I argue that ductal carcinoma in situ (DCIS), the tumor most commonly diagnosed by breast mammography, cannot be confidently classified as cancer, that is, as pathological. This is because there may not be dysfunction present in DCIS—as I argue based on its high prevalence and the small amount of risk it conveys—and thus DCIS may not count as a disease by dysfunction-requiring approaches, such as Boorse’s biostatistical theory and Wakefield’s harmful dysfunction account. Patients should decide about treatment for DCIS based (...) on the risks it poses and the risks and benefits of treatment, not on its disease status. (shrink)

Similarly to other accounts of disease, Christopher Boorse’s Biostatistical Theory (BST) is generally presented and considered as conceptual analysis, that is, as making claims about the meaning of currently used concepts. But conceptual analysis has been convincingly critiqued as relying on problematic assumptions about the existence, meaning, and use of concepts. Because of these problems, accounts of disease and health should be evaluated not as claims about current meaning, I argue, but instead as proposals about how to define and use (...) these terms in the future, a methodology suggested by Quine and Carnap. I begin this article by describing problems with conceptual analysis and advantages of “philosophical explication,” my favored approach. I then describe two attacks on the BST that also question the entire project of defining “disease.” Finally, I defend the BST as a philosophical explication by showing how it could define useful terms for medical science and ethics. (shrink)

The ambiguity regarding whether a given intervention is perceived as enhancement or as therapy might contribute to the angst that the public expresses with respect to endorsement of enhancement. We set out to develop empirical data that explored this. We used Amazon Mechanical Turk to recruit participants from Canada and the United States. Each individual was randomly assigned to read one vignette describing the use of a pill to enhance one of 12 cognitive, affective or social domains. The vignettes described (...) a situation in which an individual was using a pill to enhance the relevant domain under one of two possible enhancement conditions, one perceived as enhancing above the norm, what most people recognize as a clear case of enhancement, whereas the other perceived as enhancing towards the norm, with the individual using the enhancement having a modest, but subclinical deficit. Participants were asked how comfortable they were with the individual using the enhancement and about the impact the enhancement might have had in the individuals’ success in life. We found that irrespective of the domain to be enhanced, participants felt significantly more comfortable with ETN than with EAN, and they regarded the enhancement intervention as contributing to greater success in life with ETN rather than EAN. These data demonstrate that the therapy enhancement distinction is morally salient to the public, and that this distinction contributes to the angst that people feel when considering the propriety of CAS enhancement. (shrink)

People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility for their health; responsibility sensitive health (...) policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

The curious philosopher often answers questions by raising further, more fundamental questions. How can this be fruitful and practical in the context of Wageningen University? Philosophy offers critical reflection on conceptual and normative assumptions in science and society, and that is necessary for responsible practices. I illustrate this by analyzing the concept of quality of life – a key value in the mission of our university – and by questioning current debates about responsibility for health.

In a severe influenza pandemic, hospitals will likely experience serious and widespread shortages of patient pulmonary ventilators and of staff qualified to operate them. Deciding who will receive access to mechanical ventilation will often determine who lives and who dies. This prospect raises an important question whether pandemic preparedness plans should include some process by which individuals affected by ventilator rationing would have the opportunity to appeal adverse decisions. However, the issue of appeals processes to ventilator rationing decisions has been (...) largely neglected in state pandemic planning efforts. If we are to devise just and effective plans for coping with a severe influenza pandemic, more attention to the issue of appeals processes for pandemic ventilator rationing decisions is needed. Arguments for and against appeals processes are considered, and some suggestions are offered to help efforts at devising more rational pandemic preparedness plans. (shrink)

Helen Frowe has recently offered what she calls a “practical” account of self-defense. Her account is supposed to be practical by being subjectivist about permissibility and objectivist about liability. I shall argue here that Frowe first makes up a problem that does not exist and then fails to solve it. To wit, her claim that objectivist accounts of permissibility cannot be action-guiding is wrong; and her own account of permissibility actually retains an objectivist (in the relevant sense) element. In addition, (...) her attempt to restrict subjectivism primarily to “urgent” situations like self-defense contradicts her own point of departure and is either incoherent or futile. Finally, the only actual whole-heartedly objectivist account she criticizes is an easy target; while those objectivist accounts one finds in certain Western European jurisdictions are immune to her criticisms. Those accounts are also clearly superior to hers in terms of action-guidingness. (shrink)

