Luck egalitarianism provides a reason to object to conditionality in health incentive programmes in some cases when conditionality undermines political values such as solidarity or inclusiveness. This is the case with incentive programmes that aim to restrict access to essential healthcare services. Such programmes undermine solidarity. Yet, most people's lives are objectively worse, in one respect, in non-solidary societies, because solidarity contributes both instrumentally and directly to individuals' well-being. Because solidarity is non-excludable, undermining it will deprive both the prudent and (...) the imprudent citizens of its goods. Thereby, undermining solidarity can make prudent citizens worse off than they would have otherwise been, out of no fault or choice of their own, but rather as a result of somebody else's imprudent choice. This goes against the spirit of luck egalitarianism. Therefore (luck egalitarian) justice can require us to save the imprudent and avoid conditionality in access to essential healthcare services. (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)

This chapter concerns the normativity of the concepts of paternalism and libertarian paternalism. The first concept is central in evaluating public health policy, but its meaning is controversial. The second concept is equally controversial and has received much attention recently. It may or may not shape the future evaluation of public health policy. In order to facilitate honest and fruitful debate, I consider three approaches to these concepts, in terms of their normativity. Concepts, I claim, may be considered nonnormative, normatively (...) charged, or normative in that they involve more complex relationships between values or duties. While the last approach is often best, other approaches may be appropriate depending on the context and purpose of discussion. The chapter’s conceptual investigation is illustrated by application to two public health policies: a tax on the consumption of fat and the encouragement of health-promoting food displays in restaurants and supermarkets. (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)

Luck egalitarianism is a family of egalitarian theories of distributive justice that aim to counteract the distributive effects of luck. This article explains luck egalitarianism's main ideas, and the debates that have accompanied its rise to prominence. There are two main parts to the discussion. The first part sets out three key moves in the influential early statements of Dworkin, Arneson, and Cohen: the brute luck/option luck distinction, the specification of brute luck in everyday or theoretical terms and the specification (...) of advantage as resources, welfare, or some combination of these. The second part covers three later developments: the democratic egalitarian critique of luck egalitarianism, the luck egalitarian acceptance of pluralism, and luck egalitarian doubts about the significance of the brute luck/option luck distinction. (shrink)

According to all-luck egalitarianism, the differential distributive effects of both brute luck, which defines the outcome of risks which are not deliberately taken, and option luck, which defines the outcome of deliberate gambles, are unjust. Exactly how to correct the effects of option luck is, however, a complex issue. This article argues that (a) option luck should be neutralized not just by correcting luck among gamblers, but among the community as a whole, because it would be unfair for gamblers as (...) a group to be disadvantaged relative to non-gamblers by bad option luck; (b) individuals should receive the warranted expected results of their gambles, except insofar as individuals blamelessly lacked the ability to ascertain which expectations were warranted; and (c) where societal resources are insufficient to deliver expected results to gamblers, gamblers should receive a lesser distributive share which is in proportion to the expected results. Where all-luck egalitarianism is understood in this way, it allows risk-takers to impose externalities on non-risk-takers, which seems counterintuitive. This may, however, be an advantage as it provides a luck egalitarian rationale for assisting ‘negligent victims’. (shrink)

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal responsibility (...) would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts. (shrink)

Bariatric surgery is effective on short- and medium-term weight loss, reduction of comorbidities, and overall mortality. A large and increasing portion of the population is eligible for bariatric surgery, which increases instant health care costs. A review of the literature identifies a series of ethical challenges: unjust distribution of bariatric surgery, autonomy and informed consent, classification of obesity and selecting assessment endpoints, prejudice among health professionals, intervention in people's life-world, and medicalization of appearance. Bariatric surgery is particularly interesting because it (...) uses surgical methods to modify healthy organs, is not curative, but offers symptoms relief for a condition that it is considered to result from lack of self-control and is subject to significant prejudice. Taking the reviewed ethical issues into account is important when meeting persons eligible for bariatric surgery, as well as in the assessment of and decision making on surgery for obesity. (shrink)

