Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of the empirical (...) literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (shrink)

Paternalist policies in public health often aim to improve people’s well-being by reducing their options, regulating smoking offering a prime example. The well-being challenge is to show that people really are better off for having their options reduced. The distribution challenge is to show how the policies are justified since they produce losers as well as winners. If we start from these challenges, we can understand the importance of the empirical evidence that a very high proportion of smokers regret smoking. (...) In short, it is important that they regret it and important that the proportion is so high. This paper explains how, philosophically, regret can relate to well-being and it considers some of the strengths and weakness in the empirical research that the explanation brings out. The regret case for regulating smoking is indeed strong, although not as strong as the empirical researchers think. It is much weaker for paternalistic intervention in other public health problems, such as obesity and binge drinking. (shrink)

This paper considers a particular instance in which a liberal state –Germany -makes a claim for the limitation of tolerance of religious expression on the grounds of harm. I examine this claim with reference to three basic positions: Firstly,I examine Denise Meyerson’s argument that the domain of religion constitutes an area of intractable dispute and that the state is not entitled to limit liberty in this domain because it cannot justify limitations in a neutrally acceptable way. I argue that Ludin (...) is entitled to wear the Kopftuch on grounds of her right to religious freedom and that the attempt to deny her this entitlement constitutes a breach of individual rights. Meyerson’s arguments rest on the acceptability of Rawls’s idea of public reason. I therefore, secondly, examine Jeremy Waldron’s objections to the use of the deliberative discipline of public reason in cultural disputes as well as his objections to the use of the politics of identity which, he claims, distort our ability to engage in reasoned public debate. I argue that bracketing identity claims eliminates what is peculiar about Ludin’s case.This I bring out, thirdly, by drawing on the views of Melissa Williams, who advances the idea of sensitivity to others’ reasons as reasons, which defines a position midway between Meyerson and Waldron. It is apparent that Ludin’s dilemma is twofold: her status as ‘metic’-as member of a minority at the margins of mainstream German culture, and her status as ‘Muslimin’-as one believed to be suffering sexual discrimination in her own culture, form a double-bind of oppression. They are connected in a way that challenges the integration policies of the German state. (shrink)

Political philosophers have become increasingly interested in questions of justice as applied to health. Much of this literature works from a distributive understanding of justice. In the recent debate, however, ‘relational’ egalitarians have proposed a different way of conceptualising equality, which focuses on the quality of social relations among citizens and/or how social institutions ‘treat’ citizens. This paper explores some implications of a relational approach to health, with particular focus on health care, health inequalities and health policy. While the relational (...) account can add interesting perspectives to current debates on justice and health, we also highlight some tensions and difficulties relational egalitarians might encounter and some discontinuities between the implications of a relational account and current discourse on health equity. (shrink)

Debates on the nature and justifiability of paternalism typically focus only on adults, sometimes presuming without argument that paternalism towards children is a non-issue or obviously justified. Debates on the moral and political status of children, in turn, rarely connect with the rich literature on paternalism. This chapter attempts to bridge this gap by exploring how issues that arise in the general debate on paternalism are relevant also for the benevolent interference with children. I survey and discuss various views and (...) argue for my own: that paternalism towards children is in most respects like paternalism towards adults and stands in the same need of justification, though such justification is more often forthcoming both because children are typically less prudent than adults and so benefit more from interference, and because, in some respects, interference is less harmful to them. (shrink)

Usury ceilings seem indefensible. Their opponents insist these caps harm the consumers they are intended to help. Low ceilings are said to prevent the least advantaged agents from accessing legal credit and drive them into the black market, where prices are higher and collection methods are harsher. But in this paper, I challenge these arguments and show that the benefits of interest-rate limitations in the most expensive credit markets clearly outweigh the costs. The test case is payday lending. Deregulated pricing (...) in this market produces negative externalities that justify usury restrictions. Unless prices are capped, the more solvent majority of borrowers is compelled to cross-subsidize the least solvent debtors, who have a high rate of default. Rationing the riskiest debtors out of this market by means of a moderate usury cap puts an end to this unfairness and produces fewer bad consequences than the advocates of deregulated pricing recognize. I argue that only an extreme principle like maximizing the minimum could justify a free market in payday credit. (shrink)

Paternalistic interventions restrict individuals’ liberty or autonomy so as to guide their decisions towards options that are more beneficial for them than the ones they would choose in the absence of such interventions. Although some philosophers have emphasised that there is a case for justifiable paternalism in certain circumstances, much of contemporary moral and political philosophy works from a strong presumption against paternalistic interventions. However, Richard Arneson has argued that there are egalitarian reasons that support the case for paternalism: paternalistic (...) interventions can protect poor decision-makers from making ‘bad’ choices, thus preventing inequalities between them and those with better decision-making skills. This paper seeks to clarify and advance our understanding of the egalitarian argument for paternalism. Arneson’s argument adds an important and often neglected dimension to the debate about paternalism but also raises a number of questions about equality, paternalism and the relationship between the two. (shrink)