Several feminist philosophers of science have argued that social and political values are compatible with, and may even enhance, scientific objectivity. A variety of normative recommendations have emerged regarding how to identify, manage, and critically evaluate social values in science. In particular, several feminist theorists have argued that scientific communities ought to: 1) include researchers with diverse experiences, interests, and values, with equal opportunity and authority to scrutinize research; 2) investigate or "study up" scientific phenomena from the perspectives, interests, and (...) conditions of marginalized stakeholders potentially affected by the research; and 3) make gender, ethnicity, class, and geographical location "visible," or use them as categories of analysis when appropriate. Yet, more work is needed to determine what exactly these recommendations would require, and the benefits they would yield, in specific research contexts. Using the recent development of the human papillomavirus (HPV) vaccines, we examine how these three feminist recommendations would have applied. We argue that these principles would have yielded several epistemic and social benefits in the HPV case, as well as in biomedical research more generally. That is, biomedical research guided by these principles would not only be epistemically superior, but also more socially responsible. (shrink)

What would be a fair model for flood insurance? Catastrophic flooding has become increasingly frequent in the UK and, with climate change, is likely to become even more frequent in the future. With the UK's current flood insurance regime ending in 2013, we argues that: -/- - there is an overwhelming case for rejecting a free market in flood insurance after 2013; - this market-based approach threatens to leave many thousands of properties uninsurable, leading to extensive social blight; - there (...) are a number of possible flood insurance models that would be fairer and more sustainable. -/- We outline three approaches to 'fairness' in flood insurance, and argues that the second and third of these would be the most 'solidaristic' – i.e. those at lower risk of flooding would contribute to the support of people at higher risk: -/- 'pure actuarial fairness' – insurance costs directly reflect the level of risk faced by individuals; 'choice-sensitive fairness' – insurance costs should reflect only those risks that result from each individual's choices; 'fairness as social justice' – insurance should be provided independently of individuals' risks and choices when covering basic requirements of social justice. (shrink)

This paper critically assesses the model of evaluation of scientific research for democratic societies defended by Philip Kitcher. The “significant truth” approach proposes a viable alternative to two classic images of science: that of the “critics”, who believe that science always serves the interests of the powerful and that of the “faithful”, who argue that the pursuit of scientific knowledge is always valuable and necessary. However, the democratic justification of Kitcher’s proposal is not compatible with the ethical problems generated by (...) the international biomedical research in developing countries. To overcome this problem, I revise the national democratic framing of the significant truth approach in light of the theory of justice of John Rawls. (shrink)

Pratt, Zion, and Loff (2012) correctly point out that most international clinical research (ICR) is not intended to address the vast inequities in access to health care between developed and develo...

Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes (...) be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence. (shrink)

What should be the content of a package of health care services that we would want to guarantee to all Americans? This question cannot be answered adequately apart from also addressing the issue of fair health care rationing. Consequently, as I argue in this essay, appeal to the language of "basic," "essential," "adequate," "minimally decent," or "medically necessary" for purposes of answering our question is unhelpful. All these notions are too vague to be useful. Cost matters. Effectiveness matters. The clinical (...) circumstances of a patient matters. But what we must ultimately determine is what we mutually agree are the just claims to needed health care of each American in a relatively complex range of clinical circumstances. Answering this question will require a public moral conversation, a fair process of rational democratic deliberation aimed at defining both just claims to needed health care and just limits. (shrink)

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in jeopardy of falling beneath the threshold has (...) a legitimate claim to justice. People's entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold). (shrink)

