Millions of people in the developing world lack access to curative drugs. Pogge identifies the cause of this problem as a lack of redistribution across borders. In contrast, this article shows that institutional shortcomings within developing countries are the main issue. These different explanations are the result of diverging analytic approaches to ethics: a cosmopolitan approach versus an ordonomic approach. This article compares both approaches with regard to how they conceptualize and propose to solve the problem of providing life-saving pharmaceuticals (...) to the poor in developing countries. (shrink)

Much of the philosophical literature on health inequalities seeks to establish the superiority of one or another conception of luck egalitarianism. In recent years, however, an increasing number of self-avowed egalitarian philosophers have proposed replacing luck egalitarianism with alternatives that stress the moral relevance of distinct relationships, rather than the moral relevance of good or bad luck. After briefly explaining why I am not attracted to luck egalitarianism, I seek in this chapter to distinguish and clarify three views that have (...) been characterized in the philosophical literature as forms of relational egalitarianism. I call these three relational views equality of treatment, equality of concern, and social egalitarianism. I will explain why each claims to be a form of egalitarianism and why these three views should not be seen as competitors. I will argue that each brand of relational egalitarianism describes a plausible plank of distributive justice that bears on the evaluation of health inequalities and on the political institutions that create, sustain, or exacerbate them. To illustrate this pluralistic relational egalitarian approach, I will draw on a case study by Horton and Barker (this volume) to discuss how each of the three planks might be brought to bear on the evaluation of oral health disparities among the children of migrant Latino farmworkers in California. (shrink)

Since 1984, the idea of health equity has proliferated throughout public health discourse with little mainstream critique for its variability and distance from its original articulation signifying social transformation and a commitment to social justice. In the years since health equity’s emergence and proliferation, it has taken on a seemingly endless range of invocations and deployments, but it most often translates into proactive and apolitical discourse and practice. In Margaret Whitehead’s influential characterization, achieving health equity requires determining what is inequitable (...) by examining and judging the causes of inequalities in the context of what is going on in the rest of society. However, it also remains unclear how or if public health actors examine and judge the causes of health inequality. In this article, we take the concept of health equity itself as an object of study and consider the ways in which its widespread deployment has entailed a considerable emptying of its semantic and political content. We point toward equity’s own discursive productivity as well as the quantifying imperative embedded within evidentiary norms that govern knowledge making, and performance management regimes that govern public health practices. Under current conditions of knowledge making and performance evaluation, a range of legitimate action and inaction is produced at the same time that more socially transformative action is legitimately curtailed—not merely by politics, but by the rules of the field in which public health actors work. Ultimately, meaningful progress on a normative ethical idea like health equity will require both substantial philosophical content and an analysis of what is going on in the rest of society. (shrink)

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public (...) health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power. (shrink)

Is equality a distributive value or does it rather point to the quality of social relationships? This article criticizes the distributive character of luck egalitarian theories of justice and fleshes out the central characteristics of an alternative, relational approach to equality. It examines a central objection to distributive theories: that such theories cannot account for the significance of how institutions treat people (as opposed to the outcomes they bring about). I discuss two variants of this objection: first, that distributive theories (...) fail to account for the importance of how institutions cause good shortfalls and, second, that they fail to account for the normative attitude of social and political institutions expressed in different ways of treating people. The article argues that the causal variant of the objection has only very limited reach, and endorses the expressive variant: the attitudes expressed by institutions in their treatment of persons, such as contempt or neglect, generate potentially unjust social relationships and hierarchies. This should be the focus of a relational egalitarian approach to social justice. The article proceeds to explain how it is possible that artificial agents such as institutions have attitudes and how these attitudes are not reducible to those of the individuals that sustain them, and argues that distributive theories cannot be so modified as to account for such attitudes. It concludes by indicating several directions for the development of more worked-out conceptions of relational equality on this basis. (shrink)

