The evidence is overwhelming that members of particularly wealthy and industry-owning segments of Western societies have much larger carbon footprints than most other humans, and thereby contribute far more than their “fair share” to the enormous problem of climate change. Nonetheless, in this paper we shall counsel against a strategy focused primarily on blaming and shaming and propose, instead, a change in the ethical conversation about climate change. We recommend a shift in the ethical framework from a focus on the (...) role of individual agents and a conversation about guilt; in its place, we propose a relational approach to public health ethics that is centered around the idea of relational solidarity. We begin by briefly reviewing the most common—and woefully inadequate—approach in the West to reducing emissions and responding to the health-related impacts of climate change. We then go on to propose a relational approach to public health ethics as an alternative ethical framework that better fits the moral problems associated with climate change and holds promise for a more meaningful response. (shrink)

This chapter outlines six distinct reasons for rejecting retributivism, not the least of which is that it’s unclear that agents possess the kind of free will and moral responsibility needed to justify it. It then sketches a novel non-retributive alternative called the public health-quarantine model. The core idea of the model is that the right to harm in self-defense and defense of others justifies incapacitating the criminally dangerous with the minimum harm required for adequate protection. The model also draws on (...) the public health framework and prioritizes prevention and social justice. It is argued that not only does the public health-quarantine model offer a stark contrast to retributivism, it also provides a more humane, holistic, and effective approach to dealing with criminal behavior, one that is superior to both retributivism and other leading non-retributive alternatives. (shrink)

Human dignity is one of the key concepts of our ethical evaluations, in politics, in biomedicine, as well as in everyday life. In moral philosophy, however, human dignity is a source of intractable trouble. It has a number of characteristic features which apparently do not fit into one coherent ethical concept. Hence, philosophers tend to ignore or circumvent the concept. There is hope for a philosophically attractive conception of human dignity, however, given that one takes three crucial turns. The negative (...) turn: to start the inquiry with violations of human dignity. The inductive turn: to consider the whole range of applications of the concept of human dignity in different areas of ethics. And finally, the historical turn: to take into account the historical bonds between human dignity and traditional conceptions of dignity. Taken together they point in the direction of an understanding of human dignity as universal nobility. (shrink)

One of the most frequently voiced criticisms of free will skepticism is that it is unable to adequately deal with criminal behavior and that the responses it would permit as justified are insufficient for acceptable social policy. This concern is fueled by two factors. The first is that one of the most prominent justifications for punishing criminals, retributivism, is incompatible with free will skepticism. The second concern is that alternative justifications that are not ruled out by the skeptical view per (...) se face significant independent moral objections (Pereboom 2014: 153). Despite these concerns, I maintain that free will skepticism leaves intact other ways to respond to criminal behavior—in particular incapacitation, rehabilitation, and alteration of relevant social conditions—and that these methods are both morally justifiable and sufficient for good social policy. The position I defend is similar to Derk Pereboom’s (2001, 2013, 2014), taking as its starting point his quarantine analogy, but it sets out to develop the quarantine model within a broader justificatory framework drawn from public health ethics. The resulting model—which I call the public health-quarantine model (Caruso 2016, 2017a)—provides a framework for justifying quarantine and criminal sanctions that is more humane than retributivism and preferable to other non-retributive alternatives. It also provides a broader approach to criminal behavior than Pereboom’s quarantine analogy does on its own since it prioritizes prevention and social justice. -/- In Section 1, I begin by (very) briefly summarizing my arguments against free will and basic desert moral responsibility. In Section 2, I then introduce and defend my public health-quarantine model, which is a non-retributive alternative to criminal punishment that prioritizes prevention and social justice. In Sections 3 and 4, I take up and respond to two general objections to the public health-quarantine model. Since objections by Michael Corrado (2016), John Lemos (2016), Saul Smilanksy (2011, 2017), and Victor Tadros (2017) have been addressed in detail elsewhere (see Pereboom 2017a; Pereboom and Caruso 2018), I will here focus on objections that have not yet been addressed. In particular, I will respond to concerns about proportionality, human dignity, and victims’ rights. I will argue that each of these concerns can be met and that in the end the public health-quarantine model offers a superior alternative to retributive punishment and other non-retributive accounts. (shrink)

