D. Micah Hester thinks the residency match system helps sustain the divide between the haves and the have-nots in healthcare. He believes that the match system channels talent away from the have-nots in a more or less systematic way, damaging moral values in physicians as it goes. As a way of making inroads against these effects, he has asked whether assigning medical school graduates to residencies at random would distribute talent and educational opportunity more broadly and promote desirable moral values.¹

I pointed out what I think are serious limitations of this proposal,² and Hester has extended me the courtesy of a reply. Yet with that reply, I find that he has made it even more difficult to defend a lottery approach to residency assignment.

Hester thinks competitive aspects of the match are counterproductive to the aims of medicine: the “concerns of resource allocation of medical expertise continue to go unheeded by the current matching process. That is, those places that need help the most are the places most hurt by the match” (p. 79).³

He notes that physicians perform a vital service for their patients, their communities, and the public in general. Accordingly, he asks for a degree of self-sacrifice from would-be physicians: assignment to residencies by lottery, letting intellectual talent fall where it may. I believe, however, that too much of the baby is thrown out with the water here: residency programs lose the ability to select candidates in tune with their institutional goals, and candidates give up all choice about where they will train and under what circumstances they will live. The side effects of this approach would be just as woeful as any attaching to the current system. Hester says my analysis fails to engage considerations of justice. I will return that ball to his court: neither does he, at least not in any way that turns the desirable into the obligatory. The word “justice” does not appear in his original proposal, and its use in his reply is unhelpful to his argument. Here's why.

It is first worth observing that Hester offers no evidence or argument of any kind to show that deficits in healthcare can be traced to the talent levels of residents at a given healthcare institution. However, although this claim is well worth debating, it is not the crux of the argument, so let's move on. Everyone can agree that doctors perform vital public service and that some residency programs end up with less talent than others. What is missing in Hester's account is the moral link between need and responsibility. In other words, what is the moral rationale for overriding the choices of physicians and institutions alike in the name of a blind distribution of talent (and its opposite)? A lot of social problems could be remedied if only we could lay claim to the services of educators, attorneys, architects, plumbers, masons, and so on. But what justifies asking physicians to lay aside all consideration about where they will live and learn for the length of their residencies, some of which stretch out six and seven years? For their part, the vast majority of residents do not favor a major overhaul of the match system.⁴

Just what kind of justice should we be talking about anyway? There is no universally accepted theory of justice. Robert Nozick put consent at the center of his notion of justice as a way to deal with the acquisition, transfer, and restoration of social goods.⁵

According to this view, the disadvantages of the poor are exactly that—disadvantages. By themselves they do not generate any moral claim to provision by social institutions unless they are the consequence of wrongful acts. This is not to say, of course, that people cannot step in and help, even where they have no identifiable obligation to do so. By contrast, John Rawls puts access to social goods at the center of justice, with the effect that consent is less important as a moral criterion than seeing to it that those with the most disadvantages share in society's overall benefits.⁶ According to this view, by contrast, the worst off—in terms of their health—do have some claim to healthcare because justice is not primarily about consent but well-being relative to available social goods, including liberty. (For obvious reasons, the nature and extent of that entitlement is a matter of considerable debate.)

I can guess which approach to justice would be more valuable to Hester's argument, but I do not want to speak for him. It remains to be shown that a theory of justice permits or justifies limitations on liberty in the name of helping residency programs. But even if a theory of justice could be fitted to Hester's residency proposal, residual questions would remain, and formidable ones at that. For example, would other, less intrusive proposals defuse the problem at hand? For example, subsidies or loan forgiveness could make certain residencies more attractive than they would otherwise be. I have no doubt that some highly talented residents would be willing to serve in poor institutions if some degree of loan forgiveness came with the job. Practical incentives apart, it is also especially important, I believe, to ask why the burden of assuring the healthcare of a certain caliber falls to residents alone, burdens unshared by anyone else in the healthcare professions. More expansively, one could ask why a more far-reaching remedy should not be invoked, for example, the institution of national health insurance to insulate the worst-off from the vagaries of residency assignment?

Hester says my argument seems to support the match as it is, but that is not exactly right. In fact, I note problems with the match, and I am sensitive to the problems identified by others, such as those that Eliot Friedson has brought into plain view.⁷

I do, to be sure, support the match insofar as it allows individuals to make decisions for themselves about the residency programs that are in their best educational, economic, and familial interests. So, too, for residency programs. All I have said is that we need good reasons to alter the system, and I have not found those in the proposal Hester set forth. I am perfectly happy to see the match system changed to the extent there is reason to think that like cases are not being treated alike, that interventions are necessary as a matter of compensation to a wronged group, or that changes are necessary to achieve an important goal that is incumbent on the system and that cannot be achieved otherwise. These issues are, I believe, the criteria that slide matters from the realm of the merely preferable to the realm of the morally obligatory. As matters stand, however, I think the argument that a lottery system is obligatory as a matter of healthcare justice is unsubstantiated. I closed my original commentary by saying that a more searching argument will be necessary before we swap the existing match system for random assignment. I think that point is still the right ending for this discussion.