Liberal proponents of genetic engineering maintain that developing human germline modification technologies is morally desirable because it will result in a net improvement in human health and well-being. Skeptics of germline modification, in contrast, fear evolutionary harms that could flow from intervening in the human germline, and worry that such programs, even if well intentioned, could lead to a recapitulation of the scientifically and morally discredited projects of the old eugenics. Some bioconservatives have appealed as well to the value of (...) retaining our “given” human biological nature as a reason for restraining the development and use of human genetic modification technologies even where they would tend to increase well-being. In this article, I argue that germline intervention will be necessary merely to sustain the levels of genetic health that we presently enjoy for future generations—a goal that should appeal to bioliberals and bioconservatives alike. This is due to the population-genetic consequences of relaxed selection pressures in human populations caused by the increasing efficacy and availability of conventional medicine. This heterodox conclusion, which I present as a problem of intergenerational justice, has been overlooked in medicine and bioethics due to certain misconceptions about human evolution, which I attempt to rectify, as well as the sordid history of Darwinian approaches to medicine and social policy, which I distinguish from the present argument. (shrink)

What is the correct metric of distributive justice? Proponents of the capability approach claim that distributive metrics should be articulated in terms of individuals’ effective abilities to achieve important and worthwhile goals. Defenders of resourcism, by contrast, maintain that metrics should instead focus on the distribution of external resources. This debate is now more than three decades old, and it has produced a vast and still growing literature. The present paper aims to provide a fresh perspective on this protracted debate. (...) It does so by defending capability metrics while also criticizing the two most common arguments used to support them, and sympathetically reconstructing the arguments for resourcism. I ultimately argue that while sweeping defenses of the capability approach do not succeed, capability theorists can indeed vindicate the justice-relevance of certain capabilities while still accommodating what is plausible in resourcism. (shrink)

Thomas Pogge has included responsibilities for global health at the core of his liberal agenda and has urged corresponding, efficient reforms in practice. The current article focuses on his proposal for establishing a global fund for the development and delivery of essential medicines for the poor. It is argued that while Pogge interestingly attempts to harness both moral and non-moral human resources to serve global health, the efficiency of his proposed fund is not evident. First, its internal logic implies that (...) part of valuable development aid would end up as profit for drug corporations. Hence, the corporations should be able to utilise the other part of the public funding remarkably efficiently. Second, several existing programmes for global health (such as the Global Fund to Fight AIDS, Malaria and Tuberculosis) have achieved significant results. This provides them with a firm basis for applying for additional funding. In accordance with the United Nations Millennium Development Goals, the plea for additional funding for global health seems overwhelmingly justified; in order to coordinate its use efficiently, a significant degree of public management is needed. (shrink)

What, if anything, is wrong with high executive compensation? Is the common “lay reaction” of indignation and moral outrage justified? In this paper, my main goal is to articulate in a more systematic and philosophical manner the egalitarian responses to these questions. In order to do so, I suggest that we take some insights from recent debates on two versions of egalitarianism: a distributive one, according to which no one should be worse off than others because of unfair distributions of (...) goods and resources, especially ones based on matters of luck or arbitrary factors, and a relational one, which maintains that egalitarian justice requires members of a society to relate to one another as equals. Drawing on recent attempts to highlight the tricky nature of managerial authority, I argue that high inequalities in pay are not simply a distributional matter but should also be analyzed through a relational lens. I also attempt to show that relational egalitarians are well-equipped to question the now dominant “incentives” view of CEO compensation. (shrink)

What is the correct metric of distributive justice? Proponents of the capability approach claim that distributive metrics should be articulated in terms of individuals’ effective abilities to achieve important and worthwhile goals. Defenders of resourcism, by contrast, maintain that metrics should instead focus on the distribution of external resources. This debate is now more than three decades old, and it has produced a vast and still growing literature. The present paper aims to provide a fresh perspective on this protracted debate. (...) It does so by defending capability metrics while also criticizing the two most common arguments used to support them, and sympathetically reconstructing the arguments for resourcism. I ultimately argue that while sweeping defenses of the capability approach do not succeed, capability theorists can indeed vindicate the justice-relevance of certain capabilities while still accommodating what is plausible in resourcism. (shrink)

In the first part of the paper, three objections to the precautionary principle are outlined: the principle requires some account of how to balance risks of significant harms; the principle focuses on action and ignores the costs of inaction; and the principle threatens epistemic anarchy. I argue that these objections may overlook two distinctive features of precautionary thought: a suspicion of the value of “full scientific certainty”; and a desire to distinguish environmental doings from allowings. In Section 2, I argue (...) that any simple distinction between environmental doings and allowings is untenable. However, I argue that the appeal of such a distinction can be captured within a relational account of environmental equity. In Section 3 I show how the proposed account of environmental justice can generate a justification for distinctively “precautionary” policy-making. (shrink)

Journal of Political Philosophy, EarlyView.

