I write to engage with the thoughtful discourse regarding the proposed Petaling Jaya hospital, specifically the perspectives shared by Dr Musa Mohd Nordin, Dr Zulkifli Ismail, and Dr Soo Thian Lian, as well as the pragmatic alternative proposed by Azrul Mohd Khalib of the Galen Centre for Health and Social Policy.
The authors’ passion for our rural and East Malaysian communities is laudable, and their advocacy for distributive justice serves as an essential moral compass for our national health planning. However, when we apply a philosophical lens to this debate, we find that the pathway to true health equity is more than a simple choice between urban and rural investment.
To advance the argument on justice, we must look beyond the geographic distribution of facilities and consider the concept of the Capability Approach, championed by Amartya Sen.
True justice is not evaluated by the presence of a building, but by the freedoms individuals possess to achieve health. For the urban poor population, a hospital that exists on a map but is operationally gridlocked, unaffordable, or inaccessible fails to provide the capability to be healthy.
Simply counting hospitals within a radius ignores the reality of prohibitive costs, urban transit, wait-time fatigue, and the severe capacity constraints, all of which strip the urban poor of their right to health.
Furthermore, we must consider John Rawls’ Difference Principle, which permits social and economic inequalities only if they work to the greatest benefit of the least advantaged. Constructing a public facility in Petaling Jaya is not an abandonment of the rural poor, but a necessity to decompress the surrounding public tertiary centres.
When we alleviate the pressure on these urban “hubs”, we improve outcomes for the disadvantaged patients who currently languish on waitlists, and we preserve the integrity of our national referral network. This, in turn, benefits the rural patient who is eventually transferred to these centres for complex, life-saving care.
The urban poor and the rural poor are not natural adversaries. They are both victims of a system currently stretched beyond its breaking point.
This brings us to the ethical dimension of temporal justice and the morality of waiting. The Galen Centre’s proposal to lease and operationalise an existing private facility offers a pragmatic avenue to address immediate gaps in care. While it is not a comprehensive solution, it addresses the ethical imperative to provide relief as quickly as possible, rather than forcing vulnerable populations to wait a decade for a mega-project to come online.
By considering such flexible models, we can provide immediate relief to urban populations while simultaneously freeing up fiscal bandwidth to focus on long-term equipment modernisation, staffing, and the digital health infrastructure needed to project care into the interior of Sabah and Sarawak.
We must reject the “zero-sum fallacy” that treats our health budget as a fixed, finite pie. The real scandal is not that we are debating how to increase capacity in the Klang Valley, but that our national health expenditure as a percentage of the country’s gross domestic product (GDP) remains stagnant despite clear, documented needs across every state.
Distributive justice does not demand that we leave one patient to suffer so that another might receive care. It demands that we stop treating the national health budget as a fixed sum and start treating universal health access as a non-negotiable moral imperative.
The author is an Affiliate at the Harvard Medical School Center for Bioethics and Head of Paediatrics Department at IMU University.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
