The concept of need has been mobilised in order to effectively guide healthcare rationing and fix priorities in a context where waiting lists for non-urgent hospital care are an important drawback. These limitations led to the NHS 2000 plan, which aims to provide a more fine-tuned but less restrictive guidance for rationing at the regional or local level.
  • [6]
    Examples of ethical dilemmas include questions about priorities. For example, should the health services concentrate on treating serious conditions that are relatively rare, or less serious conditions that are widespread? Another problem relates to deciding whether to prioritise older or younger patients suffering from the same condition.
  • [7]
    For instance, social policies in such areas as sanitation, traffic, pollution and crime are fundamental to meeting health needs. Similarly, non-medical care work, done infor-mally in communities or within families, is crucial to maintaining health. Unlike these examples, most of what we discuss relates directly to clinical or medical care.
  • [8]
    This echoes earlier critical contributions to the health economics literature that see themselves as consistent with the institutionalist tradition but do not directly invoke an objectivist conception of need [Jan (1998), McMaster (2002)].
  • [9]
    We are not claiming that these challenges are decisive, nor that modern proponents of needs lists are unaware of these difficulties. Indeed, some authors, such as Braybrooke attempt to address them [Braybrooke (1987), p. 90-104].
  • [10]
    Amongst other things, the fact that existing lists do not have identical content indicates the prima facie plausibility of these general challenges.
  • [11]
    Though he defends a theory of need himself, Hamilton is unequivocally negative on the prospects of needs-lists: “Consequently, it is assumed that these theoretical lists of preconditions or needs resolve the problem of needs, and as such theorists who develop these lists repeat the follies of natural law and natural rights: they propose a meta-political theoretical solution for an inherently practical, political problem” [ibid., p. 48]. Nevertheless, Hamilton’s approach echoes Wiggins’ pioneering work on need and is intended to be consistent with it [Hamilton (2006), p. 263].
  • [12]
    Of course this can work the other way as well. Braybrooke provides an example of Karl Marx and Adam Smith’s inclusion of shirts in their respective discussions of the prime necessities of life [Braybrooke (1987), p. 101].
  • [13]
    Studies of this type have already been successfully conducted in other areas. For instance, conventionalist economists charted the emergence of systems of unemploy-ment provision through changing conceptions of juridical, statistical and popular conceptions of individual worth and corporate responsibility [Salais et alii (1998), Latsis (2006)].
  • [14]
    Hamilton argues that the excessive reliance on the idea of objective harm caused by lack is not warranted. It is not the case that I only need what I lack; many things that I already have correspond to or satisfy my needs. Hence, a focus on lack will be insensitive to those needs that are already politically and socially catered for. But this is not the only problem. A focus on lack obscures the fact that new needs arise regularly with the appearance of new technologies or changing social conditions. The crux of this element of Hamilton’s critique of needs lists is that, by emphasising lack and downplaying drives and wants, list-makers exclude many of the problems that a political theory of need aims to address.
  • [15]
    Variations in the types of treatment that are provided free of charge, or with heavy subsidies, are a good indicator of the changeable social status of claims of need. See for instance the table in Nguyen-Kim et alii [(2005), p. 4].


La notion de besoin joue un rôle crucial pour définir les inégalités légitimes en matière de santé. Le débat sur l’équité en santé se développe néanmoins dans la méconnaissance de la philosophie du need. En mobilisant des argumentations de nature morale ou politique, cet article cherche à élaborer une notion de besoin qui ne repose ni sur une liste universelle ni sur des préférences individuelles mais sur un choix de préférence sociale qui légitime les revendications de besoin. Il propose à cet effet une approche institutionnaliste du besoin insistant sur les processus sociaux qui créent ou consolident des besoins de soins spécifiques et situés.


  • besoin de soins
  • distribution des soins
  • équité
  • économie institutionnaliste
  • philosophie de l’économie


The concept of need plays an essential role in defining legitimate health inequalities. The debate on equity in healthcare policy has so far evolved independently of the philosophical discussions of need. This article draws on moral and political philosophy in order to develop a conception of need that goes beyond the current dichotomy between universal lists and individual preferences. We propose an institutionalist approach to needs that emphasises the role of social processes in creating and consolidating specific and situated healthcare needs.
JEL : I11, I18, D63, B52


  • healthcare needs
  • health care priority setting
  • equity
  • institutionalist economics
  • philosophy of economics