Bonuses, as incentives or rewards for health -related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health -care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health -care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality (...) and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices. (shrink)

Genomics provides information on genetic susceptibility to diseases and new possibilities for interventions which can fundamentally alter the design of fair health policies. The aim of this paper is to explore implications of genomics from the perspective of equal opportunity ethics. The ideal of equal opportunity requires that individuals are held responsible for some, but not all, factors that affect their health. Informational problems, however, often make it difficult to implement the ideal of equal opportunity in the context of healthcare. (...) In this paper, examples are considered of how new genetic information may affect the way individual responsibility for choice is assigned. It is also argued that genomics may result in relocation of the responsibility cut by providing both new information and new technology. Finally, how genomics may affect healthcare policies and the market for health insurance is discussed. (shrink)

Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to blame, are spent on prevention or treatment of disease that could be avoided through individual lifestyle changes. This may encourage policy makers and health care professionals to opt for a criterion of individual responsibility for medical suffering when setting priorities. The following article asks whether responsibility-based reasoning should be accepted as (...) relevant for fair and legitimate healthcare rationing. The luck-egalitarian argument that inequalities in health expectancies that derive from unchosen features of people’s circumstances are unjust and should be compensated, while inequalities that reflect personal choices of lifestyle may not, is discussed. It seems that while a backward-looking interpretation of individual responsibility cannot be relevant as a criterion of priority setting, a forward-looking conception of responsibility may be approved.Within all modern societies healthcare authorities are facing difficult priority setting problems. Various criteria for rationing medical intervention have been proposed due to scarcity of resources. Until now, individual responsibility for medical suffering has been given little attention in the public or in academic debate. This is about to change. As Alexander Cappelen and Ole Norheim have pointed out in a recent article in this journal, unhealthy lifestyle contributes increasingly to the burden of disease. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge.1 In this article the following question is addressed: should responsibility-based arguments be accepted as relevant to meeting healthcare rationing fairly and legitimately? I will argue that while a backward-looking conception of individual responsibility should not be endorsed, a forward-looking notion of responsibility may be approved. (shrink)

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these (...) philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities. (shrink)

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory of justice in (...) health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

A considerable literature has emerged around the idea of using ‘personal responsibility’ as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as ‘responsibilisation’. This discussion focuses most prominently, but not exclusively, on ‘luck egalitarianism’, the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns the two–way relationship (...) between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem. (shrink)

BackgroundThe idea that individuals are responsible for their health has been the focus of debate in the theoretical literature and in its concrete application to healthcare policy in many countries. Controversies persist regarding the form, substance and fairness of allocating health responsibility to the individual, particularly in universal, need-based healthcare systems.ObjectiveTo examine how personal health responsibility has been framed and rationalised in Norwegian key policy documents on priority setting.MethodsDocuments issued or published by the Ministry of Health and Care Services between (...) 1987 and 2018 were thematically analysed. We developed a predefined conceptual framework that guided the analysis. The framework included: the subject and object of responsibility, the level of conceptual abstraction, temporality, normative justificatory arguments and objections to the application of personal health responsibility.ResultsAs an additional criterion, personal health responsibility has been interpreted as relevant if: the patient’s harmful behaviour is repeated after receiving treatment, and if the success of the treatment is conditional on the patient’s behavioural change. When discussed as a retrospective criterion, considerations of reciprocal fairness have been dominant. When discussed as a prospective criterion, the expected benefit of treatment justified its relevance.ConclusionPersonal health responsibility appears to challenge core values of equality, inclusion and solidarity in the Norwegian context and has been repeatedly rejected as a necessary criterion for priority setting. However, the responsibility criterion seems to have some relevance in particular priority setting decisions. (shrink)

