Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health rather (...) than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to blame, are spent on prevention or treatment of disease that could be avoided through individual lifestyle changes. This may encourage policy makers and health care professionals to opt for a criterion of individual responsibility for medical suffering when setting priorities. The following article asks whether responsibility-based reasoning should be accepted as (...) relevant for fair and legitimate healthcare rationing. The luck-egalitarian argument that inequalities in health expectancies that derive from unchosen features of people’s circumstances are unjust and should be compensated, while inequalities that reflect personal choices of lifestyle may not, is discussed. It seems that while a backward-looking interpretation of individual responsibility cannot be relevant as a criterion of priority setting, a forward-looking conception of responsibility may be approved.Within all modern societies healthcare authorities are facing difficult priority setting problems. Various criteria for rationing medical intervention have been proposed due to scarcity of resources. Until now, individual responsibility for medical suffering has been given little attention in the public or in academic debate. This is about to change. As Alexander Cappelen and Ole Norheim have pointed out in a recent article in this journal, unhealthy lifestyle contributes increasingly to the burden of disease. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge.1 In this article the following question is addressed: should responsibility-based arguments be accepted as relevant to meeting healthcare rationing fairly and legitimately? I will argue that while a backward-looking conception of individual responsibility should not be endorsed, a forward-looking notion of responsibility may be approved. (shrink)

John Rawls's work has greatly contributed to rehabilitating equality as a basic social value, after decades of utilitarian hegemony,particularly in normative economics, but Rawls also emphasized that full equality of welfare is not an adequate goal either. This thesis was echoed in Dworkin's famous twin papers on equality, and it is now widely accepted that egalitarianism must be selective. The bulk of the debate on ‘Equality of What?’ thus deals with what variables ought to be submitted for selection and how (...) this selection ought to be carried out. (shrink)

The concept of agent-responsibility for an outcome (that is, of the outcome reflecting the autonomous choice of the agent) is central to both ethics and political philosophy. The concept, however, remains radically under-explored. In particular, the issue of partial responsibility for an outcome needs further development. I propose an account of partial responsibility based on partial causal contribution. Agents who choose autonomously in full knowledge of the consequences are agent-responsible, I claim, for the shift in the objective probability of the (...) outcome in question that her choice induces. Thus, agents will typically be only partially agent-responsible (that is, for a shift of less than 100 percent) for any given outcome. The model has an implication that is generally rejected: that agents who purchase lottery tickets and win are agent-responsible for only part of the winnings. (shrink)

Egalitarian thinkers have adopted Ronald Dworkin’s distinction between brute and option luck in their attempts to construct theories that better respect our intuitions about what it is that egalitarian justice should equalize. I argue that when there is no risk-free choice available, it is less straightforward than commonly assumed to draw this distinction in a way that makes brute-luck egalitarianism plausible. I propose an extension of the brute-luck–option-luck distinction to this more general case. The generalized distinction, called the ‘least risky (...) prospect view’ of brute luck, implies more redistribution than Dworkin’s own solution (although less than called for by some of his other critics). Moreover, the generalized brute-luck–option-luck distinction must be parasitical on an underlying non-egalitarian theory of which sets of options are reasonable. The presupposed prior theory may be inimical to the claim that justice requires equality rather than some other distributive pattern. (shrink)

In his Tanner Lecture of 1979 called ‘Equality of What?’ Amartya Sen asked what metric egalitarians should use to establish the extent to which their ideal is realized in a given society. What aspect of a person’s condition should count in a fundamental way for egalitarians, and not merely as cause of or evidence of or proxy for what they regard as fundamental?

The aim of this article is to refute Ronald Dworkin's claim that the provision of an equal opportunity to insure against risks is sufficient to render differences in people's circumstances that are the result of luck consistent with his theory of equality of resources. Section I addresses bad luck in the circumstances of individuals in the form of mental or physical incapacitation resulting from the vicissitudes of nature. Section II addresses bad luck which is the result of the choices of (...) other individuals to give or bequeath. (shrink)

John Rawls's work (1971) has greatly contributed to rehabilitating equality as a basic social value, after decades of utilitarian hegemony,particularly in normative economics, but Rawls also emphasized that full equality of welfare is not an adequate goal either. This thesis was echoed in Dworkin's famous twin papers on equality (Dworkin 1981a,b), and it is now widely accepted that egalitarianism must be selective. The bulk of the debate on ‘Equality of What?’ thus deals with what variables ought to be submitted for (...) selection and how this selection ought to be carried out. (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)

