This book offers an original account of a distinctly republican theory of social and global justice. The book starts by exploring the nature and value of Hegelian recognition theory. It shows the importance of that theory for grounding a normative account of free and autonomous agency. It is this normative account of free agency which provides the groundwork for a republican conception of social and global justice, based on the core-ideas of freedom as non-domination and autonomy as non-alienation. As the (...) author argues, republicans should endorse a sufficientarian account of social justice, which focuses on the nature of social relationships and their effects on people's ability to act freely and realize their fundamental interests. On the global level, the book argues for the cosmopolitan extension of the republican principles of non-domination and non-alienation within a multi-level democratic system. In so doing, the book addresses a major gap in the existing literature, presenting an original theory of justice, which combines Hegelian recognition theory and republican ideas of freedom, and applying this hybrid theory to the global domain. Fabian Schuppert creates a grand synthesis uniting neo-republican insights on freedom with Hegelian recognition theory. The result is an account of agency that arises from the idea of non-domination whose aim it is to safeguard individual freedom. When combined with Hegelian recognition theory a social focus also emerges. This amalgam comments on many of the major disputes concerning global justice from a cosmopolitan perspective. Because of the broad scope and the many contemporary discussions engaged this book will be of keen interest to scholars as well as a welcome addition to the classroom. (shrink)

Imagine a democratic society in which all members are full citizens and citizens relate to each other as equals. Social arrangements bring it about, to the maximum possible extent, that all adults are full functioning members of society. The society is not marred by caste hierarchies, invidious status distinctions, or unequal power relations. No one is able to dominate others. Moreover, the urge to dominate over others does not loom large in social life. Each person's relations with others manifest the (...) belief, shared by all, that each person is fundamentally the equal of all others and that this equality calls for treating others with civility and mutual respect and forbearance. Each is viewed as having the right to live as she chooses, within broad constraints of morality. This individual entitlement to freedom establishes a strong presumption against paternalism, restricting a person's liberty against her will for her own good. Regarding distributive justice, the norm is that each should be enabled to have enough by way of resources and opportunities to sustain herself as a full functioning member of democratic society. (shrink)

Recently, most of the discussions in Confucian political theory have concentrated on whether Confucianism is compatible with local political practices, such as liberal democracy. The question of how Confucians view global distributive justice has not yet received critical attention. This essay aims to fill this gap. I will first describe a contractualist methodology, which aims at deriving substantial political principles from a formal conception of the person. Then I will discuss what conception of the person Confucianism assumes. Finally, I will (...) use the contractualist methodology to derive three principles of global distributive justice. These three principles form a distinctive conception based on ideas that are usually ignored in the current discussions of global justice, such as virtues, community, and rituals. (shrink)

Obesity is often considered a public health crisis in rich countries that might be alleviated by preventive regulations such as a sugar tax or limiting the density of fast food outlets. This paper evaluates these regulations from the point of view of equity. Obesity is in many countries correlated with socioeconomic status and some believe that preventive regulations would reduce inequity. The puzzle is this: how could policies that reduce the options of the badly off be more equitable? Suppose we (...) distinguish: (1) the badly off have poor options from (2) the badly off are poor at choosing between their options (ie, have a choosing problem). If obesity is due to a poverty of options, it would be perverse to reduce them further. Some people in public health say that preventive regulations do not reduce options but, I shall argue, they are largely wrong. So the equity case for regulations depends on the worst off having a choosing problem. It also depends on their having a choosing problem that makes their choices against their interests. Perhaps they do. I ask, briefly, what the evidence has to say about whether the badly off choose against their interests. The evidence is thin but implies that introducing preventive regulations for the sake of equity would be at least premature. (shrink)

This article proposes ‘Recursive Consequentialism’: the moral theory which gives agents whatever advice will produce good consequences by being given. It can be thought of as a version of Donald Regan's ‘Cooperative Utilitarianism’ to which two additional elements have been added: allowing people with differing conceptions of ‘good consequences’, e.g., a Utilitarian and a non-Utilitarian, to cooperate with one another, and taking into account the full consequences of accepting, not just complying with, moral guidance. The theory is motivated by a (...) series of game-theoretic examples in which adherence to alternative Consequentialist moral theories produces bad consequences. (shrink)