This chapter discusses how justice applies to public health. It begins by outlining three different metrics employed in discussions of justice: resources, capabilities, and welfare. It then discusses different accounts of justice in distribution, reviewing utilitarianism, egalitarianism, prioritarianism, and sufficientarianism, as well as desert-based theories, and applies these distributive approaches to public health examples. Next, it examines the interplay between distributive justice and individual rights, such as religious rights, property rights, and rights against discrimination, by discussing examples such as mandatory (...) treatment and screening. The chapter also examines the nexus between public health and debates concerning whose interests matter to justice (the “scope of justice”), including global justice, intergenerational justice, and environmental justice, as well as debates concerning whether justice applies to individual choices or only to institutional structures (the “site of justice”). The chapter closes with a discussion of strategies, including deliberative and aggregative democracy, for adjudicating disagreements about justice. (shrink)

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

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

Comments and reports on synthetic biology often focus on the idea that this field may lead to synthetic life or life forms. Such claims attract general attention because “life” is a basic concept that is understood, interpreted and explained in multiple ways. While these different understandings of life may influence the ethical assessment of synthetic biology by experts and the public, this field might, in turn, influence how academics or the public view life. We suggest in this paper that synthetic (...) biology provides an opportunity to discuss and compare different views and explanations of the world, starting from the concept of life. We argue that a narrow focus on just one interpretation of this concept may be harmful and that people will benefit from being aware of a diversity of understandings of life because they provide answers to different questions. Moreover, the confrontation among views is important for the development of reasoning abilities, and a nuanced view on our world will be useful for integrating scientific findings and their implications into a wider context. At the same time, we should not only consider other understandings of life for our own benefit but also because a moral attitude of respect for and toleration toward others implies permission to express and maintain their views. For these reasons, we suggest that a diversity of views on life should be included in public education and in public engagement events on synthetic biology. Moreover, they should be on the research agenda of technology assessment studies within the ELSA or RRI frameworks. (shrink)

Within the field of medical ethics, discussions related to public health have mainly concentrated on issues that are closely tied to research and practice involving technologies and professional services, including vaccination, screening, and insurance coverage. Broader determinants of population health have received less attention, although this situation is rapidly changing. Against this backdrop, our specific contribution to the literature on ethics and law vis-à-vis promoting population health is to open up the ubiquitous presence of pets within cities and towns for (...) further discussion. An expanding body of research suggests that pet animals are deeply relevant to people’s health (negatively and positively). Pet bylaws adopted by town and city councils have largely escaped notice, yet they are meaningful to consider in relation to everyday practices, social norms, and cultural values, and thus in relation to population health. Nevertheless, not least because they pivot on defining pets as private property belonging to individual people, pet bylaws raise emotionally charged ethical issues that have yet to be tackled in any of the health research on pet ownership. The literature in moral philosophy on animals is vast, and we do not claim to advance this field here. Rather, we pragmatically seek to reconcile philosophical objections to pet ownership with both animal welfare and public health. In doing so, we foreground theorizations of personhood and property from sociocultural anthropology. (shrink)

Population health has recently grown from a series of loosely connected critiques of twentieth-century public health and medicine into a theoretical framework with a corresponding field of research—population health science. Its approach is to promote the public’s health through improving everyday human life: affordable nutritious food, clean air, safe places where children can play, living wages, etc. It recognizes that addressing contemporary health challenges such as the prevalence of type 2 diabetes will take much more than good hospitals and public (...) health departments. -/- Blending philosophy of science/medicine, public health ethics and history, this book offers a framework that explains, analyses and largely endorses the features that define this relatively new field. Presenting a philosophical perspective, Valles helps to clarify what these features are and why they matter, including: searching for health’s “upstream” causes in social life, embracing a professional commitment to studying and ameliorating the staggering health inequities in and between populations; and reforming scientific practices to foster humility and respect among the many scientists and non- scientists who must work collaboratively to promote health. -/- Featuring illustrative case studies from around the globe at the end of all main chapters, this radical monograph is written to be accessible to all scholars and advanced students who have an interest in health—from public health students to professional philosophers. (shrink)