This review article of Shlomi Segall's Health, Luck, and Justice (Princeton University Press, 2010) addresses three issues: first, Segall’s claim that luck egalitarianism, properly construed, does not object to brute luck equality; second, Segall’s claim that brute luck is properly construed as the outcome of actions that it would have been unreasonable to expect the agent to avoid; and third, Segall’s account of healthcare and criticism of rival views. On the first two issues, a more conventional form of luck egalitarianism (...) – that is, one which objects to brute luck even if it creates equality, and which construes brute luck as the inverse of agent responsibility – is defended. On the third issue, strengths and weaknesses in Segall’s criticism of Rawlsian, democratic egalitarian, and all-luck egalitarian approaches to healthcare, and in his own luck egalitarian approach, are identified. (shrink)

According to Norman Daniels, the moral significance of health needs stem from their impact on the normal opportunity range: pathological conditions involve comparative disadvantage. In this paper I defend an alternative reading of the moral importance of healthcare, which focuses on non-comparative aspects of disease. In the first section I distinguish two contrasting perspectives on pathological conditions, viz a comparative versus a non-comparative. By using this distinction I introduce a related disparity regarding the moral importance of personal responsibility for disease. (...) I claim that people are usually prepared to disregard individual responsibility for disease, if it involves non-comparative harm, but not if it entails mere disadvantage. Since disadvantage means to have less than equal opportunities, Daniels’ conception of opportunity is vital for his theory. It is therefore scrutinised more closely. I try to show that he wavers between two interpretations of the notion of opportunity, which are again linked to the distinction between a comparative and a non-comparative point of view. Finally, I criticise Daniels’ supposition that persons have an interest in the normal opportunity range. (shrink)

Chile has achieved great success in terms of growth and development. However, growing inequalities exist in relation to income and health status. The previous Chilean government began to reform the healthcare system with the aim of reducing health inequities. What is meant by “equity” in this context? What is the extent of the equity aimed for? A normative framework is required for public policy-makers to consider ideas about fairness in their decisions about healthcare reform. This paper aims to discuss the (...) main features of the Chilean healthcare reform and their implications for such a normative framework. (shrink)

The aims of the paper are (i) to introduce a framework for reasoning about equity in health distribution before and after interventions, and (ii) to assess various Gini measures applied to healthy life expectancy against explicit normative concerns. Part 1 discusses different ways of measuring pure health inequality and suggests that a modified Gini measure could be used to measure inequity in health before and after treatment. Part 2 introduces a framework for reasoning about distributions of health. Part 3 discusses (...) three normative concerns that any acceptable measure of inequity should satisfy. Part 4 describes the standard Gini measure for measuring pure inequalities in healthy life expectancy. It also examines Wagstaff's Extended Gini measure of health inequity and discusses how it can be used to make priority weights to the worst off explicit. The final section expresses some programmatic worries and possible applications. It is argued that the impact of interventions should be evaluated both in terms of reduced inequity (as measured by the Extended Gini or the Extended Proportional Gini) and improved efficiency (measured by gains in average healthy life expectancy). Measurement of pure health inequity could supplement cost-effectiveness analysis as a basis for fair priority setting. (shrink)

In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity is absolute and ongoing; and argue that (...) Kerstein and Bognar are mistaken to base their allocation principles on differences in personhood. (shrink)

This paper examines the fairness of avoidable inequalities in health. It contrasts two approaches to this question, a direct approach and an indirect approach. Most of the discussion focuses on the indirect approach advocated by Daniels, Kennedy and Kawachi (2000). Their argument that avoidable inequalities in health are not unfair when their causes are otherwise fair is criticised on two counts. First, it encounters a surprising difficulty when one attends carefully to the point at which ethics intersects with epidemiology here. (...) Second, it fails to address the fundamental issue, which is whether any version of the direct approach is valid. (shrink)

The health gradient among those who are by historical standards both remarkably healthy and well-off is of considerable moral importance with respect to benevolence, justice and the theory of welfare. Indeed it may help us to realize that for most people the good life lies in close and intricate social ties with others which can flourish only when inequalities are limited. The health gradient suggests that there is a story to be told in which egalitarian justice, solidarity, health and well-being (...) go hand-in-hand. (shrink)