We report the results of a vignette experiment with a quota sample of the German population in which we analyze the interplay between need, equity, and accountability in third-party distributive decisions. We asked subjects to divide firewood between two hypothetical persons who either differ in their need for heat or in their productivity in terms of their ability to chop wood. The experiment systematically varies the persons’ accountability for their neediness as well as for their productivity. We find that subjects (...) distribute significantly fewer logs of wood to persons who are held accountable for their disadvantage. Independently of being held accountable or not, the needier person is always compensated with a share of logs that exceeds her contribution, while the person who contributes less is punished in terms of receiving a share of logs smaller than her need share. Moreover, there is a domain effect in terms of subjects being more sensitive to lower contributions than to greater need. (shrink)

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of healthcare. But there (...) is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one. (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)

To investigate whether Swedish physicians, contrary to Swedish health care policy, employ considerations of patient responsibility for illness when rationing expensive treatments.

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)

Die epidemiologische Morbiditätsverschiebung der vergangenen Jahrzehnte hat verhaltensassoziierte Erkrankungen in das Zentrum der Public Health-Arbeit rücken lassen. Sowohl die Prävention Lebensstil-bedingter Erkrankungen als auch die Behandlung ihrer Folgen gehören angesichts steigender Morbiditäts- und Mortalitätszahlen zu den größten Herausforderungen für moderne Gesundheitssysteme. Eine Beeinflussung von Gesundheitsverhalten sowie dessen Berücksichtigung in der Mittelverteilung – prominent verhandelt in der medizinethischen Debatte um gesundheitliche Eigenverantwortung – sind jedoch kontrovers. Bisher konnte dafür noch kein allgemein akzeptiertes theoretisches Modell entwickelt werden. Im vorliegenden Beitrag wird der (...) in letzter Zeit im angloamerikanischen Raum intensiv im Public Health-Kontext verhandelte libertäre Paternalismus als ein solches Modell untersucht und einer kritischen Untersuchung zugeführt. Es wird geschlussfolgert, dass dieses Modell zwar argumentativ in wesentlicher Hinsicht unterbestimmt ist, jedoch viele willkommene und sinnvolle Impulse für die moderne Public Health-Politik liefern kann. (shrink)

This article explores the Rawlsian goal of ensuring that distributions are not influenced by the morally arbitrary. It does so by bringing discussions of distributive justice into contact with the debate over moral luck initiated by Williams and Nagel. Rawls’ own justice as fairness appears to be incompatible with the arbitrariness commitment, as it creates some equalities arbitrarily. A major rival, Dworkin’s version of brute luck egalitarianism, aims to be continuous with ordinary ethics, and so is (a) sensitive to non-philosophical (...) beliefs about free will and responsibility, and (b) allows inequalities to arise on the basis of option luck. But Dworkin does not present convincing reasons in support of continuity, and there are compelling moral reasons for justice to be sensitive to the best philosophical account of free will and responsibility, as is proposed by the revised brute luck egalitarianism of Arneson and Cohen. While Dworkinian brute luck egalitarianism admits three sorts of morally arbitrary disadvantaging which correspond to three forms of moral luck (constitutive, circumstantial, and option luck), revised brute luck egalitarianism does not disadvantage on the basis of constitutive or circumstantial luck. But it is not as sensitive to responsibility as it needs to be to fully extinguish the influence of the morally arbitrary, for persons under it may exercise their responsibility equivalently yet end up with different outcomes on account of option luck. It is concluded that egalitarians should deny the existence of distributive luck, which is luck in the levels of advantage that individuals are due. (shrink)

The majority of deaths due to tobacco in the twenty-first century will occur in the developing world, where over 80% of current tobacco users live. In November 2010 guidelines were adopted for implementing Article 14 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The guidelines call on all countries to promote tobacco treatment programs. Nevertheless, some experts argue for a strict focus, at least in developing countries, on population-based measures such as taxes and indoor air laws, which (...) they consider more cost-effective than individual treatment. In this article we defend tobacco dependence treatment in developing countries. First, these experts understate the comparative cost-effectiveness of individual treatment programs. Second, they overlook numerous ethical considerations beyond cost-effectiveness that support individual tobacco treatment in developing countries. We conclude that the strict population-based focus in developing country tobacco control advocated by some experts is misplaced. In general, developing nations should combine population-based measures and individual tobacco treatment programs. (shrink)