There are a number of important links and similarities between public health and safety. In this extended essay, Gregg D. Caruso defends and expands his public health-quarantine model, which is a non-retributive alternative for addressing criminal behavior that draws on the public health framework and prioritizes prevention and social justice. In developing his account, he explores the relationship between public health and safety, focusing on how social inequalities and systemic injustices affect health outcomes and crime rates, how poverty affects brain (...) development, how offenders often have pre-existing medical conditions (especially mental health issues), how involvement in the criminal justice system itself can lead to or worsen health and cognitive problems, how treatment and rehabilitation methods can best be employed to reduce recidivism and reintegrate offenders back into society, and how a public health approach could be successfully applied within the criminal justice system. Caruso's approach draws on research from the health sciences, social sciences, public policy, law, psychiatry, medical ethics, neuroscience, and philosophy, and he delivers a set of ethically defensible and practically workable proposals for implementing the public health-quarantine model. The essay begins by discussing recent empirical findings in psychology, neuroscience, and the social sciences that provide us with an increased understanding of the social and neurological determinants of health and criminal behavior. It then turns to Caruso's public health-quarantine model and argues that the model provides the most justified, humane, and effective approach for addressing criminal behavior. Caruso concludes by proposing a capability approach to social justice grounded in six key features of human well-being. He argues that we cannot successfully address concerns over public health and safety without simultaneously addressing issues of social justice—including the social determinants of health (SDH) and the social determinants of criminal behavior (SDCB)—and he recommends eight general policy proposals consistent with his model. (shrink)

Abstract In the last few decades, a growing number of commentators have questioned the appropriateness of the 'justice view' of ethics as a suitable approach in health care ethics, and most certainly in nursing. Essentially, in their ethical deliberations, it is argued that nurses do not readily adopt the high degree of impartiality and objectivity that is associated with a justice view; instead their moral practices are more accurately reflected through the use of alternative approaches such as relational or care-based (...) ethics. Yet, it has also been argued that this viewpoint does not necessarily 'do justice' to the broader moral responsibilities of nurses towards humanity in general, i.e. to the wider socio-cultural and socio-political issues in society, and to the concept of social justice in particular. This criticism has triggered a much closer examination of relational and care-based ethics in nursing at levels beyond individual responsiveness within relationships and brought into the spotlight the need for a more ethically refined nursing response to an increasingly complex set of socio-cultural inequalities. This article explores a relational ethic within nursing practices with contemporary ideas regarding social justice. In particular, it is argued that the synergy between the two actually produces an ethic that is capable of not only challenging the continuing predominance of justice-based ethics within health care, but of replacing it. Subsequently, in the discussion that follows, it is suggested that a combined social justice and relational care-based approach, as a social ethic, should guide the moral deliberations and actions of nurses. It is maintained that such an approach is not only possible, but crucial if nurses are to realize their full potential as ethical agents for individual and social good. © 2011 Blackwell Publishing Ltd. (shrink)

This article discusses cosmopolitanism as the moral foundation for access to health care for migrants. The focus is on countries with sufficiently adequate universal health care for their citizens. The article argues for equal access to this kind of health care for citizens and migrants alike—including migrants at special risk such as asylum seekers or undocumented migrants. Several objections against equal access are raised, such as the cosmopolitan approach being too restrictive or too permissive, or the consequences being undesirable; but (...) the objections are largely refuted. Some special cases in which a restriction of equal access to health care might be justified are described: humanitarian crisis, short term tourism, and the case of a migrant or refugee who will stay only very briefly on a state's territory. (shrink)

The American Journal of Bioethics, Volume 12, Issue 9, Page 11-13, September 2012.