Norman Daniels’ theory of justice and health faces a serious practical problem: his theory can ground the special moral importance of health and allows distinguishing just from unjust health inequalities, but it provides little practical guidance for allocating resources when they are especially scarce. Daniels’ solution to this problem is a fair process that he specifies as "accountability for reasonableness". Daniels claims that accountability for reasonableness makes limit-setting decisions in healthcare not only legitimate, but also fair. This paper assesses the (...) latter claim. Does accountability for reasonableness result in fair limit-setting decisions? It is argued that the answer to this question is not a clear yes. Daniels is remarkably unclear about the criterion of fairness that accountability for reasonableness satisfies. The paper discusses different options for resolving this lack of clarity and examines how they apply to Daniels’ accountability for reasonableness framework. It is concluded, first, that accountability for reasonableness is not a paradigm case of any of the classic notions of procedural justice; second, that what might be called "constrained pure procedural justice" best reflects how accountability for reasonableness results in fair limit-setting decisions; and third, that the procedural conditions of accountability for reasonableness must be further specified and amended to better achieve a fair process, and hence fair limit-setting decisions. (shrink)

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This article first describes a dilemma for liberalism: On the one hand restricting their own options is an important means for groups of people to shape their lives. On the other hand, group members are typically divided over whether or not to accept option-restricting solutions or policies. Should we restrict the options of all members of a group even though some consent and some do not? This dilemma is particularly relevant to public health policy, which typically target groups of people (...) with no possibility for individuals to opt out. The article then goes on to propose and discuss a series of aggregation rules for individual into group consent. Consideration of a number of scenarios shows that such rules cannot be formulated only in terms of fractions of consenters and non-consenters, but must incorporate their motives and how much they stand to win or lose. This raises further questions, including what is the appropriate impact of altruistic consenters and non-consenters, what should be the impact of costs and benefits and whether these should be understood as gross or net. All these issues are dealt with in a liberal, anti-paternalistic spirit, in order to explore whether group consent can contribute to the justification of option-restricting public health policy. (shrink)

Norman Daniels argues that health is important for justice because it affects the distribution of opportunities. He claims that a just society should guarantee fair opportunities by promoting and restoring the “normal functioning” of its citizens, that is, their health. The scope of citizens' mutual obligations with respect to health is defined by a reasonable agreement that, according to Daniels, should be based on the distinction between normal functioning and pathology drawn by the biomedical sciences. This paper deals with the (...) question whether it is legitimate to ascribe the responsibility of defining this important moral boundary to the biomedical sciences, which Daniels regards as value neutral. Daniels appeals to Christopher Boorse's sophisticated bio-statistical theory (BST) to show the plausibility of a value-neutral distinction between normal functioning and pathology. Here I argue that a careful analysis of the concept of normal functioning, such as the one offered by the recent critique by Elselijn Kingma, shows that it depends from evaluative assumptions. This, I argue, implies that Daniels's theory must give up its naturalistic commitments. In the conclusion, the paper offers a detailed discussion and an objection to one of Daniels's arguments in favor of a moderate form of normativism that remains too close to Boorse's naturalism. (shrink)

Many societies, and nearly all wealthy, developed countries, provide universal access to a broad range of public health and personal medical services. Is such access to health care a requirement of social justice, or is it simply a matter of social policy that some countries adopt and others do not? If it is a requirement of social justice, we should be clear about what kinds of care we owe people and how we determine what care is owed if we cannot (...) possibly meet every health need, as arguably no society can. We should be clear about what constitutes appropriate access to that care, given that there are diverse barriers to access. We must also be able to say why we owe these things as a matter of justice, and, of course, different accounts of social justice will bake and serve this cake in different ways. (shrink)

The aim of this article is to consider whether, when, and why it is morally right to treat members of socially disadvantaged racial or ethnic groups favorably when allocating scarce medical resources. Since the COVID 2019 pandemic has had different impacts on racial and ethnic groups, some U.S. states have given racial and ethnic minorities preferential access to COVID-19 vaccines, leading to controversy over the moral and legal permissibility of doing so. I examine three arguments for affirmative action—the compensation, equality-of-opportunity, (...) and antidiscrimination arguments—and argue that both the equality-of-opportunity and antidiscrimination arguments have the potential to provide well-founded justification for race-based affirmative action for the allocation of scarce medical resources. I also consider further moral requirements that instances of affirmative action based on both or either of the two arguments should comply with for them to be justified. (shrink)