The role that need plays in dealing with problems of distributive justice is examined in a series of vignette studies. Among other things, it becomes clear that impartial observers make gradual assessments of justice that depend on the extent to which the observed individuals are endowed with a good. If it is known how high their need for that good is, the assessments are made relative to this reference point. In addition, impartial decision-makers make hypothetical distribution decisions that take into (...) account need, productivity, and accountability. The need of individuals is partially compensated even if they have contributed less to the available amount than they themselves require. However, the willingness to do so decreases if they are accountable for needing more than others or for having contributed less than others. Lastly, both impartial observers and impartial decision-makers distinguish between different types of needs, the fulfillment of which is given different levels of importance. (shrink)

Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive resource (...) allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics. (shrink)

Abstract:The distinction between brute luck and option luck is fundamental for luck egalitarianism. Many luck egalitarians write as if it could be used to specify which outcomes people should be held responsible for. In this paper, I argue that the distinction can’t be used this way. In fact, luck egalitarians tend to rely instead on rough intuitive judgements about individual responsibility. This makes their view vulnerable to what’s known as theneutrality objection. I show that attempts to avoid this objection are (...) unsuccessful. I conclude that until it provides a better account of attributing responsibility, luck egalitarianism remains incomplete. (shrink)

We report the results of a vignette study with an online sample of the German adult population in which we analyze the interplay between need, equity, and accountability in third-party distribution decisions. We asked participants to divide firewood between two hypothetical persons who either differ in their need for heat or in their productivity in terms of their ability to chop wood. The study systematically varies the persons’ accountability for their neediness as well as for their productivity. We find that (...) participants distribute significantly fewer logs of wood to persons who are held accountable for their disadvantage. Independently of being held accountable or not, the needier person is partially compensated with a share of logs that exceeds her contribution, while the person who contributes less is given a share of logs smaller than her need share. Moreover, there is a domain effect in terms of participants being more sensitive to lower contributions than to greater need. (shrink)

There is an ongoing increase in the use of mobile health technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses ‘medical monitoring’, and the second ‘personal health surveillance’. After outlining two problems which the use of mHealth might seem to enable us (...) to overcome—fairness of burdens and reliance on self-reporting—I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim. (shrink)

Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, luck egalitarianism encounters several difficulties. (...) We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. (shrink)

Non-communicable diseases are no longer largely limited to high-income countries and the elderly. The burden of non-communicable diseases is rising across all country income categories, in part because these diseases have been relatively overlooked on the global health agenda. Historically, communicable diseases have been prioritized in many countries as they were perceived to constitute the greatest disease burden, especially among vulnerable and poor populations, and strategies for prevention and treatment, which had been successful in high-income settings, were considered feasible and (...) often affordable in low-income settings. This prioritization has reduced the communicable diseases burden globally but has left non-communicable diseases largely neglected. A new approach is urgently needed to tackle non-communicable diseases. Based on an analysis of potential features which may have underlain the different approaches to non-communicable diseases and communicable diseases until now, including acuity of disease, potential for control or cure, cost, infectiousness, blaming of individuals and logistical barriers, little ethical or rational justification can be found to support continued neglect of non-communicable diseases. Justice demands access to quality and affordable care for all. An equitable approach to non-communicable diseases is therefore strongly mandated on medical, ethical, economic, and public health grounds. Funding must not however be diverted away from communicable diseases, which continue to require attention—but concomitantly, funding for non-communicable diseases must be increased. International and multi-sectoral action is required to accelerate progress towards true universal health coverage and towards achievement of all of the sustainable development goals, such that prevention and access to care for non-communicable disease can become a global reality. (shrink)

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, (...) and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. (shrink)

