In this book, T. M. Scanlon offers new answers to these questions, as they apply to the central part of morality that concerns what we owe to each other.

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?

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal responsibility (...) would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts. (shrink)

It is often assumed that we are only blameworthy for that over which we have control. In recent years, however, several philosophers have argued that we can be blameworthy for occurrences that appear to be outside our control, such as attitudes, beliefs and omissions. This has prompted the question of why control should be a condition on blameworthiness. This paper aims at defending the control condition by developing a new conception of blameworthiness: To be blameworthy, I argue, is most fundamentally (...) to deserve to feel guilty. Being blamed by someone else is not necessarily harmful to the wrongdoer. The blame might not be expressed, or the wrongdoer might not care. But to blame oneself necessarily involves suffering. This conception of blameworthiness explains why the control condition should obtain: We are morally blameworthy for A only if A was under our control because to be blameworthy is to deserve to feel guilty, to feel guilty is to suffer, and one deserves to suffer for A only if A was under one’s control. (shrink)

Whether it is fair to use personal responsibility of patients for their own health as a rationing criterion in healthcare is a controversial matter. A host of difficulties are associated with the concept of personal responsibility in the field of medicine. These include, in particular, theoretical considerations of justice and such practical issues as multiple causal factors in medicine and freedom of health behaviour. In the article, personal responsibility is evaluated from the perspective of several theories of justice. It is (...) argued that in a healthcare system based on both equality of opportunity and solidarity, responsible health behaviour can—in principle—be justifiably expected. While the practical problems associated with personal responsibility are important, they do not warrant the common knee-jerk refusal to think more deeply about responsibility for health as a means of allocating healthcare resources. In conclusion, the possibility of introducing personal responsibility as a fair rationing criterion is briefly sketched. (shrink)

Combatting chronic, lifestyle-related disease has become a healthcare priority in the developed world. The role personal responsibility should play in healthcare provision has growing pertinence given the growing significance of individual lifestyle choices for health. Media reporting focussing on the ‘bad behaviour’ of individuals suffering lifestyle-related disease, and policies aimed at encouraging ‘responsibilisation’ in healthcare highlight the importance of understanding the scope of responsibility ascriptions in this context. Research into the social determinants of health and psychological mechanisms of health behaviour (...) could undermine some commonly held and tacit assumptions about the moral responsibility of agents for the sorts of lifestyles they adopt. I use Philip Petit's conception of freedom as ‘fitness to be held responsible’ to consider the significance of some of this evidence for assessing the moral responsibility of agents. I propose that, in some cases, factors outside the agent's control may influence behaviour in such a way as to undermine her freedom along the three dimensions described by Pettit: freedom of action; a sense of identification with one's actions; and whether one's social position renders one vulnerable to pressure from more powerful others. (shrink)

ABSTRACT Individual responsibility is now very much on the political agenda. Even those who believe that its importance has been exaggerated by the political right — either because the appropriate conditions for assigning responsibility to individuals are rarely satisfied or because not enough is done to protect individuals from the more harmful consequences of their past choices and gambles — accept that individual responsibility is at least one of the values against which a society and its institutions ought to be (...) evaluated. One might be forgiven for assuming, then, that we know exactly why individual responsibility is important. The truth is otherwise. Surprisingly little philosophical work has been undertaken to analyse and separate out the different rationales that might be in play. Several possible reasons are examined here including: utility, the social bases of self‐respect, autonomy, human flourishing and fairness. However, once we adopt a pluralistic view of the value of individual responsibility we open up the possibility of value conflict, which conflict can make it harder to arrive at definitive prescriptions about which social policies best advance our concerns for individual responsibility. It is nevertheless possible to draw at least some conclusions about which policies we should favour. One important conclusion is that sometimes it is better not to hold individuals responsible for their past choices by denying them aid now, so that they might be better able to assume individual responsibility at a later date. (shrink)

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be met in order to ensure (...) that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)