An issue about the privacy of the clustered groups designed by algorithms arises when attempts are made to access certain pieces of information about those groups that would likely be used to harm them. Therefore, limitations must be imposed regarding accessing such information about clustered groups. In the discourse on group privacy, it is argued that the right to privacy of such groups should be recognised to respect group privacy, protecting clustered groups against discrimination. According to this viewpoint, this right (...) places a duty on others, for example, private companies, institutions, and governments, to refrain from accessing such information. To defend the idea that the right to privacy should be recognised for clustered groups, at least two requirements must be satisfied. First, clustered group privacy must be conceived of as either a collective good or a participatory good. Since these forms of good are of the type from which no member of a group can be excluded from benefiting, the right to them is defined as a group right. Second, there must be group interests on which to base a group right. Group interests can be either the interests of those members that are a result of their being in the group or the interests of the group as a whole that transcend the interests of its members. However, this paper argues that clustered group privacy cannot be conceived of as either a collective or a participatory good because it is possible for some individuals to be excluded from benefiting from it. Furthermore, due to the lack of awareness among individuals that they are members of a clustered group and the nature of a clustered group itself, such groups cannot have the group interests necessary to establish a group right. Hence, the group right to privacy cannot be recognised for these groups, implying that the group right cannot be considered a means to protect clustered groups against discrimination. Instead, this paper suggests that moral principles need to be articulated within an ethics of vulnerability to identify the moral obligations of protecting vulnerable clustered groups. The duty owed to the vulnerable should involve refraining from accessing certain information about clustered groups in specific contexts. This duty is not engendered by the right to privacy of such groups; it is the duty owed to the vulnerable. The findings highlight the need to articulate moral principles regarding privacy and data protection to protect clustered groups in contexts in which accessing information about them could constitute a reason for discriminatory targeting. (shrink)

This World Bank Report offers a new conception of fair decision processes in health financing. It argues that such procedural fairness can contribute to fairer outcomes, strengthen the legitimacy of decision processes, build trust in authorities, and promote the sustainability of reforms on the path to health coverage for all.

In this paper, I defend a version of the medical model of disability, which defines disability as an enduring biological dysfunction that causes its bearer a significant degree of impairment. We should accept the medical model, I argue, because it succeeds in capturing our judgments about what conditions do and do not qualify as disabilities, because it offers a compelling explanation for what makes a condition count as a disability, and because it justifies why the federal government should spend hundreds (...) of billions of dollars, annually, on aid and accommodations for disabled people. After responding to a pair of objections Elizabeth Barnes has raised against the medical model, I contrast it with Guy Kahane and Julian Savulescu's welfarist account of disability, and with Barnes's own mere-difference view. Both of these accounts face serious challenges, although elements of Barnes's view can—and, in my opinion, should—be adopted by proponents of the medical model. (shrink)

The use of genome embryo editing tools in reproduction is often touted as a way to ensure the birth of healthy and genetically related children. Many would agree that this is a worthy goal. The purpose of this paper is to argue that, if we are concerned with justice, accepting such goal as morally appropriate commits one to rejecting the development of embryo editing for reproductive purposes. This is so because safer and more effective means exist that can allow many (...) more prospective parents to achieve the same valued goal and that offer additional benefits. (shrink)

Vaccine scarcity and availability distinguish two central ethics questions raised by the Covid-19 pandemic. First, in situations of scarcity, which groups of persons should receive priority? Second, in situations where safe and effective vaccines are available, what circumstances and reasons can support mandatory vaccination? Regarding the first question, normative approaches converge in prioritizing most-vulnerable groups. Though there is room for prudential judgement regarding which groups are most vulnerable, the human dignity principle is most relevant for prioritization consideration of both medical (...) and non-medical issues. The second question concerning mandates is distinct from considerations about persons’ individual moral duty to receive vaccines judged reasonably safe and critical for individual and public health. While there is consensus regarding the potential normative support for mandated vaccination, the paternalistic government intervention of vaccine mandates requires a high bar of demonstrated vaccine safety and public health risk. We discuss stronger and weaker forms of paternalism to deal with the Covid-19 pandemic from an “integrative” approach that integrates leading normative approaches. We argue against a population-wide compulsory vaccination and support prudential measures to 1) protect vulnerable groups; 2) focus upon incentivizing vaccine participation; 3) maintain maximum-possible individual freedoms, and 4) allow schools, organizations, and enterprises to implement vaccine requirements in local contexts. (shrink)

