While in America most people think of “welfare” as means-tested programs such as Aid to Families with Dependent Children, in reality in the United States and other affluent democracies the heart of the welfare state is social insurance programs, such as health insurance, old-age or retirement pensions, and unemployment insurance. They are insurance programs in the sense that they protect against common risks of a loss of income if and/or when certain events come to pass ; they are “social” because (...) unlike market insurance they are not run on a sound actuarial basis, the premiums are not voluntarily incurred but compulsory, and there is very limited choice or flexibility concerning the type of policy one can purchase. Why have social insurance rather than market insurance? In this essay, I take up this question with regard to old-age or retirement pensions, which at present absorb around 9 percent of the gross domestic product and 25 percent of government spending of the affluent industrial countries comprising the Organization for Economic Cooperation and Development. My aim is to show that old-age or retirement social insurance is worse in virtually every relevant normative respect than its alternative, some form of market or private pensions. By relevant normative respect, I mean those values or principles which are used by contemporary political philosophers in their discussions and justifications of welfare-state policies, and which are applicable to assessments of different systems of old-age or retirement pensions. (shrink)

Through users’ cross-system comparative experience engaging with the health systems in Taiwan and other countries, this article probes into their understandings and value judgments and specifically their reasonings for the ‘solidarity with whom?’ question in the health sector solidarity. With the cross-system comparison approach, the study adopted semi-structured interviews with 30 Taiwanese participants who have studied, lived or worked abroad and engaged with the health system in Canada, the USA or the UK. This approach offers the opportunity for one to (...) evaluate the health system in the home country from a relative viewpoint from the host country. The participants suggested that the boundary of Taiwan’s National Health Insurance (NHI) should be as inclusive as possible, covering all legal residents in Taiwan regardless of their status, and that the citizens should share more financial responsibility. The ethical reasons for supporting the NHI include recognizing health sector solidarity among people, considering the coverage as a protection of the human right to health, humanitarian reasons and self-interest. Three archetypes of users emerged from the synthesis: Universalists, Rationalists and Republicans. The cross-system comparative experience makes the participants have more supportive attitudes toward the ideals of health sector solidarity. (shrink)

This thesis has two aims. The first aim is to set out an argument for social insurance in the form of compulsory income insurance in the event of sickness or unemployment, and to explore two lines of arguments for social insurance policies that are commonly associated with an active welfare state that seeks to prevent or reduce reliance on social insurance. The second aim is to outline and defend an account of legitimacy that takes moral autonomy seriously by making legitimacy (...) partly dependent on our entrenched values and preferences. The first aim is relevant for articles I-VI. In article I it is argued that the extent to which behavioural responses to social insurance is seen as ethically problematic, it is primarily a problem that concerns the institution rather than the morality of the individual whose behaviour is influenced by social insurance. Thus, insofar as behavioural responses to social insurance are an ethical problem, it is a problem for political philosophy rather than individual ethics. In article II an argument for social insurance in the form of compulsory income insurance in the event of sickness or unemployment is presented, viz. the argument from autonomy. It is based on a concern for the protection of our identity according to what is called a “thick” conception of the person, which holds that our identities as separate persons are constituted by our central aims and commitments. It is also argued that contrary to what has been claimed by its opponents; social insurance needs not lead to the bad risks exploiting the good risks, or be head-on in conflict with individual freedom. Article III identifies normative issues that deserve attention in relation to in relation to a general introduction of prevention policies in social insurance and market insurance. It is argued that the importance of these issues suggests that arguments and distinctions drawn from moral and political philosophy should play a more prominent role both in the debate on the shift towards an active welfare state and the use of prevention policies in market insurance. Article IV is a response to comments from Professor David Buchanan initiated by article III. Article V explores what is called the argument from autonomy for reduced compensation rates in social insurance or making compensation from such insurance conditional on different kinds of requirements such as participation in rehabilitation or vocational training. It is argued that such policies are justified if they tend to ensure an adequate level of autonomy, where autonomy is understood in the sense of a “thick” conception of personal autonomy based on Norman Daniel’s extension of the principle of fair equality of opportunity. Article VI discusses the objection that arguments pertaining to the principle of fairness often are irrelevant since the principle of fairness is based on the acceptance of the relevant benefits. It is argued that this objection from non-acceptance fails because we can – and do – accept the benefits form such institutions on a practical level and this is enough to ground obligations pertaining fairness. The implications of this argument for policies associated with the active welfare state are explored, taking a reform of the Swedish sickness insurance as an example. The second aim is relevant for article VII. In article VII it is argued that an account of legitimacy should satisfy three conditions. The justification thesis and the legitimacy thesis are presented as accounts of justification and legitimacy respectively. It is argued that the proposed accounts satisfy these conditions. An account of political obligations is also given. (shrink)

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models in which physicians provide insured services while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such (...) practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician–patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy. (shrink)

Solidarity is presumed to underpin the redistributive health and welfare systems in modern democracies; however, it is often considered a Western—or more specifically, European—concept. While health and welfare systems have been transplanted successfully to many non-Western developed countries, whether the solidarity necessary for such systems exists or is intellectually available remains under debate. Using an East Asian country with the Confucian tradition as an illustrative case, I first argue that the Confucian tradition has special theoretical and sociological importance for health (...) and welfare solidarity. Then, through investigating the classic Confucian writings, I propose transformed interpretations of the essential concepts of Confucian thought, namely filial piety, benevolent governance and the mandate of heaven. With these interpretations, the differentiated family-based solidarity and the people-rooted thought in Confucianism could be reimagined to fit with the modern liberal-democratic political regime and welfare arrangements. I call this model Confucian welfarism, which I argue could form the intellectual origins of solidarity for people who believe in or have an affinity to Confucian ethos. (shrink)