The overall aim of this article is to discuss the organization of limit setting in healthcare in terms of legitimacy. We argue there is a strong ethical demand that such processes should be arranged to provide adversely affected people well-justified reasons to confer legitimacy to the processes despite favouring a different decision-making outcome. Two increasingly popular approaches, Accountability for Reasonableness (A4R) and Multi-Criteria Decision Analysis (MCDA), can both be applied to support legitimate decision-making processes. However, the role played by ‘fair-minded (...) people’ in the A4R framework can be shown to undermine an adequate conceptualization of legitimacy according to the ethical demand. We discuss and specify conditions enabling A4R to meet this ethical demand when being implemented in a real-world setting without having to renounce the aim of striving for ‘reasonableness’ and impartiality. The methodological approach MCDA describes how to arrange for transparent resource allocation. This approach does not encompass any normative guidance on how to shape limit settings in terms of ‘reasonableness’; it basically promotes ‘rational’ decisions. We discuss how this practical methodology can be integrated with the theoretical A4R framework to meet the ethical demand while at the same time promoting politically required impartiality of healthcare limit setting. (shrink)

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)

In her recent, provocative essay “What Is the Point of Equality?”, Elizabeth Anderson argues against a common ideal of egalitarian justice that she calls “ luck egalitarianism” and in favor of an approach she calls “democratic equality.”1 According to the luck egalitarian, the aim of justice as equality is to eliminate so far as is possible the impact on people’s lives of bad luck that falls on them through no fault or choice of their own. In the ideal luck egalitarian (...) society, there are no inequalities in people’s life prospects except those that arise through processes of voluntary choice or faulty conduct, for which the agents involved can reasonably be held responsible. Anderson asserts that the adherents of luck egalitarianism, which can be elaborated in many different ways, include John Roemer, Erik Rakowski, Thomas Nagel, Ronald Dworkin, Gerald Cohen, Richard Arneson, and Philippe Van Parijs.2 In contrast, according to the democratic equality conception, justice as equality requires an end to oppressive social relationships. In the ideal society of democratic equality, the social conditions of everyone’s freedom are secured, each stands to every other in a relationship of fundamental equality, including equal respect, and all have real freedom to participate in democratic self-government. (shrink)

Luck egalitarians need to address the question of cost-responsibility: If an individual is responsible for being worse off than others, then what benefits, if any, is that individual uniquely cost-responsible for? By applying luck egalitarianism to justice in health I discuss different answers to this question inspired by two different interpretations of luck egalitarianism, namely ‘standard luck egalitarianism’ and ‘all luck egalitarianism’, respectively. Even though I argue that the latter is more plausible than the former, I ultimately suggest and defend (...) a third interpretation of luck egalitarianism, which I label ‘universal luck egalitarianism’. Finally, I adjust my findings to a (all things considered) more plausible currency, namely welfare. (shrink)

What does it take for an individual to be personally responsible for behaviors that lead to increased risk of disease? We examine three approaches to responsibility that cover the most important aspects of the discussion of responsibility and spell out what it takes, according to each of them, to be responsible for behaviors leading to increased risk of disease. We show that only what we call the causal approach can adequately accommodate widely shared intuitions to the effect that certain causal (...) influences—such as genetic make-up or certain social circumstances—diminish, or undermine personal responsibility. However, accepting the causal approach most likely makes personal responsibility impossible. We therefore need either to reject these widely shared intuitions about what counts as responsibility-softening or undermining or to accept that personal responsibility for behaviors leading to increased risk of disease rests on premises so shaky that personal responsibility is probably impossible. (shrink)

Luck egalitarianism is often taken to task for its alleged harsh implications. For example, it may seem to imply a policy of nonassistance toward uninsured reckless drivers who suffer injuries. Luck egalitarians respond to such objections partly by pointing to a number of factors pertaining to the cases being debated, which suggests that their stance is less inattentive to the plight of the victims than it might seem at first. However, the strategy leaves some cases in which the attribution of (...) individual responsibility is appropriate . One such case is oral health or significant aspects of this. It is appropriate, the paper argues, to hold people responsible for a number of factors that affect their oral health. A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing. (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

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)

Many prominent theories of moral responsibility rely on the notion of “tracing,” the idea that responsibility for an outcome can be located in (i.e., “traced back to”) some prior moment of control, perhaps significantly antecedent to the proximate sources of a considered action. In this article, I show how there is a problem for theories that rely on tracing. The problem is connected to the knowledge condition on moral responsibility. Many prima facie good candidate cases for tracing analyses appear to (...) violate the knowledge condition on moral responsibility. So, either we need to dispense with tracing approaches or we must refine our understanding of the knowledge condition or we are responsible less frequently than we suppose. (shrink)