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)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

Limited health literacy is a pervasive and independent risk factor for poor health outcomes. Despite decades of reports exhibiting that the healthcare system is overly complex, unneeded complexity remains commonplace and endangers the lives of patients, especially those with limited health literacy. In this article, we define health literacy and describe the empirical evidence associating health literacy and poor health outcomes. We recast the issue of poor health literacy from within the ethical perspective of the least well-off and argue that (...) poor health outcomes deriving from limited health literacy ought to be understood as a fundamental injustice of the healthcare system. We offer three proposals that attempt to rectify this injustice, including: universal precautions that presume limited health literacy for all healthcare users; expanded use of technology supported communication; and clinical incentives that account for limited health literacy. (shrink)

In this paper, we explore the role of reciprocity in the employment of restrictive measures in contexts of contagion. Reciprocity should be understood as a substantive value that governs the use, level and extent of restrictive measures. We also argue that independent of the role reciprocity plays in the legitimisation the use of restrictive measures, reciprocity can also motivate support and compliance with legitimate restrictive measures. The importance of reciprocity has implications for how restrictive measures should be undertaken when preparing (...) and evaluating public health responses to contagion. (shrink)

While Powers and Faden do not consider possible anti-paternalism objections to their view, there are two variants of this objection that a social justice perspective is susceptible to. It is worth exploring which responses to such objections may be less promising than others. It is argued that for most public health measures targeting the disadvantaged, theorists and practitioners taking a social justice perspective should bite the paternalist bullet. Insofar as the government has the ability to reduce mortality and morbidity within (...) the population in a way that is fair and in everyone’s interests, then the use of paternalistic means or resultant paternalistic effects should be thought to be the lesser evil. (shrink)

Philosophy of epidemiology has recently emerged as a distinct branch of philosophy. The field will surely benefit from pluralism, reflected in the broad range of topics and perspectives in this special issue. Here, I argue that a healthy pluralistic field of philosophy of epidemiology has social responsibilities that require the field as a whole to engage actively with research on social determinants of health and health disparities. Practicing epidemiologists and the broader community of public health scientists have gradually acknowledged that (...) much of their attention ought to be paid to these, i.e. inequitable between-population health variations that largely reflect the world’s inequitable distribution of resources and social conditions. The paper illustrates how and why health disparities and social determinants of health, through no ill will, become de facto secondary concerns in Alex Broadbent’s field-defining Philosophy of Epidemiology, showing the ease with which these topics can be incidentally sidelined. As means for philosophy of epidemiology to meet its social responsibility obligations, I suggest philosophy of epidemiology expand its attention to two particular lines research. First, the paper discusses Geoffrey Rose’s concept of “causes of incidence”—causes of disparities between populations—and argues for the importance of engaging with these causes. Second, the paper argues for the value of engaging with Bruce Link and Jo Phelan’s “fundamental causes” model of how flexible social resources serve as buffers from harms, generating a plethora of shifting and locally-contingent health effects. (shrink)

Public deliberation about health policy in the United States often hinges on two untenable basic assumptions about political legitimacy. The first assumption, common in public debate throughout the United States, is that federal oversight of health care is justified under a federal compact binding all citizens. This assumption is false because the federal compact precludes such oversight. Indeed, the ascendancy of national government (and demise of federalism) over the past 70 years was engineered through the subversion of the federal compact, (...) creating an expansive legitimation gap. The second assumption—that political legitimacy can be established through appeals to expert consensus about fundamental conceptions of justice or human rights—is prevalent among bioethicists. I argue that this assumption is illicit because it hinges on a weak, rationalistic form of majoritarian democracy that conflates public acquiescence with public approval. If the public mission of academic bioethics involves protecting the integrity of public deliberation, then these two basic assumptions should be challenged. (shrink)

The “Father of the United States Constitution,” James Madison, once described justice as “the end” of both government and of civil society. Yet curiously, Madison said little about justice in elaborating the principles of American federalism in The Federalist Papers and elsewhere. His fundamental concerns, to the contrary, were in contriving a system of separated, countervailing powers and in establishing a first federal principle of enumerated powers — in which federal powers “are few, and defined.” This strategy, for Madison, was (...) the most feasible way of checking the innate tendency of political power to accumulate, centralize, and trample on citizens’ liberties. (shrink)

That liberalism requires governments to be agnostic to at least some deeply-held commitments of their citizens is uncontroversial. Much less agreed-upon is why....