  • Asadi-Lari M., Packham C. and Gray D., 2003, “Need for redefining needs”, Heath and Quality of Life Outcomes, p. 1-34.
  • OnlineBaertschi B., 2002, « Justice et santé. Chacun doit-il recevoir des soins en proportion de ses besoins ? », Revue de Métaphysique et de Morale, vol. 1, n°33, p. 83-101.
  • Batifoulier P. et Gadreau M. (éds.), 2005, Éthique médicale et politique de santé, Paris, Economica.
  • Bowles S., 1998, “Endogenous preferences: the cultural consequences of markets and other economic institutions”, Journal of economic literature, vol. XXXVI, march, p. 75-111.
  • Braybrooke D., 1987, Meeting Needs, Princeton, Princeton UP.
  • OnlineBrouwer W., Culyer A., Van Exel J. and Rutten F., 2008, “Welfarism vs extra-welfarism”, Journal of Health Economics, 27, p. 325-338.
  • OnlineCookson R. and Dolan P., 2005, “Principles of justice in health care rationing”, Journal of Medical Ethics, 26, p. 323-329.
  • OnlineCulyer A., 1989, “The normative economics of health care finance and provision”, Oxford review of economic policy, vol. 5, n°1, p. 34-58.
  • Online– 1995, “Need: the idea won’t do – But we still need it”, Social Sciences and Medicine, vol. 40, n°6, p. 727-730.
  • OnlineCutler D., 2002, “Equality, efficiency, and the market fundamentals: the dynamics of international medical-care reform”, Journal of economic literature, vol. XL, Sept, p. 881-906.
  • OnlineDavis J. and Mcmaster R., 2007, “The individual in mainstream health economics: a case of persona non-grata”, Health care analysis, n°15, p. 195‑210.
  • OnlineDavis J.B. (ed.), 2001, The Social Economics of Health Care, London, Routledge.
  • OnlineDevaux M., Jusot F., Sermet C. et Tubeuf S., 2008, « Hétérogénéité sociale de déclaration de l’état de santé et mesure des inégalités de santé », Revue française des affaires sociales, janv.-mars, p. 29-47.
  • Doyal L. and Gough I., 1991, A Theory of Human Need, London-New York, The Guilford Press.
  • OnlineEtilé F. and Milcent C., 2006, “Income-related reporting heterogeneity in self-assessed health: evidence from France”, Health economics, 15, p. 965-981.
  • OnlineEvans R., 1974, “Supplier-induced demand: some empirical evidence and implications”, in M. Perlman (ed.), The economics of health and medical care, London, Macmillan, p. 162-173.
  • OnlineFleurbaey M., 2006, “Health, equity and social welfare”, Annales d’économie et de statistiques, 83-84, p. 21-59.
  • Online– 2007, « Le revenu équivalent-santé, un outil pour l’analyse des inégalités sociales de santé », Revue d’épidémiologie et de santé publique, 55/1, p. 39-46.
  • Online— and Schokkaert E., 2009, “Unfair inequalities in health and health care”, Journal of health economics, vol. 28, n°1, p. 73-90.
  • OnlineHamilton L., 2003, The Political Philosophy of Needs, Cambridge, Cambridge UP.
  • Online– 2006, “The context and argument on the political philosophy of needs”, South African Journal of Philosophy, 25 (3), p. 224-232.
  • OnlineHasman A., Hope T. and Osterdal P., 2006, “Health Care Need: Three Interpretations”, Journal of Applied Philosophy, vol. 3, n°2, p. 143-156.
  • OnlineHodgson G., 2008, “An institutional and evolutionnary perspective on health economics”, Cambridge Journal of Economics, 32, p. 235-256.
  • OnlineHuber H., 2008, “Decomposing the causes of inequalities in health care use: a micro-simulations approach”, Journal of health economics, vol. 27, n°6, p. 1605‑1613.
  • Hurley J., 2000, “An overview of the normative economics of the health sector”, in A. Culyer and J. Newhouse (eds.), Handbook of health economics, vol. 1A, chap. 34, Amsterdam, North Holland, p. 56-118.
  • OnlineJan S., 1998, “A holistic approach to the economic evaluation of health programs using institutionalist methodology”, Social Science and Medicine, vol. 47, n°10, p. 1565-1572.
  • Kahneman D., Slovic P. and Tversky A., 1984, Judgement Under Uncertainty, Heuristics and Biases, Cambridge, Cambridge UP.
  • OnlineLatsis J.S., 2006, “Convention and Intersubjectivity: New Developments in French Economics”, Journal for the Theory of Social Behaviour, vol. 36, n°3, p. 255-277.