Proponents of permitting living kidney sales often argue as follows. Many jobs involve significant risks; people are and should be free to take these risks in exchange for money; the risks involved in giving up a kidney are no greater than the risks involved in acceptable hazardous jobs; so people should be free to give up a kidney for money, too. This paper examines this frequently invoked but rarely analysed analogy. Two objections are raised. First, it is far from clear (...) that kidney sales and dangerous jobs involve comparable risks on an appropriately broad comparison. Second, and more importantly, even if they do involve comparable risks it does not follow that kidney sales must be permitted because dangerous jobs are. The analogy assumes that kidney sales are banned for paternalistic reasons. But there may be other, non-paternalistic reasons for the ban. And paternalists, too, can consistently defend the ban even if kidney sales are no riskier than occupations that they find acceptable. Soft paternalists may want to protect would-be vendors from harms that they have not voluntarily chosen. Egalitarian hard paternalists may want to protect already badly off vendors from further worsening their situation. For neither species of paternalist is the size of the risk prevented decisive. I conclude that the analogy with dangerous jobs, while rhetorically powerful, pulls little real argumentative weight. Future debates on living kidney sales should therefore proceed without it. (shrink)

Cass Sunstein and Richard Thaler contend that the government is justified in shaping certain choices of individuals to advance their well-being. In this paper, I argue that those who are committed to a robust notion of autonomy, which I call autonomy as authority, have good reason to reject the Sunstein-Thaler argument for libertarian paternalism. I draw from Joseph Raz’s idea of exclusionary reasons and Daniel Groll’s conception of autonomy to argue that the S/T argument for libertarian paternalism fails to respect (...) autonomy. I consider if soft paternalism could be called upon as a foundation for libertarian paternalism, but argue against this possibility. I conclude that an adequate defense of libertarian paternalism would need to directly attack the notion of autonomy as authority, but such an attack has yet to be mounted by the defenders of libertarian paternalism. (shrink)

This thesis is an attempt to constructively interpret and critically evaluate the liberal doctrine that we may not limit a person’s liberty for her own good, and to discuss its implications and alternatives in some concrete areas of public health policy. The thesis starts theoretical and goes ever more practical. The first paper is devoted to positive interpretation of anti-paternalism with special focus on the reason component – personal good. A novel generic definition of paternalism is proposed, intended to capture, (...) in a generous fashion, the object of traditional liberal resistance to paternalism – the invocation of personal good reasons for limiting of or interfering with a person’s liberty. In the second paper, the normative aspect of this resistance is given a somewhat technical interpretation in terms of invalidation of reasons – the blocking of reasons from influencing the moral status of actions according to their strength. It is then argued that normative anti-paternalism so understood is unreasonable, on three grounds: 1) Since the doctrine only applies to sufficiently voluntary action, voluntariness determines validity of reasons, which is unwarranted and leads to wrong answers to moral questions. 2) Since voluntariness comes in degrees, a threshold must be set where personal good reasons are invalidated, leading to peculiar jumps in the justifiability of actions. 3) Anti-paternalism imposes an untenable and unhelpful distinction between the value of respecting choices that are sufficiently voluntary and choices that are not. The third paper adds to this critique the fourth argument that none of the action types typically proposed to specify the action component of paternalism is such that performing an action of that type out of benevolence is essentially morally problematic. The fourth paper ignores the critique in the second and third papers and proposes, in an anti-paternalistic spirit, a series of rules for the justification of option-restricting policies aimed at groups where some members consent to the policy and some do not. Such policies present the liberal with a dilemma where the value of not restricting people’s options without their consent conflicts with the value of allowing people to shape their lives according to their own wishes. The fifth paper applies the understanding of anti-paternalism developed in the earlier papers to product safety regulation, as an example of a public health policy area. The sixth paper explores in more detail a specific public health policy, namely that of mandatory alcohol interlocks in all cars, proposed by the former Swedish government and supported by the Swedish National Road Administration. The policy is evaluated for cost-effectiveness, for possible diffusion of individual responsibility, and for paternalistic treatment of drivers. The seventh paper argues for a liberal policy in the area of dissemination of information about uncertain threats to public health. The argument against paternalism is based on common sense consequentialist considerations, avoiding any appeal to the normative anti-paternalism rejected earlier in the thesis. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 1, Page 55-74, February 2022. Many find that the objectionable nature of paternalism has something to do with belief. However, since it is commonly held that beliefs are directly governed by epistemic as opposed to moral norms, how could it be objectionable to hold paternalistic beliefs about others if they are supported by the evidence? Drawing on central elements of relational egalitarianism, this paper attempts to bridge this gap. In a first step, it (...) argues that holding paternalistic beliefs about others implies a failure to regard them as equals in terms of their moral agency. In a second step, it shows that the fact that we should regard others as equals in this sense raises the threshold for sufficiency of evidence for paternalistic beliefs to be epistemically justified. That is, moral reasons of relational equality encroach on the epistemic. However, these reasons are not decisive. In cases where others are about to jeopardize critical goods such as their lives, mobility or future autonomy, relational equality sometimes calls for paternalistic action and, by extension, the formation of beliefs that render such action rational. The upshot is that in order to meet demands of relational equality we have a pro tanto reason to not hold paternalistic beliefs about others. (shrink)