In this article, I propose a novel characterization of sufficientarianism. I argue that sufficientarianism combines three claims: a priority claim that we have non-instrumental reasons to prioritize benefits in certain ranges over benefits in other ranges; a continuum claim that at least two of those ranges are on one continuum; and a deficiency claim that the lower a range on a continuum, the more priority benefits in that range have. This characterization of sufficientarianism sheds new light on two long-standing philosophical (...) debates, namely about the distinctiveness of sufficientarianism as a distributive principle and about the common objections to sufficientarianism. (shrink)

We live in an era where our health is linked to that of others across the globe, and nothing brings this home better than the specter of a pandemic. This paper explores the findings of town hall meetings associated with the Canadian Program of Research on Ethics in a Pandemic , in which focus groups met to discuss issues related to the global governance of an influenza pandemic. Two competing discourses were found to be at work: the first was based (...) upon an economic rationality and the second upon a humanitarian rationality. The implications for public support and the long-term sustainability of new global norms, networks, and regulations in global public health are discussed. (shrink)

This paper considers the morally relevant ways in which population-based research is a distinct type of human subjects research that have unique moral considerations relevant for public health practitioners and researchers. By defining population-based research, the authors distinguish it from public health practice and then consider, in more detail, the ways in which population-based research differs from clinical human subjects research. Based upon the distinctions between these types of research and practice, they identify five important issues that arise in the (...) design and conduct of certain kinds of population-based research. The authors hope that public health practitioners find these distinctions useful in determining when their work may actually be population-based research and that public health researchers use them to identify the areas where ethical issues in their research may arise. (shrink)

Multiple scholars and institutions have asked what distinguishes public health research from public health practice. Most often, they ask in order to have a clear definition of what one does in various public health settings to assess oversight and/or regulation of human subjects research. More importantly, however, whether something is considered public health research or public health practice has real ethical implications in terms of the general moral considerations at stake and the obligations of public health researchers/practitioners to the populations (...) they serve or study.Numerous examples in recent history of research ethics, including the Kennedy Krieger Lead Abatement Study and EPA’s Children’s Environmental Exposure Research Study, suggest that an exploration of the ethics of public health, or more generally population-based research, may be warranted. Although we acknowledge that there are important ethical issues to consider in the implementation of public health practice, we leave that discussion for other authors. (shrink)

Courts are increasingly obliged to adjudicate upon challenges to allocative decisions in healthcare, but their involvement continues to be regarded with unease, imperilling the legitimacy of the judicial role in this context. A central reason for this is that judges are perceived to lack sufficient expertise to determine allocative questions. This article critically appraises the claim of lack of judicial expertise through an examination of the various components of a limit-setting decision. It is argued that the inexpertise argument is weak (...) when compared with other rationales for judicial restraint, such as the procedural unsuitability and lack of constitutional competence of courts. (shrink)

In this paper, I argue that disabled people have a right to assistive technology, but this right cannot be grounded simply in a broader right to health care or in a more comprehensive view like the capabilities approach to justice. Both of these options are plagued by issues that I refer to as the problem of constriction, where the theory does not justify enough of the AT that disabled people should have access to, and the problem of overextension, where the (...) theory cannot adequately identify an upper limit on the AT that people have a right to. As an alternative to these justificatory frameworks, I argue that disabled people are owed access to AT at the expense of nondisabled people as a matter of compensatory justice. That is, I defend the position that disabled people are owed AT as part of due compensation for the harms they experience from being disadvantaged by society’s dominant cooperative scheme and the violation of their right to equality of opportunity that such disadvantage entails. I also propose a method for identifying an upper limit to what this right to AT requires. In this way, I argue that compensatory justice avoids both the problem of constriction and the problem of overextension. (shrink)

