What are the respective roles and responsibilities of global, national, and local communities as well as individuals themselves to address health deprivations and avert health threats? This article offers the beginnings of a theory of global health justice, arguing for universal ethical norms (general duty) with shared global and domestic responsibility (specific duties) for health. It offers a global minimalist view I call ‘ provincial globalism ’ as a mean between nationalism and cosmopolitanism, in which a provincial consensus must accompany (...) a global consensus on health morality. This minimalist account asserts global and national duties to promote human flourishing and, more specifically, individuals’ central health capabilities. In this view, justice requires prioritizing responsibilities through shared health governance to reduce shortfall inequalities in central health capabilities — a general duty to reduce premature mortality and escapable morbidity. It examines the difficulties presented by the philosophical principles of connectedness, causality, remediation, partiality, and capacity in the allocation of responsibility for global health. It offers a theory of responsibility allocation based on a functional, health agency centered and homeostatic balanced understanding of the analytical components required to solve global health problems and parcels out roles and responsibilities at the global, national, local, and individual levels accordingly. Allocations of responsibility rest on the effectiveness and special obligations of different actors, respecting self-determination by groups and individuals and seeking voluntary commitments . This view understands that the remedy for global health problems must be sustainable to take nations and the global health community to a new global health equilibrium that remedies current problems and prepares for new health threats to come. (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)

One major way of arguing for the moral attractiveness of luck egalitarianism is indirect; it consists in showing that the view follows from competing views on distributive justice which one actually endorses. Kasper Lippert-Rasmussen (KLR) claims that luck egalitarianism is indirectly supported in this way by Rawls’s intuitive argument for the difference principle. That argument begins by asserting that the impact of social and natural contingencies on distributive shares is unjust. After clarifying the notion of indirect support, I argue against (...) KLR’s claim. Whether the argument goes on to support luck egalitarianism is a matter of interpretation which can only be decided by looking closer at what Rawls has to say about the difference principle than KLR’s own treatment of the argument allows. In its most plausible reading, the intuitive argument veers away from luck egalitarianism in favor of a non-egalitarian view of the difference principle as a principle of compensating advantage. On this view, inequality due to bad luck is not in any respect unjust when the least advantaged cannot be made better off under alternative arrangements. In conclusion I explain why there are good reasons of fairness to understand the difference principle in this way. (shrink)

This article discusses various arguments for and against treating equality as a fundamental norm in law and political philosophy, combining prior arguments to the effect that equality is essentially an empty idea with arguments that treat it as a non‐empty but mistaken value that should be rejected. After concluding that most of the arguments for treating equality as a fundamental value fall victim to one or both of these arguments, it considers more closely arguments made by philosophers such as Ronald (...) Dworkin and Thomas Nagel that base a duty of promoting equality on the fact that governments impose a legal order on persons without their consent. It concludes that these arguments are mistaken: if the legal order imposed by government is justified then imposing it is not wrongful and generates no duty of equal treatment, while if that order is not justified no requirement of equality of treatment would cure the lack of justification. It concludes that equality should not be a value in law or political theory, but in some cases other considerations may justify particular rules that are sometimes mistakenly thought to be based on equality. (shrink)

In Citizens United v. Federal Election Commission , the US Supreme Court sharply curtailed the ability of the state to limit political speech by for-profit corporations. This new legal situation elevates the question of corporate political involvement: in what manner and to what extent is it ethical for for-profit corporations to participate in the political process in a liberal democratic society? Using Scanlon’s version of contractualism, I argue for a number of substantive and procedural constraints on the political activities of (...) businesses. Central to this contractualist analysis is an identification of the self-governance-based interests of individuals that are affected by corporate political activity and a method for judging the various assignments of social rights, duties and roles according to how they collectively meet those interests. Together, these two features make this contractualist approach distinctive and allow it to generate substantive ethical results. (shrink)

In this thesis I defend the principle of global egalitarianism. According to this idea most of the existing detrimental inequalities in this world are morally objectionable. As detrimental inequalities I understand those that are not to the benefit of the worst off people and that can be non-wastefully removed. To begin with, I consider various justifications of the idea that only those detrimental inequalities that occur within one and the same state are morally objectionable. I identify Thomas Nagel’s approach as (...) the most promising defence of this traditional position. However, I also show that Nagel’s argument does not even justify the elimination of detrimental inequalities within states. A discussion of the concept of political legitimacy rather shows that egalitarian justice is not a necessary condition of the justifiability of the exercise of coercive political power. I, then, consider other, more Rawlsian approaches to the question of detrimental inequalities. These views appear more plausible than Nagel’s position and argue that egalitarian duties also arise in certain international contexts. But also these more global theories of distributive justice suffer from shortcomings. Since they make the application of duties of justice dependent on the existence of social practices they cannot adequately account for the justified interests of non-participants that are affected by these practices. The counter-intuitive implications of practice-dependent theories lead me to investigate the plausibility of a theory that does not limit justice to existing practices and that argues for the inherent value of equality. This theory is global egalitarianism. I defend global egalitarianism by debilitating three objections that opponents of this idea frequently present in the relevant literature. Finally I also address two particular objections to the idea that global egalitarian duties are institutionalizable with the help of coercive global authorities. (shrink)

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