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can ‘take responsibility’ for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms (...) of moral responsibility should be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents have prudential reasons to maintain their health, in order to pursue those things which make their lives go well—i.e. that maintenance of a certain level of health is rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

According to US law, insurance companies can lawfully differentiate individual health insurance premiums on the basis of non-genetic medical information, but not on the basis of genetic information. The article reviews the case for such genetic exceptionalism. First, I critically assess some standard justifications. Next, I scrutinize an argument appealing to the view that genetically based premium differentiation expresses that persons do not all merit equal concern and respect. In the final section, I argue that even if genetic exceptionalism is (...) unjustified, there is a forceful luck egalitarian argument against basing premiums on genetic risks, to wit, that this tends to make some individuals worse off than others as a result of the bad brute luck involved in having a genetically determined, above-average risk of developing health problems. (shrink)

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual’s role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change (...) how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare. (shrink)

As lifestyle diseases put a heavy burden on health care expenditures, voices are raised and win in sound to hold people responsible for their unhealthy lifestyle. Most of the arguments in favour of responsibility are backward-looking. In this article, we describe the distributional consequences of these backward-looking measures and show that they are very harsh on those who regret a past unhealthy lifestyle. We demonstrate that it is possible to take policy measures which respect individual responsibility but which are at (...) the same time able to grant fresh starts to individuals who regret their past unhealthy lifestyle (which is an application of Fleurbaey (2005)). This ‘forgiving’ policy is confronted with a moral hazard problem, however. In general the regulator does not observe whether individuals really regret their past choices or they just pretend to have changed preferences in order to enjoy the compensatory measures for regretful people. In this article, we argue that the health setting offers interesting opportunities to move beyond this moral hazard problem and offer a solution through the use of redistributive instruments that are conditional on lifestyle changes. (shrink)

Although the responsibility for health debate has intensified in several ways between Norman Daniels’ 1985 Just healthcare and Just health: meeting health needs fairly of 2008, comparatively little space is dedicated to the issue in Just health, and Daniels notes repeatedly that his account “says nothing about personal responsibility for health”. Daniels considers health responsibility mainly in a particular luck-egalitarian version which he rejects because of its potentially unfeasible, penalising and inhumane character. But I show that he nonetheless acknowledges and (...) endorses explicitly other dimensions of health responsibility. I develop a wider, more nuanced and less punitive concept of health responsibility, which expands Daniels’ brief consideration and is compatible with the overall approach set out in Just health. In its application to preventative medicine and health promotion in particular, the concept is suited to support and complement the notion that “health is special”, which is central in Just health. The concept of health responsibility as co-responsibility specifies the subjects and objects of health responsibilities. It permits the attribution of responsibility without blame and disconnects the question of assigning responsibility from decisions about entitlement to treatment or different status in prioritisation decisions. This approach secures conceptual plausibility and clarity of the concept of health responsibility, is of use in policy making, and can help reduce political tensions. (shrink)

Background and objectives: Summary measures of overall health inequality are independent of group membership and enable international comparisons of distribution of health. We compare inequality between and within countries over time and identify normative issues underlying such comparisons. Methods: We used a set of modeled historical life tables for 193 World Health Organization member states from the years 1990, 2000 and 2008 and calculated inequality in age at death and inequality-adjusted life expectancy. Results: Our calculations suggest that overall health inequalities (...) in age at death have been decreasing in the period 1990–2008 in most countries of the world. Only 20 countries experienced increasing distribution in age at death. Simultaneously, overall life expectancy has increased in 85 per cent of all countries. Thus, the combined measure IALE has improved globally. The same overall trend of reduced health inequality applies to all groups of countries stratified by income level. Conclusion: Overall health inequalities, in addition to average health outcomes, could be reported regularly to monitor the health status of populations and the performance of health systems. We find, on normative grounds, the combined measure IALE to be preferable to measuring trends in inequality only. Likewise, we find the Absolute GiniH to be preferable to Relative GiniH. (shrink)

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of the interdependence of (...) humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society. (shrink)

