Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health rather (...) than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

According to luck egalitarianism, it is unjust if some are worse off than others through no fault or choice of their own. The most common criticism of luck egalitarianism is the ‘harshness objection’, which states that luck egalitarianism allows for too harsh consequences, as it fails to provide justification for why those responsible for their bad fate can be entitled to society's assistance. It has largely gone unnoticed that the harshness objection is open to a number of very different interpretations. (...) We present four different interpretations of the harshness objection in which the problem pertains to counterintuitive implications, badness of outcome, disproportionality, or inconsistency, respectively. We analyse and discuss appropriate luck egalitarian replies. Disentangling these different versions clarifies what is at the heart of this dispute and reveals the point of the harshness objection. We conclude that only the inconsistency version involves a durable problem for luck egalitarianism. (shrink)

While COVID-19 vaccines provide light at the end of the tunnel in a difficult time, they also bring forth the complex ethical issue of global vaccine distribution. The current unequal global distribution of vaccines is unjust towards the vulnerable living in low-income countries. A vaccine tax should be introduced to remedy this. Under such a scheme, a small fraction of the money spent by a country on vaccines for its own population would go into a fund, such as COVAX, dedicated (...) to buying vaccines and distributing them to the world’s poorest. A vaccine tax would provide a much-needed injection of funds to remedy the unequal distribution of vaccines. The tax allows for a distribution that, to a lesser degree, reflects the ability to pay and is superior to a donation-based model because it minimises the opportunity for free-riding. (shrink)

The wishes of registered organ donors are regularly set aside when family members object to donation. This genuine overruling of the wishes of the deceased raises difficult ethical questions. A successful argument for providing the family with a veto must (a) provide reason to disregard the wishes of the dead, and (b) establish why the family should be allowed to decide. One branch of justification seeks to reconcile the family veto with important ideas about respecting property rights, preserving autonomy, and (...) preventing harm. These arguments are ultimately unsuccessful. Another branch of arguments is consequentialist, pointing out the negative consequences of removing the veto. Whether construed as concerning family distress or as a potential drop in the organs available, these arguments are unsuccessful; the first fails to recognize the tremendous distress associated with waiting for an organ, while the second has little supporting evidence. A final section considers and rejects whether combining some of the arguments just examined could justify the family veto. We should thus remove the family veto in organ donation. (shrink)

In the luck egalitarian literature, one influential formulation of luck egalitarianism does not specify whether equalities that do not reflect people’s equivalent exercises of responsibility are bad with regard to inequality. This equivocation gives rise to two competing versions of luck egalitarianism: asymmetrical and symmetrical luck egalitarianism. According to the former, while inequalities due to luck are unjust, equalities due to luck are not necessarily so. The latter view, by contrast, affirms the undesirability of equalities as well as inequalities insofar (...) as they are due to luck. The symmetrical view, we argue, is by far the more compelling, both by internal luck egalitarian standards and in light of the external rightist emphasis on choice and responsibility to which luck egalitarianism may partly be seen as a response. Our main case for the symmetrical view is that when some people, against a background of equal opportunities, do not exercise their responsibility to the same degree as others, they cannot justifiably call for equalizing measures to be put in place. Indeed, such measures would be positively unfair. The symmetrical view, accordingly, rejects compensation in such cases, whereas the asymmetrical view, implausibly, enjoins it. We also examine two objections to this argument. First, that this view fails to qualify as genuinely egalitarian, instead collapsing the notion of equality into the notion of desert. Second, that the opposing asymmetrical view, in contrast to the symmetrical view, can draw support from its compatibility with sufficientarian concerns. Both objections are rebutted. We conclude that luck egalitarians are best served by endorsing the symmetrical, luck-neutralizing stance. (shrink)

Rare diseases pose a particular priority setting problem. The UK gives rare diseases special priority in healthcare priority setting. Effectively, the National Health Service is willing to pay much more to gain a quality-adjusted life-year related to a very rare disease than one related to a more common condition. But should rare diseases receive priority in the allocation of scarce healthcare resources? This article develops and evaluates four arguments in favour of such a priority. These pertain to public values, luck (...) egalitarian distributive justice the epistemic difficulties of obtaining knowledge about rare diseases and the incentives created by a higher willingness to pay. The first is at odds with our knowledge regarding popular opinion. The three other arguments may provide a reason to fund rare diseases generously. However, they are either overinclusive because they would also justify funding for many non-rare diseases or underinclusive in the sense of justifying priority for only some rare diseases. The arguments thus fail to provide a justification that tracks rareness as such. There are no data in this work. (shrink)