This book sets forth a novel theory of distributive justice premised on the fundamental moral equality of persons. It argues that, subject to certain limitations on personal sacrifice, no one should have less valuable resources and opportunities available to him than anyone else, simply invirtue of some chance occurrence the risk of which he did not choose to incur. Applying this principle to the distribution of wealth and income, the specification of property rights, and the allocation of scarce medical resources, (...) Professor Rakowski reaches challenging, often unconventional,conclusions. He further criticizes the economic analysis of law as a normative theory, and develops an alternative account of tort law.Among the topics discussed are the principles by which earnings, wealth, and gifts should be taxed; whether the compulsory removal of organs for transplantation can be justified; how doctors and public officials should make life-or-death decisions when all those endangered cannot be saved; and themorality of killing human beings and nonhuman animals. (shrink)

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases ’s 2015 Health Survey, this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual (...) lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies. The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. (shrink)

ABSTRACTIt has recently become fashionable among those who write on questions of moral responsibility to distinguish two different concepts, or senses, of moral responsibility via the labels ‘responsibility as attributability’ and ‘responsibility as accountability’. Gary Watson was perhaps the first to introduce this distinction in his influential 1996 article ‘Two Faces of Responsibility’ , but it has since been taken up by many other philosophers. My aim in this study is to raise some questions and doubts about this distinction and (...) to argue that it has led to confusion rather than clarification in debates over moral responsibility. In place of the attributability/accountability distinction, I propose that there is a single concept of moral responsibility underlying our actual moral practices. This core notion of moral responsibility, which I call ‘responsibility as answerability’, is well positioned to explain thos.. (shrink)

Although the responsibility for health debate has intensified in several ways between Norman Daniels’ 1985 Just healthcare and Just health: meeting health needs fairly of 2008, comparatively little space is dedicated to the issue in Just health, and Daniels notes repeatedly that his account “says nothing about personal responsibility for health”. Daniels considers health responsibility mainly in a particular luck-egalitarian version which he rejects because of its potentially unfeasible, penalising and inhumane character. But I show that he nonetheless acknowledges and (...) endorses explicitly other dimensions of health responsibility. I develop a wider, more nuanced and less punitive concept of health responsibility, which expands Daniels’ brief consideration and is compatible with the overall approach set out in Just health. In its application to preventative medicine and health promotion in particular, the concept is suited to support and complement the notion that “health is special”, which is central in Just health. The concept of health responsibility as co-responsibility specifies the subjects and objects of health responsibilities. It permits the attribution of responsibility without blame and disconnects the question of assigning responsibility from decisions about entitlement to treatment or different status in prioritisation decisions. This approach secures conceptual plausibility and clarity of the concept of health responsibility, is of use in policy making, and can help reduce political tensions. (shrink)

Bonuses, as incentives or rewards for health -related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health -care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health -care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality (...) and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices. (shrink)

Reflections about the role of human choice in determining personal health occur in the writings of practitioners and laymen throughout history. The Greek and Roman writers emphasized the effect of life's activities. During the Middle Ages and Renaisance, disease continued to be seen as a consequence of disorder of the bodily humors, which were under the individual's control. The rise of the paternalistic national regimes in Europe produced the view that society had the responsibility to maintain health. Jacksonian egalitarianism led (...) to a reaction against the agressive therapies of established professional experts, a view furthered by the Thomsonian belief that people should wrest control of their health away from orthodox physicians. Among the twentieth century reactions was the movement to urge people to have doctors evaluate laypersons' health. By the 1970s a movement emerged emphasizing again personal responsibility, which, in turn, produced a concern that this was merely "victim-blaming". Views on the role of lay people in determining personal health are heavily influenced by prevailing social, political, and moral climates. Keywords: "responsibility for health: social, personal, or professional?", "causes of illness", "self-reliant health care", historical influences, responsibility for health, "victim-blaming" CiteULike Connotea Del.icio.us What's this? (shrink)