Robert Sparrow (2014) argues that moral bioenhancement - the project of attempting to improving moral character via medical or biological means - ought to be of great concern to egalitarians. Importantly, Sparrow's argument is meant to apply regardless of whether such bioenhancement is likely to be successful. In this response, I argue against Sparrow's worries concerning successful moral bioenhancement. This response highlights that it may not be possible to separate moral questions of the permissibility of bioenhancement from scientific and conceptual (...) questions regarding its possibility. (shrink)

Controversial cases in medical ethics are, by their very nature, divisive. There are disagreements that revolve around questions of fact or of value. Ethical debate may help in resolving those disagreements. However, sometimes in such cases, there are opposing reasonable views arising from deep-seated differences in ethical values. It is unclear that agreement and consensus will ever be possible. In this paper, we discuss the recent controversial case of Vincent Lambert, a French man, diagnosed with a vegetative state, for whom (...) there were multiple court hearings over a number of years. Both family and health professionals were divided about whether artificial nutrition and hydration should be withdrawn and Lambert allowed to die. We apply a ‘dissensus’ approach to his case and argue that the ethical issue most in need of scrutiny is different from the one that was the focus of attention. (shrink)

Standard tools used in societal risk management such as probabilistic risk analysis or cost–benefit analysis typically define risks in terms of only probabilities and consequences and assume a utilitarian approach to ethics that aims to maximize expected utility. The philosopher Carl F. Cranor has argued against this view by devising a list of plausible aspects of the acceptability of risks that points towards a non-consequentialist ethical theory of societal risk management. This paper revisits Cranor’s list to argue that the alternative (...) ethical theory responsibility-catering prioritarianism can accommodate the aspects identified by Cranor and that the elements in the list can be used to inform the details of how to view risks within this theory. An approach towards operationalizing the theory is proposed based on a prioritarian social welfare function that operates on responsibility-adjusted utilities. A responsibility-catering prioritarian ethical approach towards managing risks is a promising alternative to standard tools such as cost–benefit analysis. (shrink)

This thesis is based on the assumption that the intersection of moral philosophy and practical risk management is a rewarding area to study. In particular, the thesis assumes that concepts, ideas, and methods that are used in moral philosophy can be of great benefit for risk analysis, but also that practices in risk regulation provide a useful testing ground for moral philosophical theories. The thesis consists of an introduction and five articles. Article I is a review article on social and (...) ethical aspects of radiation protection related to nuclear power generation. The paper concludes that four areas of social and ethical issues stand out as central: The first is uncertainty and the influence of value judgments in scientific risk assessments. The second is the distributions of risks and benefits between different individuals, in both space and time. The third is the problem of setting limits when there is no known level of exposure associated with a zero risk. The fourth is related to stakeholder influence and risk communication. Article II discusses ethical issues related to the proposal that doses below a certain level should be excluded from the system of radiation protection, without any regard for the number of people exposed. Different arguments for excluding small radiation doses from regulation are examined and a possible solution to the problem of regulating small risks is proposed in the article: Any exclusion of small doses from radiation protection ought to be based on a case-by-case basis, with the condition that the expected value of harm remains small. Article III examines what makes one distribution of individual doses better than another distribution. The article introduces a mathematical framework based on preference logic, in which such assessments can be made precisely in terms of comparisons between alternative distributions of individual doses. Principles of radiation protection and from parallel discussions in moral philosophy and welfare economics are defined using this framework and their formal properties analyzed. Article IV argues that the ethical theory of “responsibility-catering prioritarianism” is well positioned to deal with the reasonable requirements in an ethical theory of risk. The article shows how responsibility-catering prioritarianism can be operationalized using a prioritarian social welfare function based on hypothetical utilities. For this purpose, a hypothetical utility measure called ‘responsibility-adjusted utility’ is proposed, which is based on the utility that would normally be expected given circumstances outside of the control of the individual. Article V was written as a response to the Fukushima disaster. Several authors have called the Fukushima disaster a ‘black swan.’ However, the article argues that the hazards of large earthquakes and tsunamis were known before the accident, and introduces and defines the concept of a ‘black elephant,’ as a high-impact event that lies beyond the realm of regular expectations, but is ignored despite existing evidence. (shrink)