Whether it is fair to use personal responsibility of patients for their own health as a rationing criterion in healthcare is a controversial matter. A host of difficulties are associated with the concept of personal responsibility in the field of medicine. These include, in particular, theoretical considerations of justice and such practical issues as multiple causal factors in medicine and freedom of health behaviour. In the article, personal responsibility is evaluated from the perspective of several theories of justice. It is (...) argued that in a healthcare system based on both equality of opportunity and solidarity, responsible health behaviour can—in principle—be justifiably expected. While the practical problems associated with personal responsibility are important, they do not warrant the common knee-jerk refusal to think more deeply about responsibility for health as a means of allocating healthcare resources. In conclusion, the possibility of introducing personal responsibility as a fair rationing criterion is briefly sketched. (shrink)

Many countries have imposed strict regulations on the genetic information to which insurers have access. Commentators have warned against the emerging body of legislation for different reasons. This paper demonstrates that, when confronted with the argument that genetic information should be available to insurers for health insurance underwriting purposes, one should avoid appeals to rights of genetic privacy and genetic ignorance. The principle of equality of opportunity may nevertheless warrant restrictions. A choice-based account of this principle implies that it is (...) unfair to hold people responsible for the consequences of the genetic lottery, since we have no choice in selecting our genotype or the expression of it. However appealing, this view does not take us all the way to an adequate justification of inaccessibility of genetic information. A contractarian account, suggesting that health is a condition of opportunity and that healthcare is an essential good, seems more promising. I conclude that if or when predictive medical tests (such as genetic tests) are developed with significant actuarial value, individuals have less reason to accept as fair institutions that limit access to healthcare on the grounds of risk status. Given the assumption that a division of risk pools in accordance with a rough estimate of people's level of (genetic) risk will occur, fairness and justice favour universal health insurance based on solidarity. (shrink)

The geographically inequitable distribution of physicians has long posed a serious social problem in Japan. The government tackled this problem by establishing and managing Jichi Medical University (JMU) and regional quotas (RQs) for medical schools. JMU/RQs recruit local students who hope to work as physicians in rural areas, educate them for 6 years without tuition (JMU) or with scholarship (RQs), and after graduation, assign them to their home prefectures for 9 years, including 4–6 years of rural service. JMU/RQs entrants now (...) occupy 11.6% of all medical school entrants. While JMU/RQs have been shown to be highly effective in securing physicians for rural areas, ethical issues related to these policies have been raised, such as whether the government truly needs to implement these policies using tax money, and whether it is acceptable to limit the personal freedoms of the physicians. In this paper, we discuss these issues from the perspectives of social justice, utilitarianism, luck egalitarianism, liberty, medical professionalism and consistency with national health insurance and the Japanese Constitution. We conclude that JMU/RQs are necessary and ethically valid policies, and also propose some institutional improvements to better secure the integrity and maturity of these systems. (shrink)

When it comes to determining how healthcare resources should be allocated, there are many factors that could—and perhaps should—be taken into account. One such factor is a patient’s responsibility for his or her illness, or for the behavior that caused it. Policies that take responsibility for the unhealthy lifestyle or its outcomes into account—responsibility-sensitive policies—have faced a series of criticisms. One holds that agents often fail to meet either the control or epistemic conditions on responsibility with regard to their unhealthy (...) lifestyles or their outcomes. Another holds that even if patients sometimes are responsible for these items, we cannot know whether a particular patient is responsible for them. In this article, we propose a type of responsibility-sensitive policy that may be able to surmount these difficulties. Under this type of policy, patients are empowered to change to a healthier lifestyle by being given what we call a ‘Golden Opportunity’ to change. Such a policy would not only avoid concerns about patients’ fulfilment of conditions on responsibility for their lifestyles, it would also allow healthcare authorities to be justified in believing that a patient who does not change her lifestyle is responsible for the unhealthy lifestyle. We conclude with a discussion of avenues for further work, and place this policy in the broader context of the debate on responsibility for health. (shrink)