Negligence is a problematic basis for being morally blamed and punished for having caused some harm, because in such cases there is no choice to cause or allow—or risk causing or allowing—such harm to occur. The standard theories as to why inadvertent risk creation can be blameworthy despite the lack of culpable choice are that in such cases there is blame for: (1) an unexercised capacity to have adverted to the risk; (2) a defect in character explaining why one did (...) not advert to the risk; (3) culpably acquiring or failing to rid oneself of these defects of character at some earlier time; (4) flawed use of those practical reasoning capacities that make one the person one is; or (5) chosen violation of per se rules about known precautions. Although each of these five theories can justify blame in some cases of negligence, none can justify blame in all cases intuitively thought to be cases of negligence, nor can any of these five theories show why inadvertent creation of an unreasonable risk, pure and simple, can be blameworthy. (shrink)

Negligence is a problematic basis for being morally blamed and punished for having caused some harm, because in such cases there is no choice to cause or allow—or risk causing or allowing—such harm to occur. The standard theories as to why inadvertent risk creation can be blameworthy despite the lack of culpable choice are that in such cases there is blame for: (1) an unexercised capacity to have adverted to the risk; (2) a defect in character explaining why one did (...) not advert to the risk; (3) culpably acquiring or failing to rid oneself of these defects of character at some earlier time; (4) flawed use of those practical reasoning capacities that make one the person one is; or (5) chosen violation of per se rules about known precautions. Although each of these five theories can justify blame in some cases of negligence, none can justify blame in all cases intuitively thought to be cases of negligence, nor can any of these five theories show why inadvertent creation of an unreasonable risk, pure and simple, can be blameworthy. (shrink)

Beliefs are held to norms in a way that seems to require control over what we believe. Yet we don’t control our beliefs at will, in the way we control our actions. I argue that this problem can be solved by recognising a different form of control, which we exercise when we revise our beliefs directly for reasons. We enjoy this form of attitudinal control not only over our beliefs, but also over other attitudes, including intentions—that is, over the will (...) itself. Closely tied to our capacity for reasoning, attitudinal control is in important respects more fundamental than the voluntary control that we exercise over our actions. In the course of developing this account I respond to two objections recently raised against an earlier version of it by Booth. (shrink)

Governments, physicians, media and academics have all called for individuals to bear responsibility for their own health. In this article, I argue that requiring those with adverse health outcomes to bear responsibility for these outcomes is a bad basis for policy. The available evidence strongly suggests that the capacities for responsible choice, and the circumstances in which these capacities are exercised, are distributed alongside the kinds of goods we usually talk about in discussing distributive justice, and this distribution significantly explains (...) why people make bad health choices. These facts suggest that we cannot justifiably hold them responsible for these choices. We do better to hold responsible those who determine the ways in which capacities and circumstances are distributed: they are indirectly responsible for these adverse health outcomes and possess the capacities and resources to take responsibility for these facts. (shrink)

Accounts of moral responsibility can be divided into those that claim that attributability of an act, omission, or attitude to an agent is sufficient for responsibility for it, and those which hold that responsibility depends crucially on choice. I argue that accounts of the first, attributionist, kind fail to make room for the relatively stringent epistemic conditions upon moral responsibility, and that therefore an account of the second, volitionist, kind ought to be preferred. I examine the various arguments advanced on (...) behalf of attributionist accounts, and argue that for each of them volitionism has a reply that is in every case at least as, and often more, persuasive. Most significantly, only volitionism can accommodate the intuitively important distinction between the bad and the blameworthy. (shrink)

In this paper I consider fairness of blaming a wrongdoer. In particular, I consider the claim that blaming a wrongdoer can be unfair because blame has a certain characteristic force, a force which is not fairly imposed upon the wrongdoer unless certain conditions are met--unless, e.g., the wrongdoer could have done otherwise, or unless she is someone capable of having done right, or unless she is able to control her behavior by the light of moral reasons. While agreeing that blame (...) has a characteristic force, I am skeptical of this charge of unfairness. My skepticism concerns itself less with the particular conditions of fairness proposed than with the idea that blame can be rendered unfair by its characteristic force. If to blame a person were simply to perform certain intentional actions, then, as we will see, blame could be rendered unfair by its force. But to blame a person is not just to act in certain ways. It is, at least in large part, to make certain judgments or adopt certain attitudes. However, it is unclear how these attitudes or judgments carry "force"? and also unclear whether they can be rendered unfair by their force. Examining these issues, I will suggest that much of the force of blame is found in a set of judgments--most centrally, the judgment that one person failed to show proper regard for others. But, I will argue, once it is granted that such judgments are true, their characteristic force cannot render them unfair. (shrink)