The predominant influences on health are social or upstream factors. Poverty, inadequate education, insecure and toxic environments, and inferior opportunities for jobs and positions are inequitable disadvantages that adversely affect health across the globe. Many causal pathways are yet to be understood. However, elimination of these social inequalities is a moral imperative of the first order. Some physicians by word and deed argue that medical doctors should oppose the “structural violence” of social inequalities that greatly shorten lives and wreak so (...) much suffering. (shrink)

Sweatshop labor is often cited as an example of the worst and most pervasive form of exploitation today, yet understanding what is meant by the charge has proven surprisingly difficult for philosophers. I develop an account of what I call “Needs Exploitation,” grounded in a specification of the duty of beneficence. In the case of sweatshop labor, I argue that employers face a duty to extend to employees a wage sufficient to meet their basic needs. This duty is limited by (...) the degree of the employees’ dependence on the employer for basic needs and a reasonability standard where the employer may remain within a range of well-being between deficiency and luxury. (shrink)

Health equity is increasingly identified as a principal goal to be achieved through public health policies and activities. However, what is to be measured in the assessment of health equity and how inequities in health ought to be redressed are among the pressing questions that must be answered if health equity is to serve as a meaningful and consistent ethical guide for measurement and intervention in public health. In this article I argue that the concept of health equity, in the (...) form it is predominantly found in public health, suffers from normative indeterminacy and is therefore unlikely to provide actionable normative guidance to public health policy-makers, practitioners and researchers. I argue that the concept of health equity, as it is commonly defined in public health, ultimately rests upon assumptions of a more fundamental, yet tacit, conception of justice to do its normative work. In this vein, I expand upon a critique of Margaret Whitehead’s oft-cited definition of health equity made by James Wilson to raise additional reasons not explored by Wilson, or others, as to why Whitehead’s definition remains inadequate in providing normative guidance to policy-makers, practitioners and researchers in public health. (shrink)

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, (...) the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well. (shrink)

In her target article “Shared health governance” (AJOB 11(7): 32-45, 2011) and in her book Health and Social Justice (2009), Jennifer Prah Ruger defends an original model of governance dubbed “Shared Health Governance” (SHG). This model borrows elements from many other models of governance, and one may wonder what is the secret sauce that holds together these diverse ingredients. In response, Ruger would perhaps ultimately turn to public moral norms. My comment raises some concerns about the function and content of (...) these norms in her model and their connection to her claims about shared sovereignty within SHG. (shrink)

Surveillance plays a crucial role in public health, and for obvious reasons conflicts with individual privacy. This paper argues that the predominant approach to the conflict is problematic, and then offers an alternative. It outlines a Basic Interests Approach to public health measures, and the Unreasonable Exercise Argument, which sets forth conditions under which individuals may justifiably exercise individual privacy claims that conflict with public health goals. The view articulated is compatible with a broad range conceptions of the value of (...) health. (shrink)

Virtue ethics has a rich history; yet, its application in health ethics has been minimal compared to other major ethical frameworks. Even more, its application to health policy and population-level questions has been almost nonexistent. A new concept in moral theology, structures of virtue, provides impetus for ethicists to consider how virtue ethics can be a valuable addition to existing frameworks in public health ethics. This article offers a basic overview of virtue ethics and its value for analysis of social (...) structures in public health. It does so by explaining how virtue can be seen not only in the process of public health—the promotion of habituated behavior—but also in the content of public health—values such as temperance, fortitude and prudence. It concludes with two extended applications of virtue ethics: vaccination policy and healthy eating. (shrink)

Recent efforts by legislative officials and public health advocates to reform the US food stamp program, or Supplemental Nutrition Assistance Program, have focused on restricting the types of foods eligible for purchase with SNAP benefits, specifically sugar-sweetened beverages. We argue that it is, in principle, permissible for the US government to enact a SNAP-specific SSB ban prohibiting the purchase of SSBs with SNAP benefits. While the government has a duty to ensure that citizens meet their nutritional needs, since SSBs provide (...) negligible nutrition, it has no obligation to subsidize them. Additionally, there is good reason to think that a SNAP-specific SSB ban would enable the government to better fulfill two other duties—improving citizens’ health and providing public services like Medicaid and Medicare in a more cost-effective manner. Still, because the costs and benefits of such a ban remain uncertain, we argue that the government should conduct well-designed pilot projects to help determine the effects of an SSB ban. (shrink)