Hassoun argues that the poor in the world have a right to health and that the Global Health Impact Index provides consumers in well-off countries with the opportunity to ensure that more people have access to essential medicines. Because of this, these consumers would be ethically obliged to purchase Global Health Impact Index-labeled products in the face of existing global inequalities. In presenting her argument, Hassoun rejects the so-called democratic account of ethical consumption in favor of the positive change account. (...) Two versions of the democratic change account are relevant. One underscores the importance of democratic procedures and institutions, while the other stresses our fundamental moral equality. While at least one prominent institutionalist account has problems, revised versions would be less vulnerable to Hassoun’s counterexamples. Furthermore, institutionalist accounts come with the epistemological gains from democratic procedures and deliberations, which may be especially important under uncertainty. Finally, and perhaps more challenging for the Global Health Impact index project, this measure may place the burden unfairly on those who need to buy medicines. This is a pivotal insight from the non-institutionalist version of the democratic account of ethical consumption. (shrink)

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd out altruistic donation, (...) that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide. (shrink)

According to luck egalitarianism, it is not unfair when people are disadvantaged by choices they are responsible for. This implies that those who are disadvantaged by choices that prevent disadvantage to others are not eligible for compensation. This is counterintuitive. We argue that the problem such cases pose for luck egalitarianism reveals an important distinction between responsibility for creating disadvantage and responsibility for distributing disadvantage which has hitherto been overlooked. We develop and defend a version of luck egalitarianism which only (...) holds people responsible for creating disadvantage. This revision enables luck egalitarianism to offer compensation to those who are disadvantaged by preventing disadvantage to others, like dependent caretakers, without compromising the responsibility–sensitivity at the heart of luck egalitarianism. (shrink)

Luck egalitarianism is often taken to task for its alleged harsh implications. For example, it may seem to imply a policy of nonassistance toward uninsured reckless drivers who suffer injuries. Luck egalitarians respond to such objections partly by pointing to a number of factors pertaining to the cases being debated, which suggests that their stance is less inattentive to the plight of the victims than it might seem at first. However, the strategy leaves some cases in which the attribution of (...) individual responsibility is appropriate . One such case is oral health or significant aspects of this. It is appropriate, the paper argues, to hold people responsible for a number of factors that affect their oral health. A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing. (shrink)

In December 2015, Wales became the first country in the UK to move away from an opt-in system in organ procurement. The new legislation introduces the concept of deemed consent whereby a person who neither opt in nor opt out is deemed to have consented to donation. The data released by the National Health Service in July 2017 provide an excellent opportunity to assess this legislation in light of concerns that it would decrease procurement rates for living and deceased donation, (...) as well as sparking an increase in family refusals. None of these concerns have come to pass, with Wales experiencing more registered donors, fewer family refusals and more living donations. However, as the number of actual donors has dropped slightly from a high level, the situation must be monitored closely in the years to come. (shrink)

Deceased organ donation is widely considered as a case of easy rescue―that is, a case in which A may bestow considerable benefits on B while incurring negligent costs herself. Yet, the policy implications of this observation remain unclear. Drawing on Christopher H. Wellman’s samaritan account of political obligations, the paper develops a case for a so-called opt-out system, i.e., a scheme in which people are defaulted into being donors. The proposal’s key idea is that we may arrange people’s options in (...) specific ways for the sake of others. (shrink)

In 1970, Stewart advocated disenfranchising everyone reaching retirement age or age 70, whichever was earlier. The question of whether senior citizens should be disenfranchised has recently come to the fore due to votes on issues such as Brexit and climate change. Indeed, there is a growing literature which argues that we should increase the voting power of non-senior citizens relative to senior citizens, for reasons having to do with intergenerational justice. Thus, it seems that there are reasons of justice to (...) disenfranchise senior citizens, or at least to grant them a lower voting weight than non-senior citizens. In this paper, we investigate whether there are democratic reasons to do so. To answer this question, we turn to the boundary problem in democratic theory, i.e., the question of who should be included in democratic decision-making. Two prominent solutions, and a more recent one, are particularly relevant: the all-affected principle, the all-subjected principle, and the relational egalitarian principle. When it comes to the all-affected principle and the all-subjected principle, we argue that there is reason to grant most senior citizens a lower voting weight than most non-senior citizens in most decisions. Whether that is the case on the relational egalitarian principle depends on how people relate to each other in society. Indeed, it is sometimes in accordance with the relational egalitarian view to grant senior citizens a greater voting weight than non-senior citizens. (shrink)

Eli Feiring has developed a concept of forward-looking responsibility in healthcare. On this account, what matters morally in the allocation of scarce healthcare resources is not people's past behaviours but rather their commitment to take on lifestyles that will increase the benefit acquired from received treatment. According to Feiring, this is to be preferred over the backward-looking concept of responsibility often associated with luck egalitarianism. The article critically scrutinises Feiring's position. It begins by spelling out the wider implications of Feiring's (...) view. Against this background, it shows that (i) Feiring's distinction between backward-looking and forward-looking responsibility is incompatible with the Scanlonian notion of responsibility she apparently endorses; (ii) her favoured forward-looking notion of responsibility is subject to the objections levelled against the luck egalitarian view (whatever the strength of such objections). (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