One of the strongest objections to the development and use of substantially life-extending interventions is that they would exacerbate existing unjust disparities of healthy lifespans between rich and poor members of society. In both popular opinion and ethical theory, this consequence is sometimes thought to justify a ban on life-prolonging technologies. However, the practical and ethical drawbacks of banning receive little attention, and the viability of alternative policies is seldom considered. Moreover, where ethicists do propose alternatives, there is scant effort (...) to consider their merits in light of developing world priorities. In response to these shortcomings, I distinguish four policy options and, on the basis of a plausible intuition about fairness, evaluate their implications for a fair distribution of healthy lifespans. I claim that even in developing nations it would be fairest to favor policies that promote equal access to at least one promising category of substantially life-extending intervention: calorie restriction mimetics. (shrink)

According to luck egalitarianism, inequalities are justified if and only if they arise from choices for which it is reasonable to hold agents responsible. This position has been criticised for its purported harshness in responding to the plight of individuals who, through their own choices, end up destitute. This paper aims to assess the Harshness Objection. I put forward a version of the objection that has been qualified to take into account some of the more subtle elements of the luck (...) egalitarian approach. Revising the objection in this way suggests that the Harshness Objection has been overstated by its proponents: because luck egalitarians are sensitive to the influence of unequal brute luck on individuals’ choices, it is unlikely that there will be any real world cases in which the luck egalitarian would not have to provide at least partial compensation. However, the Harshness Objection still poses problems for the luck egalitarian. First, it is not clear that partial compensation will be sufficient to avoid catastrophic outcomes. Second, the Harshness Objection raises a theoretical problem in that a consistent luck egalitarian will have to regard it as unjust if any assistance is provided to the victim of pure option luck, even if such assistance could be provided at no cost. I consider three strategies the luck egalitarian could pursue to accommodate these concerns and conclude that none of these strategies can be maintained without either violating basic luck egalitarian principles or infringing upon individual liberty. (shrink)

Total views imply what Derek Parfit has called ‘the repugnant conclusion’. There are several strategies aimed at debunking the intuition that this implication is repugnant. In particular, it goes away when we consider the principle of unrestricted instantiation, according to which any instantiation of the repugnant conclusion must appear repugnant if we should be warranted in relying on it as evidence against total theories. However, there are instantiations of the conclusion where it doesn't seem to be at all repugnant. Hence (...) there is nothing repugnant about the repugnant conclusion as such. The faults with total views have nothing to do with large numbers or with the conclusion as such. It is possible, if you like, to correct these putative faults even if you adopt some total view (different from utilitarianism). (shrink)

Is the overall value of a world just the sum of values contributed by each value-bearing entity in that world? Additively separable axiologies (like total utilitarianism, prioritarianism, and critical level views) say 'yes', but non-additive axiologies (like average utilitarianism, rank-discounted utilitarianism, and variable value views) say 'no'. This distinction appears to be practically important: among other things, additive axiologies generally assign great importance to large changes in population size, and therefore tend to strongly prioritize the long-term survival of humanity over (...) the interests of the present generation. Non-additive axiologies, on the other hand, need not assign great importance to large changes in population size. We show, however, that when there is a large enough `background population' unaffected by our choices, a wide range of non-additive axiologies converge in their implications with additive axiologies—for instance, average utilitarianism converges with critical-level utilitarianism and various egalitarian theories converge with prioritarianism. We further argue that real-world background populations may be large enough to make these limit results practically significant. This means that arguments from the scale of potential future populations for the astronomical importance of avoiding existential catastrophe, and other arguments in practical ethics that seem to presuppose additive separability, may succeed in practice whether or not we accept additive separability as a basic axiological principle. (shrink)

According to prioritarianism, an influential theory of distributive justice, we have a stronger reason to benefit people the worse off these people are. Many authors have adopted a consequentialist version of prioritarianism. On this account, we have a consequentialist reason to benefit the worse off because the state of affairs where the worse off gains a given amount of utility is more valuable than the state of affairs where the better off gains roughly the same amount of utility. In this (...) paper, we argue that the consequentialist approach to prioritarianism is problematic. However, it doesn't follow that the prioritarian doctrine per se is groundless. We then suggest that we can make sense of prioritarianism by appeal to a contractualist approach. (shrink)

This essay argues that culpability and responsibility are independent notions, even though some of the same facts make us both responsible and culpable. Responsibility for one’s conduct is grounded in the strength of the agential connection between oneself and one’s conduct. Culpability for one’s conduct is the vices that give rise to that conduct. It then argues that responsibility and culpability for causing a threat are each grounds of liability to defensive harm independent of the other.