Construed as a theory of justice, relational egalitarianism says that justice requires that people relate as equals. Construed as a theory of what makes democracy valuable, it says that democracy is a necessary, or constituent, part of the value of relating as equals. Typically, relational egalitarians want their theory to provide both an account of what justice requires and an account of what makes democracy valuable. We argue that relational egalitarians with this dual ambition face the justice-democracy dilemma: Understanding social (...) relations in such a way that renders relational egalitarianism plausible as an answer to what makes democracy valuable comes at the price of understanding social relations in a way that makes it less plausible as a theory of justice, and vice versa. We also argue that there is no easy way out of the dilemma and that relational egalitarians, who want relational equality to provide both accounts mentioned, may simply have to set their ambitions lower on behalf of relational equality. (shrink)

The strong correlation between people’s socioeconomic position and health within high income countries is a well-documented fact. A person’s occupation, income and education level tell us a lot about that person’s prospects on a long and healthy life, such that we can speak of a ‘social gradient in health’, or a ‘socioeconomic health gap’. This association is often perceived to be unjust. Therefore, it is generally thought that governments should aim to reduce socioeconomic health inequalities. However, this idea needs ethical (...) justification, for it is not evident if and why exactly these inequalities are unjust. For instance, are inequalities in health unjust per se? Or because the underlying socioeconomic inequalities are unjust? And does justice require equal health levels, or a minimum level of health? What complicates the issue, is that the width of the health gap, or the steepness of the social gradient, depends on what health measures are used. Overall, the more subjective the measure, the greater the inequalities appear to be. But are all these measures equally morally relevant? This dissertation aims to give a better understanding of these philosophical questions. It does so by investigating the question of what we should understand by health in the first part, after which it addresses the question of how to evaluate socioeconomic health inequalities in the light of justice. The introduction begins with a description of the phenomenon of socioeconomic health inequalities, and how it has been addressed by politicians, epidemiologists and philosophers in the past and today. The chapter continues by formulating the central question of the dissertation – that of which health inequalities should be focused in the light of a concern with social justice. It explicates how this dissertation contributes to answering that question, by discussing the potential relation between the conceptualisation of health and justice evaluations, and by discussing which questions are addressed in each of the following chapters. The chapter 2 addresses the question of how health is conceptualised in the philosophical and public heath literature, and how theoretical concepts of health differ. It proposes to approach health concepts as a Wittgensteinian family of thick concepts and argues that while theories on health generally argue in favour of one specific concept, a comparison of concepts shows that we may need different concepts of health given the variety of health practices. By explicating the differences between five concepts of health, this chapter argues that each captures aspects of health that all seem relevant when we talk and think about health. Classifying these concepts based on their distinctions reveals them as members of a conceptual family: each of the discussed concepts differs from the others in at least one respect and resembles the others in several respects. Moreover, the discussion of the concepts shows that ‘health’ always both describes a condition and values that condition at the same time. Having both descriptive and evaluative dimensions, we can see health concepts as ‘thick concepts’. Given this evaluative dimension, it is important to reflect on the question of what understanding of health guides specific practices. Moreover, the distinctions revealed by the classification can serve as a conceptual toolbox for reflection on the assumptions and purposes of health practices. How such reflection could work is illustrated by a brief exploration of what health aspects are focused upon in three specific health practices. Chapter 3 presents a study into the question of how health is conceptualised by ordinary citizens and to what extent conceptualisations of health differ between socioeconomic groups. By making use of the method of concept mapping, this study analyses how different socioeconomic groups formulate their own answers regarding the question ‘what does health mean to you?’. It presents concept maps of health for three different socioeconomic groups living in the city of Utrecht that reveal that all groups have a multidimensional understanding of health. An interpretation of the concept maps reveals nuanced differences between groups. The multiple aspects of health were also ranked by importance. It appears that each group assigned most importance to mental health. All in all, the study shows that people in lower socioeconomic groups are more likely to show a conceptualisation of health that refers to 1) the absence of health threats, 2) a person within his/her circumstances, 3) the value of functional notions, and 4) an accepting attitude towards life. Chapter 4 addresses the question of what the theoretical and empirical study to concepts of health could imply for health equity practices. It does so by exploring further the suggestions made in chapters 2 and 3. Regarding the question of which health aspects should guide health equity policies, this chapter discusses the question of whether we should primarily