Various U.S. laws, such as the Clean Air Act and the Food Quality Protection Act, require additional protections for susceptible subpopulations who face greater environmental health risks. The main ethical rationale for providing these protections is to ensure that environmental health risks are distributed fairly. In this article, we (1) consider how several influential theories of justice deal with issues related to the distribution of environmental health risks; (2) show that these theories often fail to provide specific guidance concerning policy (...) choices; and (3) argue that an approach to public decision making known as accountability for reasonableness can complement theories of justice in establishing acceptable environmental health risks for the general population and susceptible subpopulations. Since accountability for reasonableness focuses on the fairness of the decision-making process, not the outcome, it does not guarantee that susceptible subpopulations will receive a maximum level of protection, regardless of costs or other morally relevant considerations. (shrink)

Soziale Faktoren haben einen starken Einfluss auf die Gesundheit und Lebenserwartung. Auch in Wohlfahrtsstaaten bestehen signifikante gesundheitliche Ungleichheiten zwischen besser und schlechter gestellten Bevölkerungsgruppen. Sie werden zunehmend als ein Problem der sozialen Gerechtigkeit wahrgenommen. Public Health dient dem Abbau gesundheitlicher Ungleichheiten und somit der Förderung der sozialen Gerechtigkeit. Obwohl Public Health-Maßnahmen effizienter zur Förderung und Angleichung der Bevölkerungsgesundheit beitragen können als viele medizinische Versorgungen, erhalten sie einen geringeren gesundheitspolitischen Stellenwert. Diese Prioritätensetzung zu Gunsten der Medizin kann als irrational kritisiert werden. (...) Allerdings ist zu beachten, dass die medizinische Versorgung eine hohe symbolische Bedeutung für die Fürsorge und soziale Anerkennung hat, die bei Public Health nicht in gleichem Maße gegeben ist. Gesundheitliche Ungleichheiten sind nicht per se sozial ungerecht, sondern dann, wenn sie auf einer ungerechten Verteilung sozialer Gesundheitsfaktoren beruhen. Diese Faktoren wie z. B. Einkommen und Bildung haben auch unabhängig von ihren gesundheitlichen Auswirkungen eine Bedeutung für die soziale Gerechtigkeit. Daher kann die Gesundheitsgerechtigkeit nicht isoliert, sondern nur im Kontext einer umfassenden Theorie der sozialen Gerechtigkeit bestimmt werden. (shrink)

This article challenges a key tacit assumption underpinning legal and ethical instruments in health care, namely, that people are ideally bounded, independent, and often also strategically rational individuals. Such an understanding of personhood has been criticized within feminist and other critical scholarship as being unfit to capture the deeply relational nature of human beings. In the field of medicine, however, it also causes tangible problems. I propose that a solidarity-based perspective entails a relational approach and as such helps to formulate (...) new solutions to complex ethical and regulatory questions, ranging from caring for people at the end of their lives to improving policies for organ donation and better governance of health data. It also underscores the importance of universal health care. Although a solidarity-based perspective does not require health to be seen as an individually enforceable right, it does influence our understanding of individual rights: it draws attention to how their meaning is shaped by shared social practices. I conclude by arguing that, in light of current pressures for medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much needed endeavor. (shrink)

Social justice has been identified as a foundational moral commitment for global health research ethics. Yet what a commitment to social justice means for community engagement in such research has not been critically examined. This paper draws on the rich social justice literature from political philosophy to explore the normative question: What should the ethical goals of community engagement be if it is to help connect global health research to social justice? Five ethical goals for community engagement are proposed that (...) promote well-being, agency, and self-development, particularly for those considered disadvantaged and marginalized. The paper also considers how key terms used in the proposed goals should be defined using existing theories of health and social justice. This analysis is done to give global health researchers and their partners a better idea of what the ethical goals mean. Patterns of convergence amongst different theories are identified that support relying on particular definitions of key terms. (shrink)

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the C...