Justice is a contested concept. There are many different and competing conceptions, i.e. interpretations of the concept. Different domains of justice deal with different fields of application of justice claims, such as structural justice, distributive justice, participatory justice or recognition. We present a formal conceptual structure of justice applicable to all these domains. We show that conceptions of justice can be described by specifying the following conceptual elements: the judicandum, the community of justice including claim holders and claim addressees, their (...) claims, the informational base for the assessment, the principles of justice, and on a more practical level, the instruments of justice. By specifying these conceptual elements of justice, it is possible to analyse and compare different conceptions of justice, to assess their internal consistency, to explore new definitions of justice in an analytical way, and to explicate an idea of justice in a manner that provides concrete links to the relevant context. (shrink)

This article examines the business case for diversity, according to which diversity should be promoted because diverse groups outperform nondiverse groups. Philosophers who defend BCD usually...

I consider two difficulties which have been presented to egalitarianism: Parfit’s “Levelling Down Objection” and my “Paradox of the Baseline”. I show that making things worse for some people even with no gain to anyone is actually an ordinary and indeed necessary feature of our moral practice, yet nevertheless the LDO maintains its power in the egalitarian context. I claim that what makes the LDO particularly forceful in the case against egalitarianism is not the very idea of making some people (...) worse off with no gain to others, but the disrespect for value inherent in egalitarianism; and similarly that the POB is a reductio of choice -egalitarianism because of its inversion of the intuitively correct attitude to the generation of value. I conclude that in the light of the absurdity and paradox so frequently lurking in moral and social life, and particularly with the complexity of modern life and obliquity of change, we need to be much more modest than egalitarians have been in putting forth ambitious moral and social models. (shrink)

Public healthcare systems are increasingly refusing (temporarily) to reimburse newly approved medical treatments of insufficient or uncertain cost-effectiveness. As both patient demand for these treatments and their list prices increase, a market might arise for voluntary additional health insurance (VHI) that covers effective but (very) expensive medical treatments. In this paper, we evaluate such potential future practices of VHI in public healthcare systems from a justice perspective. We find that direct (telic) egalitarian objections to unequal access to expensive treatments based (...) on different ability to afford VHI do not stand up to scrutiny. However, such unequal access might lead to loss of self-respect among individuals, or loss of fraternity within society, rendering it more difficult for citizens to interact on equal moral footing. This would be problematic from a relational egalitarian perspective. Moreover, the introduction of VHI might turn out to have negative consequences for the comprehensiveness and/or the quality of the public healthcare services that are offered to all patients equally through basic health insurance. These consequences must be weighed against potential health gains and the value of liberty. We conclude that governments should be careful when considering the introduction of VHI in public healthcare systems. (shrink)

Telic sufficientarians hold that there is something special about a certain threshold level such that benefiting people below it, or raising them above it, makes an outcome better in at least one respect. The article investigates what fundamental value might ground that view. The aim is to demonstrate that sufficientarianism, at least on this telic version, is groundless and as such indefensible. The argument is advanced in three steps: first, it is shown that sufficientarianism cannot be grounded in a personal (...) value. Neither, secondly, is it committed to the person-affecting view, the view that says that nothing can be better if there is no one for whom it is better. This, in itself, is of interest because some sufficientarians reject egalitarianism precisely for its alleged incompatibility with the person-affecting view. Sufficientarians' disavowal of the person-affecting view implies that their view, similarly to egalitarianism, must be anchored in some impersonal value. But crucially, and this is the third step of the argument, there is no apparent value that can fit that role. We must conclude, then, that telic sufficientarianism is groundless. (shrink)