A common objection to paternalism concerns its expressive content. Many reject paternalistic policies and actions on the ground that they arguably involve insulting expressions of disrespect toward those subjected to them. The paper challenges this view. It argues that refraining from acting paternalistically can be disrespectful. Specifically, the paper argues that there is a relevant way in which A disregards the moral worth of B if A stands idly by when B is about to act very imprudently. If true, treating (...) others with equal respect and concern, as relational egalitarians and others rightly ask us to do, will somewhat surprisingly sometimes involve treating them paternalistically. (shrink)

In 1987, Machan provided a libertarian case against the right to occupational safety. Since before Machan’s essay appeared, many business ethicists and legal scholars have given considerable attention to the overall position Machan endorses: the acceptance of employment at will and the rejection of employee rights. No one yet has given adequate attention, however, to the fact that Machan’s argument against the right to occupational safety actually stands or falls independently of his overall position on employee rights. His argument ultimately (...) rests on two values: the promotion of employee interests and anti-paternalism. Insofar as those who support the right to occupational safety share those values, they must find a strategy for opposing Machan’s argument that preserves those values. In this paper, I demonstrate why Machan’s argument ultimately rests on the promotion of employee interests and anti-paternalism. Then, I develop an objection to Machan’s argument that preserves those values. (shrink)

Drawing the line on physician assistance in physician-assisted death continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill that (...) can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill. (shrink)

Whatever else liberalism involves, it involves the idea that it is objectionable, and often wrong, for the state, or anyone else, to intervene, in certain ways, in certain choices. This article aims to evaluate different possible sources of support for this core liberal idea. The result is a pluralistic view. It defends, but also stresses the limits of, some familiar elements: that some illiberal interventions impair valuable activities and that some violate rights against certain kinds of invasion. More speculatively, it (...) points to two further sources of support for liberalism, each of which represents a certain kind of social standing: a self-sovereignty compromised simply by being subject to certain kinds of commands and a relational equality compromised by the condemnation of choices with which one’s group is identified. (shrink)

In this article I defend a rule utilitarian approach to paternalistic policies in research with human participants. Some rules that restrict individual autonomy can be justified on the grounds that they help to maximize the overall balance of benefits over risks in research. The consequences that should be considered when formulating policy include not only likely impacts on research participants, but also impacts on investigators, institutions, sponsors, and the scientific community. The public reaction to adverse events in research (such as (...) significant injury to participants or death) is a crucial concern that must be taken into account when assessing the consequences of different policy options, because public backlash can lead to outcomes that have a negative impact on science, such as cuts in funding, overly restrictive regulation and oversight, and reduced willingness of individuals to participate in research. I argue that concern about the public reaction to adverse events justifies some restrictions on the risks that competent, adult volunteers can face in research that offers them no significant benefits. The paternalism defended here is not pure, because it involves restrictions on the rights of investigators in order to protect participants. It also has a mixed rationale, because individual autonomy may be restricted not only to protect participants from harm but also to protect other stakeholders. Utility is not the sole justification for paternalistic research policies, since other considerations, such as justice and respect for individual rights/autonomy, must also be taken into account. (shrink)

This is the first in a series of five papers on the role, remit and function of research ethics committees which are intended to provide for REC members a broad understanding of the most important issues in research ethics and governance. The first considers the rationale for having ethics review by committee at all; seeking to explain why ethics committees, as we currently have them, are so important to the wider system of governing research.

The use of tanning beds has been identified as being among the most significant causes of melanoma and non-melanoma skin cancer. Accordingly, the activity is properly seen as one that involves profound harm to self. The article examines paternalistic reasons for restricting sunbed usage. We argue that both so-called soft and hard paternalistic arguments support prohibiting the use of sunbeds. We make the following three arguments: an argument from oppressive patterns of socialization suggesting that the autonomous nature of the conduct (...) in question is questionable; an argument from so-called evaluative delusions in which individuals attach incorrect weights to some of their values; a strictly hard paternalistic argument appealing to the harm in itself pertaining to the use of sunbeds. (shrink)

This paper scrutinizes the tension between individuals’ rights and paternalism. I will argue that no normative account that includes rights of individuals can justify hard paternalism since the infringement of a right can only be justified with the right or interest of another person, which is never the case in hard paternalism. Justifications of hard paternalistic actions generally include a deviation from the very idea of having rights. The paper first introduces Tom Beauchamp as the most famous contemporary hard paternalist (...) by outlining his moral theory (principlism) and showing why it, as it stands, has to allow for hard paternalism. Secondly, the paper focuses on the notion of rights within principlism. I will employ traditional theories of rights to make sense of rights in principlism. Unfortunately, this attempt fails. In the third part, then, I claim that rights can only be limited with reference to the rights or interests of others. This structure is the very point of rights, it is their bite. I will argue for this claim and show its implications. The most important implication is that not only principlism, but every normative theory that includes rights of individuals, has to abolish hard paternalism. (shrink)