In the old days, material egalitarians tended to favor equality of outcome advantage, on some suitable conception of advantage. Under the influence of Dworkin’s seminal articles on equality, contemporary material egalitarians have tended to favor equality of brute luck advantage---on the grounds that this permits people to be held appropriately accountable for the benefits and burdens of their choices. I shall argue, however, that a plausible conception of egalitarian justice requires neither that brute luck advantage always be equalized nor that (...) people always bear the full cost of their voluntary choices. Instead, justice requires that initial opportunities for advantage be equalized---roughly along the lines suggested by Arneson and Cohen. Brute luck egalitarianism and initial opportunity egalitarianism are fairly similar in motivation, and as a result they have not been adequately distinguished. Once the two views are more clearly contrasted, equality of opportunity for advantage will, I claim, be seen to be a more plausible conception of equality. (shrink)

Many recent political philosophers have attempted to demonstrate that choice and responsibility can be incorporated into the framework of an egalitarian theory of distributive justice. This article argues, however, that the project of developing a responsibility-based conception of egalitarian justice is misconceived. The project represents an attempt to defuse conservative criticism of the welfare state and of egalitarian liberalism more generally. But by mimicking the conservative’s emphasis on choice and responsibility, advocates of responsibility-based egalitarianism unwittingly inherit the conservative’s unsustainable justificatory (...) ambitions, unattractive moralism, and questionable metaphysical commitments. More importantly, they misrepresent the nature of our concern with equality as a value. (shrink)

The notion of individual responsibility has gained prominence in recent debates about health care. First, responsibility has been proposed as a rationing criterion; second, some policies use rewards and sanctions to encourage individuals to ‘take responsibility’ for their health; finally, acting responsibly within the health care system is portrayed as a requirement of reciprocity. The aim of this paper is two-fold. First, I assess these different kinds of appeal to individual responsibility from the perspective of equality. The literature has identified (...) important concerns about equality and fairness with proposals to use individual responsibility as a rationing criterion; I suggest that there are similar concerns about incentive schemes and reciprocity-based appeals to individual responsibility. The analysis will draw on luck egalitarian accounts of equality, which emphasise the importance of individual responsibility. This allows me to pursue the second objective for paper: to reconsider the luck egalitarian perspective on these different appeals to responsibility. Applying the arguments of recent contributions to the luck egalitarian literature to the health arena suggests that luck egalitarians need not support the use of responsibility as a rationing criterion, and they can also identify problems with incentives and reciprocity-based arguments. However, the language of individual responsibility and its prominence in public debates may have implications for individuals’ health and well-being, which raises challenging issues for luck egalitarians as they attempt to apply their theory to the real world. (shrink)

In the article by Kristin Voigt in the April 2013 issue of Cambridge Quarterly of Healthcare Ethics, quotation marks around certain phrases were deleted.

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as a criterion for (...) the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments. (shrink)

Background: Some members of the general public feel that patients who cause their own organ failure through smoking, alcohol use, or drug use should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) cause their own illness, (2) have poor transplant prognoses or, (3) are simply unworthy. We explore the role that social acceptability, personal responsibility, and prognosis play in people's judgments about transplant allocation. Methods: By random allocation, we presented 283 prospective (...) jurors in Philadelphia county with one of five questionnaire versions. In all questionnaires, subjects were asked to distribute transplantable hearts between patients with and without a history of three controversial behaviors (eating high fat diets against doctors’ advice, cigarette smoking, or intravenous drug use). Across the five questionnaire versions, we varied the relative prognosis of the transplant candidates and whether their behavior caused their primary organ Results: Subjects were significantly less willing to distribute organs to intravenous drug users than to cigarette smokers or people eating high fat diets (p le; 0.0005), even when intravenous drug users had better transplant outcomes than other patients. Subjects’ allocation decisions were influenced by transplant prognosis, but not by whether the behavior in question was causally responsible for the patients’ organ failure. Conclusion: People's unwillingness to give scarce transplantable organs to patients with controversial behaviors cannot be explained totally on the basis of those behaviors either causing their primary organ failure or making them have worse transplant prognoses. Instead, many people believe that such patients are simply less worthy of scarce transplantable organs. (shrink)

Justice is a constant and perpetual will to give every man his due. The principles of law are these: to live virtuously, not to harm others, to give his due to everyone. Jurisprudence is the knowledge of divine and human things, the science of the just and the unjust. Law is the art of goodness and justice. By virtue of this [lawyers] may be called priests, for we cherish justice and profess knowledge or goodness and equity, separating right from wrong (...) and legal from the illegal. (shrink)