ABSTRACT: Among recent criticisms of impartial moral theories, especially in consequentialist and deontological forms, Bernard Williams’ integrity objection is perhaps the most tantalizing. This objection is a complaint—at once both general and deep—that impartial moral theories are systematically incapable of finding room for integrity in human life and character. Kantians have made forceful responses to this integrity objection and have moved on. Consequentialists have found the objection more trying. I offer reasons to think that consequentialists too can safely move on. (...) These reasons suggest the relationship between integrity and impartiality is less antagonistic than often supposed.RÉSUMÉ : Parmi les récentes critiques des théories morales impartiales, notamment les critiques conséquentialiste et déontologique, l’objection d’intégrité de Bernard Williams est possiblement la plus attrayante. Cette objection—à la fois générale et profonde—reproche aux théories morales impartiales d’être incapables de retrouver l’intégrité dans la vie et le caractère humains. Les kantiens ont répondu vigoureusement à cette objection, puis sont passés à autre chose. Les conséquentialistes ont trouvé l’objection plus éprouvante. Je soutiens que les conséquentialistes peuvent, eux aussi, passer à autre chose, en suggérant que le rapport entre l’intégrité et l’impartialité est moins antagonique que supposé. View HTML Send article to KindleTo send this article to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle. Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply. Find out more about the Kindle Personal Document Service.Integrity and Impartial MoralityVolume 51, Issue 2Greg Scherkoske DOI: https://doi.org/10.1017/S0012217312000455Your Kindle email address Please provide your Kindle [email protected]@kindle.com Available formats PDF Please select a format to send. By using this service, you agree that you will only keep articles for personal use, and will not openly distribute them via Dropbox, Google Drive or other file sharing services. Please confirm that you accept the terms of use. Cancel Send ×Send article to Dropbox To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Dropbox. Integrity and Impartial MoralityVolume 51, Issue 2Greg Scherkoske DOI: https://doi.org/10.1017/S0012217312000455Available formats PDF Please select a format to send. By using this service, you agree that you will only keep articles for personal use, and will not openly distribute them via Dropbox, Google Drive or other file sharing services. Please confirm that you accept the terms of use. Cancel Send ×Send article to Google Drive To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Google Drive. Integrity and Impartial MoralityVolume 51, Issue 2Greg Scherkoske DOI: https://doi.org/10.1017/S0012217312000455Available formats PDF Please select a format to send. By using this service, you agree that you will only keep articles for personal use, and will not openly distribute them via Dropbox, Google Drive or other file sharing services. Please confirm that you accept the terms of use. Cancel Send ×Export citation Request permission. (shrink)

Fairness is a central, but under-theorized, notion in moral and political philosophy. This paper makes two contributions. Firstly, it criticizes Broome’s seminal account of fairness in Proc Aristotelian Soc 91:87–101, showing that there are problems with restricting fairness to a matter of relative satisfaction and holding that it does not itself require the satisfaction of the claims in question. Secondly, it considers the justification of lotteries to resolve cases of ties between competing claims, which Broome claims as support for his (...) theory, and contrasts random procedures to contests of skill, which may also be considered lotteries in a broader sense. I offer no alternative account of fairness of my own, but hope to point the way for future research on the nature of fairness. (shrink)

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, consequentialist and (...) virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. (shrink)

Conceptions of desert and responsibility have had a powerful influence in justifying economic inequality. Currently, they are being reaffirmed in policies advocated by the centre left in Britain. In contrast, luck egalitarianism, one of the dominant theoretical positions in contemporary political philosophy, puts equality at the top of the agenda and notoriously undermines traditional notions of desert and rejects the conception of personal responsibility on which traditional ideas rely. Although luck egalitarians are sceptical about desert and redefine responsibility to reduce (...) its role in arguments for just distribution, they nevertheless retain a commitment to holding people responsible for the distributive consequences of what they freely choose to do. They attempt to demonstrate that equality can be reconciled with responsibility. I will argue that luck egalitarians have not gone far enough in eliminating desert and responsibility from the armoury of social justice, and that their own arguments should have led them to do so. My aim in this article is to push the ideas implicit in luck egalitarian's arguments to their logical conclusion. I argue that for practical and conceptual reasons, they should have formulated their theories as though hard determinism is true, or nearly true, even if it is not. Denying the pertinence of judgements of desert and responsibility to questions of distributive justice removes an obstacle to egalitarian aims by suggesting a more egalitarian distribution than one that is hostage to voluntary choice. It could be accepted that luck egalitarianism cannot accommodate the concept of personal responsibility without accepting the conclusion that considerations of responsibility should be abandoned. However, any plausible account of responsibility would demonstrate that existing inequalities are undeserved, and that these inequalities make a mockery of politicans current emphasis on personal responsibility. (shrink)