In this paper I sketch an account of moral blame and blameworthiness. I begin by clarifying what I take blame to be and explaining how blameworthiness is to be analyzed in terms of it. I then consider different accounts of the conditions of blameworthiness and, in the end, settle on one according to which a person is blameworthy for φ-ing just in case, in φ-ing, she violates one of a particular class of moral requirements governing the attitudes we bear, and (...) our mental orientation, toward people and other objects of significant moral worth. These requirements embody the moral stricture that we accord to these others a sufficient level of respect, one that their moral worth demands. This is a familiar theme which has its roots in P. F. Strawson’s pioneering views on moral responsibility. My development of it leads me to the conclusion that acting wrongly is not a condition of blameworthiness: violating a moral requirement to perform, or refrain from performing, an action is neither necessary nor sufficient for being blameworthy. All we are ever blameworthy for, I will argue, are certain aspects of our mental bearing toward others. We can be said to be blameworthy for our actions only derivatively, in the sense that those actions are the natural manifestations of the things for which we are strictly speaking blameworthy. (shrink)

This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand the (...) debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall. (shrink)

Control-based models of moral responsibility typically employ a notion of "tracing," according to which moral responsibility requires an exercise of control either immediately prior to the behavior in question or at some suitable point prior to the behavior. Responsibility, on this view, requires tracing back to control. But various philosophers, including Manuel Vargas and Angela Smith, have presented cases in which the plausibility of tracing is challenged. In this paper we discuss the examples and we argue that they do not (...) in fact impugn an attractive and natural tracing component. Our discussion can function in part as a defense of a control-based account of moral responsibility, but also as simply a defense of tracing. (shrink)

Our aim in this paper is to put the concept of moral responsibility under a microscope. At the lowest level of magnification, it appears unified. But Gary Watson has taught us that if we zoom in, we will find that moral responsibility has two faces: attributability and accountability. Or, to describe the two faces in different terms, there is a difference between being responsible and holding responsible. It is one thing to talk about the connection the agent has with her (...) action; it is quite another to talk about the potential interaction the agent might have with her moral community. It turns out, though, that the faces of moral responsibility can themselves be viewed under an even higher level of magnification. If moral responsibility has two faces, then our aim in this paper is to examine their features. To do so reveals subtle distinctions in our concept of moral responsibility and its interaction with surrounding issues that, we argue, can help illuminate various debates in the literature. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

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)

This essay explores a conception of responsibility at work in moral and criminal responsibility. Our conception draws on work in the compatibilist tradition that focuses on the choices of agents who are reasons-responsive and work in criminal jurisprudence that understands responsibility in terms of the choices of agents who have capacities for practical reason and whose situation affords them the fair opportunity to avoid wrongdoing. Our conception brings together the dimensions of normative competence and situational control, and we factor normative (...) competence into cognitive and volitional capacities, which we treat as equally important to normative competence and responsibility. Normative competence and situational control can and should be understood as expressing a common concern that blame and punishment presuppose that the agent had a fair opportunity to avoid wrongdoing. This fair opportunity is the umbrella concept in our understanding of responsibility, one that explains it distinctive architecture. (shrink)

Setting out to defend luck egalitarianism in matters of justice in health, Shlomi Segall outlines a pluralistic version of the luck egalitarian framework allowing egalitarian justice to be traded-off against other moral requirements. The suggested pluralism enables luck egalitarian justice to coexist with a concern for meeting everyone’s basic needs thereby avoiding Elizabeth Anderson’s ‘abandonment objection’. In this article, however, we present three objections to Segall’s luck egalitarian justice in health. Firstly, the account is vulnerable to the common objection that (...) luck egalitarianism becomes too expansive, and that Segall’s defence against this is inadequate. Secondly, Segall’s pluralist attempt to balance luck egalitarian justice and other moral requirements ends up compromising its own ideal of justice. Due to the fact that resource scarcity is the reality of health and health care distribution, this problem would often arise in actual health policy. Finally, the account has a way of intensifying blameworthy behaviour which seems contrary to luck egalitarian principles. Based on these three objections, we conclude that Segall’s luck egalitarian account of justice in health must either be rejected or qualified further. (shrink)