look at subjective or objective health measures, and whether a universal or relative standard of health should be central. While justice-related concerns of impartiality and equal treatment may seem to favour an objective perspective and a universal health standard, it appears that we have good reason to account for the subjective perspective as well. It is also argued that a concern for recognition and participatory parity gives room for relative health standards. Th room for relative health standards confronts us with the question of how to deal with mechanisms like adaptive preferences that the concept maps reveal. It proposes a way out, by arguing for society-relative health standards. Chapter 5 examines the question of whether inequalities in health should be evaluated ‘directly’, thus independently of a distribution of their social determinants. It proposes a sufficientarian perspective, such that the central question of evaluation is that of whether everyone is – or can be – healthy enough. By discussing two sufficientarian approaches to health and social justice – by Powers & Faden and by Nussbaum – this chapter distinguishes two ways of setting a threshold level for health. Both approaches appear to provide an unsatisfactory basis for justice evaluations and lead us away from direct evaluation if we try to settle health minima that are less arbitrary. In anticipation to chapters 6 and 7, it is argued that the perspective of sufficient health for relational equality escapes this arbitrariness: compared to that of a decent human life, it better helps to answer both the question of what socioeconomic health inequalities a society is due to avoid, and the question of when socioeconomic health inequalities are unjust considering their consequences. Chapter 6 discusses to what extent Daniels’s theory of health justice provides a satisfactory answer to the question of what health inequalities a society is due to avoid. Daniels proposes an indirect evaluative approach by arguing that we should evaluate socioeconomic health inequalities in the light of Rawls’s principles of justice as fairness. That is, if socioeconomic inequalities are in accordance with fair equality of opportunity and with the difference principle, the corresponding health inequalities would be just. It is shown that the suggestion that Rawls’s principles regulate the social determinants of health neglects that not all social determinants of health belong to society’s basic structure as conceived of by Rawls and are thereby not subjected to the principles of justice. To acknowledge the social mechanisms leading to socioeconomic health inequalities in their full complexity, it is argued that we should broaden our understanding of society’s structure in accordance with Young’s notion of social structural processes. This renders the question of what health inequalities a society is due to avoid into a question of what we can expect from the side of the various actors that uphold the social structures that produce socioeconomic health inequalities. Lastly, it is discussed how a shift to Young’s theory completes the shift to non-ideal theorising that seem already initiated by Daniels, and that with this, the distinction between direct and indirect evaluation dissolves. Chapter 7 discusses to what extent equality in health is of instrumental value for a society of free and equals. It thus takes up the idea proposed in chapter 5, that an evaluation of the consequences of health inequalities is also due. Taking relational equality as an evaluative framework reveals three ways in which inequalities in life expectancy threaten this ideal. That is, via unequal risks to stigmatisation, unequal risks to unemployment and the risk of unequal pension enjoyments. It is thereby shown that these risks are especially great for those lower down the socioeconomic strata. It thus concludes that equality in health is of instrumental value to relational equality. The chapter continues to argue that our instrumental approach opens a new perspective: to mitigate the identified injustices by changing society, rather than by reducing inequalities in health. This is argued to be an advantage in the light of the realistic assumption that of the socioeconomic health inequalities will persist. The paper thus offers a complementary approach to both the evaluation and the mitigation of the injustice of socioeconomic inequalities in health. The discussion chapter summarises the central findings of the analyses of health concepts and discusses questions regarding the philosophical and practical merits of comparing theoretical health concepts, the need for developing new health measures or concepts and the importance or nonsense of studying citizen’s views on health. Repeating this for the dissertation’s second part, the central findings of the chapters on justice evaluation are summarised and followed by a discussion of questions and issues that have remained unaddressed so far. Here, central points of discussion are my take on rules of distribution, the distinction of direct and indirect evaluation, the role of ideal and non-ideal theory, the idea of relational equality, and personal responsibility for health. The chapter concludes by noting that also in the light of justice evaluations, all commonly used health measures are relevant for justice. Therefore, my recommendations for policy and further research entail that inequalities in each of these measures deserve attention by both policymakers and researchers. Specifically, policymakers and researchers should give attention to how exactly each of these health inequalities come about, in such a way that a discussion about the question of who can be assigned responsibility to alleviate them is well-informed; and both should give attention to the effects of health inequalities on the opportunities for people to live on equal standing, in such a way that when these opportunities are diminished, actions can be considered to aim to restore relational equality. (shrink)