This thesis discusses the possibility of limited moral trade-offs between different people’s welfare. In chapter 2, I introduce the two central limited trade-off conditions. First, according to minimal infinite superiority, significantly benefiting one person matters more than slightly benefiting each of any number of better-off people. Second, according to minimal finite superiority, significantly benefiting many people matters more than slightly benefiting one person. I consider both axiological and deontic interpretations of these conditions. However, I explain why none of the simple (...) classic moral principles—the simple total and the maximin principles—satisfy both conditions. Furthermore, in chapter 3, I strengthen several proved impossibility results according to which no moral theory satisfies weak interpretations of these central trade-off conditions and several other seemingly plausible minimal conditions. I show that giving up structural axiological and deontic conditions is not a satisfactory solution to these paradoxes. In chapter 4, I discuss the modification of a background assumption of these impossibility results on the measurement of welfare. I show that, given a modification that allows for lexicographically ordered welfare components, a total principle can satisfy all the conditions of the impossibility results. However, I argue that such a modification is not entirely satisfactory because it does not apply in certain instances of the paradoxes. In chapter 5, I discuss a further weakening of minimal infinite superiority. However, I show that a suggested possibility result based on this modification is not valid and that further moral conditions, such as minimal finite superiority, need to be modified. Moreover, I argue that these modified conditions and the principle suggested in the possibility proof—a minimax complaint principle—do not capture the basic idea of the two central limited trade-off conditions sufficiently well. In chapter 6, I argue that other principles suggested for the task—the total claim principles—share the same fate as the simple total principles or the minimax complaint principle. In chapter 7, I propose new principles that take their structural roots from voting theory. I show that, in contrast to the other principles discussed, these principles give plausible verdicts where the other principles failed. Finally, in chapter 8, I consider possible objections levelled against this proposal, and I suggest solutions and avenues for future research. (shrink)

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly’. Indeed, we describe how the current clinical guidance on prioritisation issued (...) by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context. (shrink)

The use of genetic testing has prompted the question of whether insurance companies should be able to use predictive genetic test results (GTRs) in their risk classification of clients. While some jurisdictions have passed legislation to prohibit this practice, the UK has instead adopted a voluntary code of practice that merely restricts the ways in which insurance companies may use GTRs. Critics have invoked various theories of justice to argue that this approach is unfair. However, as well as sometimes relying (...) on somewhat idealised assumptions, these analyses have tended to invoke theories that have wide-ranging and highly revisionary implications for insurance. Moreover, they fail to adequately engage with a conception of justice that plausibly undergirds the status quo approach to insurance in the UK. I argue that it is a mistake to simply invoke a single contestable theory in seeking to develop sound policy on the use of GTRs in insurance. To that end, in this paper, I outline three plausible principles of justice that policy on this issue ought to balance: A principle of equity, a principle of equal access and a principle of need. In doing so, I shall offer a pluralist justice-based argument in support of the spirit, if not the precise letter, of the UK approach. (shrink)

Some theorists, especially egalitarians, seek to ‘apply’ theories of justice to a specific area or good, such as health, and assess the distribution of that good at the bar of justice. On the one hand, this is understandable, given that egalitarians are often interested in making policy recommendations and these would have to be area-specific. On the other hand, it is surprising in light of the fact that theories of justice normally envisage the ‘total package of goods’ or an overall (...) good as the distribuendum. This article aims to show that this approach is problematic at least in the area of health. (shrink)

The main aim of this paper is to investigate the views of healthcare professionals in Portugal about healthcare rationing, and compare them with the views of college students. A self-administered questionnaire was used to collect data from a sample of 60 healthcare professionals and 180 college students. Respondents faced a hypothetical rationing dilemma where they had to order four patients and justify their choices. Multinomial logistic regressions were used to test for differences in orderings, and content analysis to categorize the (...) written justifications. The findings suggest that both groups appeared to support three main rationing principles: health maximization, priority to the severely ill and priority to the young. However, professionals seemed to give less weight to the latter principle. In conclusion, professionals have similar views to students about healthcare rationing, though may be slightly less inclined to give priority to the young. (shrink)