  • OnlineLawson T., 1997, Economics and Reality, New York, Routledge.
  • OnlineMcintyre D. and Mooney G., 2007, The economics of health equity, Cambridge, Cambridge UP.
  • OnlineMcmaster R., 2002, “A Socio-instutionalist Critique of the 1990s’ Reforms of the United Kingdom’s National Health Service”, Review of Social Economy, vol. 60, n°3, p. 403-433.
  • – 2007, “On the need for a heterodox health economics”, Post-Autistic Economics Review, vol. 41, p. 9-22.
  • OnlineMooney G., 1998, “Communitarian claims as an ethical basis for allocating health care resources”, Social Sciences and Medicine, vol. 47, n°9, p. 1171-1180.
  • Online– 2005, “Communitarian claims and community capabilities: furthering priority setting? », Social Sciences and Medicine, vol. 60, p. 247-255.
  • Nguyen-Kim L., OR Z., Paris V. and Sermet C., 2005 “The politics of drug reimbursement in England, France and Germany”, IRDES, Health economics letter, n°99.
  • Powers M. and Faden R., 2006, Social justice: the moral foundations of public health and health policy, Oxford, Oxford UP.
  • Pratten S., 1997, “Needs and wants: the case of broadcasting policy”, Centre for Business Research Working Papers (64), University of Cambridge.
  • Reader S. (ed.), 2005, The Philosophy of Need, Cambridge, Cambridge UP.
  • OnlineRice T., 1983, “The impact of changing medicare reimbursement rates on physician-induced demand”, Medical care, vol. 21, n°8, p. 803-815.
  • OnlineRochaix L. et Tubeuf S., 2009, « Mesures de l’équité en santé : fondements éthiques et implications », Revue économique, vol. 60, n°2, à paraître.
  • Salais, Baverez et Reynaud, 1998, L’invention du chômage, Paris, PUF.
  • Sen A., 1993, Éthique et économie, Paris, PUF.
  • OnlineTessier P., 2005, « La réconciliation des mesures des préférences sur la santé dans le certain et dans le risque », Revue d’économie politique, vol. 115, n°6, p. 779-799.
  • Online– 2009, « Harsanyi, Sen ou Bentham : qui suivre pour évaluer le bien être en santé ? », Revue économique, vol. 60, n°1, forthcoming.
  • Veblen T.B., 1914, The Instinct of Workmanship and the State of the Industrial Arts, New York, Macmillan.
  • Wagstaff A. and Van Doorstaer E., 2000, “Equity in health care finance and deliver », in A. Culyer and J. Newhouse (eds.), Handbook of health economics, Amsterdam, North Holland, vol. 1B, chap. 34, p. 1803-1862.
  • Wiggins D., 1998 (1987), Needs, Values, Truth, Oxford, Clarendon Press.
  • – 2005, “An Idea we Cannot do Without”, in S. Reader (ed.), The Philosophy of Need, Cambridge, Cambridge UP, p. 25-50.
  • – 2006, Ethics, Twelve Lectures on The Philosophy of Morality, London, Penguin Books.
  • Online— and Dermen S., 1987, “Needs, Need, Needing”, Journal of Medical Ethics, vol. 13, p. 61-68.
  • Williams A. and Cookson R., 2000, “Equity in health”, in A. Culyer and J. Newhouse (eds.), Handbook of health economics, Amsterdam, North Holland, vol. 1B, chap. 35, p. 1863-1910.
Philippe Batifoulier
John Latsis
Jacques Merchiers [*]
  • [*]
    Draft versions of this paper were presented at the “Séminaire Conventions” (University of Paris Ouest Nanterre La Défense) and the “Cambridge Realist Workshop”, where we received insightful comments and criticisms. We would also like to thank Bernard Baertschi, Louise Braddock, Robert McMaster, Tony Lawson and two referees of this journal for detailed comments and suggestions.
    Philippe Batifoulier: EconomiX-Paris Ouest.
    John Latsis: Balliol College, Oxford University.
    Jacques Merchiers: EconomiX-Paris Ouest.
This is the latest publication of the author on cairn.
Uploaded on on 16/12/2014
Distribution électronique pour Vrin © Vrin. Tous droits réservés pour tous pays. Il est interdit, sauf accord préalable et écrit de l’éditeur, de reproduire (notamment par photocopie) partiellement ou totalement le présent article, de le stocker dans une banque de données ou de le communiquer au public sous quelque forme et de quelque manière que ce soit.
Loading... Please wait