As political instruments, human rights can be challenged in two important ways: first, by undermining the claim to universality by appealing to a kind of cultural relativism, and second, by accusing human rights of unjustifiably imposing values that are not genuinely universal (which I dub the problem of parochialism). The human right to health is no exception. If a human right to health is to be a useful instrument in mobilizing action for global health justice, then we need to take (...) seriously the ways that health intersects with culture. Universal applicability is essential to both the legitimacy and efficacy of human rights. But without cultural sensitivity, additional injustices and imperialistic harms may be perpetuated. There are two goals within this paper—(1) to show that cultural imperialism is a moral and practical hazard, both in general and for the human right to health in particular and (2) to articulate a way of thinking about the human right to health that can minimize these hazards and arm it with moral credibility and political weight. (shrink)

Debates about the ethics of health care and medical research in contemporary pluralistic democracies often arise partly from competing religious and secular values. Such disagreements raise challenges of balancing claims of religious liberty with claims to equal treatment in health care. This paper proposes several mid-level principles to help in framing sound policies for resolving such disputes. We develop and illustrate these principles, exploring their application to conscientious objection by religious providers and religious institutions, accommodation of religious priorities in biomedical (...) research, and treatment of patients’ religious views in doctor–patient encounters. Given that no sound set of guiding principles yields precise solutions for every policy dispute, we explore how morally sound democracies might deliberatively resolve such policy issues, following our proposed principles. Taken together and carefully interpreted, these principles may help in guiding difficult decision making in the indefinitely large realm where government, medical providers, and patients encounter problems concerning religion and medicine. (shrink)

As individuals grow older, they usually require assistance with the daily tasks of self-care. This type of assistance, ancillary care, is essential to maintaining the health of those who need these services. In his prudential lifespan account, Norman Daniels includes access to such services making his account an attractive proposal given the current demographic shift. In this paper, I examine the prudential lifespan account through the lens of old age and I focus on the two concepts on which the lifespan (...) account relies. I show that these two concepts, normal species functioning and opportunity cannot buttress Daniels’s lifespan account; at least it cannot do so for older persons. The tensions that I identify in the prudential lifespan account in relation to aging are instructive for the more recent proposals to include aging in a theory of health and health justice. In addition, my analysis allows me to demonstrate that Daniels’s view of opportunity is irreconcilable to capabilities, the latter being more adaptable to the realities of aging. If capabilities appear more promising, it is nonetheless imperative that the specificities of extended care, such as the need for unpaid caregiving, be taken into consideration. (shrink)

Context. Public engagement efforts in health policy have posed many value-laden questions, yet those that appreciate the complexity and diversity of the concept of health equity are rare. We introduce the Fairness Dialogues, a new method for deliberating health equity among the general public. We provide its theoretical underpinning and present its empirical illustration and qualitative assessment. Methods. Primarily informed by the scholarship of deliberation, we designed the Fairness Dialogues, featured by reason-giving and inclusive group deliberation using a hypothetical scenario (...) that presents carefully designed, simple, open-ended cases focusing on a chosen equity and fairness issue. To assess whether the Fairness Dialogues encourages reflective views, we conducted a qualitative investigation by focusing on fairness and unfairness of inequalities in life expectancy. Findings. Our results revealed the complex intuitions that people have and their curiosity, patience, and willingness to scrutinize them in-depth through a small group dialogue. Intuitions shared by our study participants are similar to those presented in the scholarly philosophical literature. Conclusions. The Fairness Dialogues is a promising method to incorporate the public’s views into policy-making involving value judgment and to develop the capacity of the public to discuss value-laden questions in a reflective and inclusive manner. (shrink)

In this special issue about the moral agenda after the corona crisis, I argue that the true utilitarian would not - as some have suggested - push for rapid relaxation of the lockdown "to save the economy", but rather press for more redistribution to help those whom the crisis hits the hardest. [Dutch].