It is widely believed that consequentialists are committed to the claim that persons are mere containers for well-being. In this article I challenge this view by proposing a new version of consequentialism, according to which the identities of persons matter. The new theory, two-dimensional prioritarianism, is a natural extension of traditional prioritarianism. Two-dimensional prioritarianism holds that wellbeing matters more for persons who are at a low absolute level than for persons who are at a higher level and that it is (...) worse to be deprived of a given number of units than it is good to gain the same number of units, even if the new distribution is a permutation of the original one. If a fixed amount of well-being is transferred from one person to another and then transferred back again, two-dimensional prioritarianism implies that it would have been better to preserve the status quo. (shrink)

In the debate on the basis of moral equality, one conclusion achieves near consensus: that we must reject all accounts that ground equality in the possession of some psychological capacity (Psychological Capacity Accounts). This widely held view crystallises around three objections. The first is the Arbitrariness Objection, which holds that the threshold at which the possession of the relevant capacities places an individual within the required range is arbitrary. The second is the Variations Objection, which holds that there is rational (...) pressure to acknowledge that variations in psychological capacities between individuals are morally relevant. The third is the No Rational Agency Objection, according to which Psychological Capacity Accounts have unpalatable implications for our treatment of humans who do not possess the relevant capacities. We develop a Psychological Capacity Account based on the capacity for a conception of the good and offer a novel defence of the account against these objections. (shrink)

It is a common view that benefits to the worse off should be given priority when health benefits are distributed. This paper addresses how to understand who is worse off in this context when individuals are differently well off at different times. The paper argues that the view that this judgment about who is worse off should be based solely on how well off individuals are when their complete lives are considered (i.e. 'the complete lives view') is implausible in this (...) context. Instead, it is argued that a pluralistic stance toward this issue should be accepted. This pluralistic stance recognizes that also the view that only focuses on how well off individuals are now and in the future (i.e. 'the forward-looking view') is relevant. The argument is based on appeals to intuitive judgments concerning who is worse off in different cases and reference to various underlying reasons why priority to benefits to the worse off is justified. (shrink)

Prioritarianism is the moral view that a fixed improvement in someone's well-being matters more the worse off they are. Its supporters argue that it best captures our intuitions about unequal distributions of well-being. I show that prioritarianism sometimes recommends acts that will make things more unequal while simultaneously lowering the total well-being and making things worse for everyone ex ante. Intuitively, there is little to recommend such acts and I take this to be a serious counterexample for prioritarianism.

ABSTRACT: What kinds of markets, market regulations, and business organizations are compatible with contemporary egalitarian theories of justice? This article argues that any thoughtful answer to this question will have to draw on recent developments in political philosophy that are concerned not only with the equality of the distribution of core goods but also with the requirements for equality of status, voice, and so on, in the relations between individuals and within organizations. The dominance of theories of distributive justice in (...) egalitarian political philosophy since Rawls may have contributed, on the one hand, to the oft-recognized gulf between these theories and their theorists and, on the other, to discussions of corporate governance and business ethics. The main purpose of this article is to introduce business ethicists to some of the less-familiar features of recent relational theories of justice and equality, and to suggest that some of these notions may help bridge the gap between business ethics and political philosophy more generally. (shrink)

The present paper constitutes an introduction to a special issue of Diametros devoted to Setting Health-Care Priorities. What Ethical Theories Tell Us by Torbjörn Tännsjö. The book in question states that there are three moral theories which have valid implications in the field of the distribution of medical resources in a healthcare system: utilitarianism, the maximin/leximin view, and egalitarianism. A number of authors have contributed to this special issue with papers which challenge this thesis. Robert E. Goodin argues that, besides (...) general moral theories, some local principles of justice might be valid. Quinn Hiroshi Gibson states that Tännsjö should have considered the Rawlsian view on justice in its contractualist reading. Jay A. Zameska argues that his “revised lexical sufficientarianism” constitutes a more reliable moral view than prioritarianism. Finally, Lasse Nielsen points out that there is more to say about distributive justice than consequentialist theories can grasp. Moreover, he puts forward an argument in defense of prioritarianism. The final article in this issue constitutes Tännsjö’s replies to his critics. (shrink)