Christian Munthe, David Fumagalli and Erik Malmqvist argue that well-known healthcare resource allocation principles, such as need, prognosis, equal treatment and cost-effectiveness, should be supplemented with a principle of sustainability.1 Employing such a principle would entail that the allocation of healthcare resources should take into account whether a specific allocation causes negative dynamics, which would limit the amount of resources available in the future. As examples of allocation decisions, which may have such negative dynamics, they mention those who cause a (...) lack of vaccines, anti-bioethics resistance and drug shortages. Thus, the overall thought is that we can spend and allocate healthcare resources in a certain way at t1, which means that we will have fewer resources available at a later point, t2. The authors argue that we should include a principle of sustainability to justify allocations, which avoids or diminishes the negative dynamics. The authors argue that existing principles cannot sufficiently include proper regard for how our current decisions affect future allocation decisions and, therefore, the people who need healthcare resources in the future. I am sympathetic to the developed argument and believe that the authors are correct that negative dynamics provide reasons to take our ability to meet future health needs …. (shrink)

Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste, Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices in health are disadvantaged in (...) a relevant way and should receive compensation. Employing the ideal that people should be made equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the luck egalitarian position is more compelling than they admit. (shrink)

The late G.A. Cohen is routinely considered a founding father of luck egalitarianism, a prominent responsibility-sensitive theory of distributive justice. David Miller argues that Cohen’s considered beliefs on distributive justice are not best understood as luck egalitarian. While the relationship between distributive justice and personal responsibility plays an important part in Cohen’s work, Miller maintains that it should be considered an isolated theme confined to Cohen’s exchange with Dworkin. We should not understand the view Cohen defends in this exchange as (...) Cohen’s considered view. Accepting this thesis would change both our understanding of Cohen’s political philosophy and many recent luck egalitarian contributions. Miller’s argument offers an opportunity to reassess Cohen’s writings as a whole. Ultimately, however, the textual evidence against Miller’s argument is overwhelming. Cohen clearly considers the exchange with Dworkin to be about egalitarianism as such rather than about the best responsibility-sensitive version of egalitarianism. Furthermore, Cohen often offers luck egalitarian formulations of his own view outside of the exchange with Dworkin and uses luck egalitarianism as an independent yardstick for evaluating principles and distributions. (shrink)

The exposure of doctors, nurses and other medical professionals to risks in the context of epidemics is significant. While traditional medical ethics offers the thought that these dangers may limit the extent to which a duty to care is applicable in such situations, it has less to say about what we might owe to medical professionals who are disadvantaged in these contexts. Luck egalitarianism, a responsibility-sensitive theory of distributive justice, appears to fare particularly badly in that regard. If we want (...) to maintain that medical professionals are responsible for their decisions to help, cure and care for the vulnerable, luck egalitarianism seems to imply that their claim of justice to medical attention in case of infection is weak or non-existent. The article demonstrates how a recent interpretation of luck egalitarianism offers a solution to this problem. Redefining luck egalitarianism as concerned with responsibility for creating disadvantages, rather than for incurring disadvantage as such, makes it possible to maintain that medical professionals are responsible for their choices and that those infected because of their choice to help fight epidemics have a full claim of justice to medical attention. (shrink)

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in (...) Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive. (shrink)

As the debate over an English opt-out policy for organ procurement intensifies, assessing existing experiences becomes even more important. The Welsh introduction of opt-out legislation provides one important point of reference. With the introduction of deemed consent in December 2015, Wales became the first part of the UK to introduce an opt-out system in organ procurement. My article ‘Deemed consent: assessing the new opt-out approach to organ procurement in Wales’ conducted an early assessment of this.1 Taking its starting point in (...) important concerns often raised in discussion over opt-out legislation, it identified four key parameters to assess the effects. These are living donor rates, deceased donor rates, donor registrations and family refusals. My article compares these indicators before and after the enactment of the Welsh legislation employing a different-in-different design. In his reply to my article ‘Deemed consent: assessing the new opt-out approach to organ procurement in Wales’, Jordan Alexander Parsons offers two interesting critiques. The first pertains to the choice of indicators. Parsons prefer a narrower focus on the effect on deceased donor rates. The second pertains to the choice of data, Parsons preferring a time series of Wales to my different-in-different design. Parsons refers mainly to the official Welsh evaluation,2 a report I also cited in supplement to the NHS Activity Report data I employed. …. (shrink)

Book review: Joseph Fishkin: Bottlenecks—A New Theory of Equality of Opportunity.

Review: Shlomi Segall (2013) Equality and opportunity.