The idea of using responsibility in the allocation of healthcare resources has been criticized for, among other things, too readily abandoning people who are responsible for being very badly off. One response to this problem is that while responsibility can play a role in resource allocation, it cannot do so if it will leave those who are responsible below a “sufficiency” threshold. This paper considers first whether a view can be both distinctively sufficientarian and allow responsibility to play a role (...) even for those who will be left with very poor health. It then draws several further distinctions that may affect the application of responsibility at this level. We conclude that a more plausible version of the sufficientarian view is to allow a role for responsibility where failure to do so will leave someone else who is not responsible below the sufficiency threshold. However, we suggest that individuals must exhibit “sufficient responsibility” in order for this to apply, involving both a sufficient level of control and an avoidable failure to respond adequately to reasons for action. (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)

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)

Este essay-paper busca aportar algunos elementos para el debate de la caracterización del acceso a los medicamentos como un derecho global, partiendo de una serie de reflexiones que teóricos realizan sobre un asunto que se constituye en uno de los principales focos de desigualdad en el mundo.

Beneficence is a foundational ethical principle in medicine. To provide benefit to a patient is to promote and protect the patient’s wellbeing, to promote the patient’s interests. But there are different conceptions of wellbeing, emphasizing different values. These conceptions of wellbeing are contrary to one another and give rise to dissimilar ideas of what it means to benefit a patient. This makes the concept of beneficence ambiguous: is a benefit related to the patient’s goals and wishes, or is it a (...) matter of objective criteria that constitute wellbeing? This paper suggests a unified conception of wellbeing for use in medicine to determine what counts as a benefit. Two components of wellbeing are identified: (1) objective functioning/health and (2) the patient’s view of her own good. The paper explores how to apply, balance, and weigh these components in clinical situations to determine what counts as a benefit to a patient. (shrink)

Research on how to understand legally recognized socio-economic rights produced many insights into the nature of rights. Legally recognized rights to health and, by extension, health care could contribute to health justice. Yet a tension remains between widespread international and transnational constitutional recognition of rights to health and health care and compelling normative conditions for rights recognition from both philosophers seeking to identify the scope and structure of the rights and policy scholars seeking to understand how to practically realize such (...) rights. This work identifies an overlooked source of these difficulties: the right to health care and other health rights are necessarily ‘complex’, consisting of multiple related, but irreducible, morally valuable components. ‘Complex rights’ do not fit the traditional structure of human rights, so legal recognition of same can appear confused from a philosophical perspective, but there is ample reason to admit complex rights into our moral ontology and doing so can help bridge the divide between global health practices and ongoing work in the philosophy of rights and public policy. Recognition of complex rights admittedly shifts the burden for justifying health rights, but it does so in a way that is instructive for general philosophical analysis of socio-economic rights. (shrink)

I explore the role that values and interests, especially ideological interests, play in managing and balancing epistemic risks in medicine. I will focus in particular on how diseases are identified and operationalized. Before we can do biomedical research on a condition, it needs to be identified as a medical condition, and it needs to be operationalized in a way that lets us identify sufferers, measure progress, and so forth. I will argue that each time we do this, we engage in (...) epistemic risk balancing that inevitably draws upon values and interests, often including social and ideological values. My main interest here is in the conceptualization of infertility as a disease. Infertility is a rich test case for exploring the interplay between interests and epistemic risk management. There is no uncontested or standardized definition of infertility. The various definitions of it are internally ambiguous and tension-ridden, and in spectacular contradiction with one another. Many interest groups who are invested in framing infertility as a pressing problem deserving of social and medical redress are quick to insist that it is a legitimate ‘disease,’ but they cannot agree on which disease it is, what its symptoms or diagnostic markers are, or even what its basic ontology is. I suggest that there are political explanations for this epistemic mess. Indeed, I contend that there are good scientific and ethical reasons to reduce away the category of ‘infertility,’ especially understood as a scientific or medical category; I argue that we should excise the concept from our research and clinical practices. (shrink)

Volume 20, Issue 2, February 2020, Page 20-22.