If it is true, as suggested by Sir Michael Marmot and other researchers, that status impacts health and therefore accounts for some of the social gradient in health, then it seems to be the case that it would be possible to bring about more equality in health by equalizing status. The purpose of this article is to analyze this suggestion. First, we suggest a working definition of what status precisely is. Second, following a luck egalitarian approach to distributive justice, we (...) consider whether and to which extent individuals are responsible themselves for their position in a status hierarchy. Third, we consider the contours of a difficult question, namely which political measures are feasible in order to reduce health-affective inequalities in status and fourth, whether or to what extent such measures are legitimate. We argue that on the basis of these considerations, we have at least some prima facie reasons to counter (at least some) status inequalities in order to equalize health. (shrink)

Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this analysis, the (...) paper arrives at the following three conclusions: that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case. (shrink)

A comprehensive theory of rational prudence would explain how a person should adjudicate among the conflicting interests of her past, present, future and counterfactual selves. For example, when a person is having an identity crisis, perhaps because she has suddenly become disabled, she may be left with no sense of purpose to keep her going. In her despondent state, she may think it prudent to give up on life now even if she would soon adopt a different set of values (...) that would give her a renewed sense of meaning. Yet we may think that, in many cases, it would be irrational for such a person to allow herself to die. My aim is to explain this prudential intuition by developing a partial framework of rational prudence that interprets and applies the idea that a prudent person acts in ways that are justifiable to herself over time. (shrink)

Luck egalitarians claim that disadvantage is worse when it emerges from an unchosen risk than when it emerges from a chosen risk. I argue that disadvantage is also worse when it emerges from an unchosen risk that the disadvantaged agent would have declined to take, had he or she been able to do so, than when it emerges from an unchosen risk that the disadvantaged agent would not have declined to take. Such a view is significant because it allows both (...) luck egalitarians and prioritarians to respond to Voorhoeve and Fleurbaey's charge that they fail to accommodate intuitions about the moral relevance of interpersonal boundaries – the so-called separateness of persons objection. I argue that the view is plausible independently of its ability to answer the separateness of persons objection, and is a natural extension of the luck egalitarian concern with the impact of unchosen circumstance. (shrink)

This article is about the justifiability of accepting worse cost effectiveness for orphan drugs, that is, treatments for rare diseases, in a publicly financed health care system. Recently, three arguments have been presented that may be used in favour of exceptionally advantageous economic terms for orphan drugs. These arguments share the common feature of all referring to considerations of justice or fairness: the argument of the irrelevance of group size, the argument from the principle of need, and the argument of (...) identifiability. It is argued that all of these arguments fail to support the conclusion that orphan drugs should be subsidized to a larger extent than treatments for common diseases. The argument of the irrelevance fails to distinguish between directly and indirectly relevant considerations of fairness or justice. The recent attempt to revive the moral relevance of identifiability has provided no novel reasons to think that identifiability is morally relevant in itself or due to considerations of fairness and justice. The argument from the principle of need does not fail due to any inherent flaw in the principle as such. Rather, this principle can be interpreted in different ways, and none of these interpretations support exceptionally advantageous terms economically for treating rare diseases specifically. It is concluded that we are awaiting justice based reasons for the preferential treatment of orphan drugs. (shrink)

Torbjörn Tännsjö has written a clear and thought-provoking book on healthcare priority setting. He argues that different branches of ethical theory—utilitarianism, egalitarianism, and prioritarianism—are in general agreement on real-world healthcare priorities, and that it is human irrationality that stands in the way of complying with their recommendations. While I am generally sympathetic to the overall project and line of argumentation taken by the book, this paper raises two concerns with Tännsjö’s argument. First, that he is wrong to set aside deontic (...) constraints as irrelevant or as pointing in the same direction as consequentialism. Secondly, that his argument against prioritarianism in favor of utilitarianism is insufficient and under-developed. Given these problems, I conclude that we should welcome Tännsjö’s contribution but with these qualifications in mind. (shrink)