Everyone wants to be healthy, but many of us decline to act in healthy ways. Should these choices have any bearing on the ethics of clinical practice and health policy? How may personal responsibility for health be manipulated in health policy debates.

Principles of sufficiency are widely discussed in debates about distributive ethics. However, critics have argued that sufficiency principles are vulnerable to important objections. This paper seeks to clarify the main claims of sufficiency principles and to examine whether they have something distinctive and plausible to offer. The paper argues that sufficiency principles must claim that we have weighty reasons to secure enough and that once enough is secured the nature of our reasons to secure further benefits shifts. Having characterized sufficientarianism (...) in this way, the paper shows that the main objections to the view can be avoided; that we can examine the plausibility of sufficiency principles by appealing to certain reasons that support a shift; and that we should be optimistic about the prospects for sufficientarianism because many of our strongest reasons seem to be of this sort. This shift, I claim, is the overlooked grain of truth in sufficientarianism. (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)

Health systems that provide for universal patient access through a scheme of prepayments—whether through taxes, social insurance, or a combination of the two—need to make decisions on the scope of coverage that they secure. Such decisions are inherently controversial, implying, as they do, that some patients will receive less than comprehensive health care, or less than complete protection from the financial consequences of ill-heath, even when there is a clinically effective therapy to which they might have access.Controversial decisions of this (...) sort call for a public justification for covering or not covering a given treatment. Priority-setting agencies play a key role in providing such a justification. A recent... (shrink)

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in jeopardy of falling beneath the threshold has (...) a legitimate claim to justice. People's entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold). (shrink)

In a world of limited resources, competition between the young and old prompt difficult questions of justice. In countries with public pension and health care systems, or with aging populations, there is often a concern that members of different generations are not always treated fairly. Dennis McKerlie's monograph examines justice between age-groups with the ultimate goal of a new theory of justice that effectively grapples with those questions. In the realm of public policy and medical ethics this is an important (...) and timely topic, but surprisingly one that has received relatively little attention from moral philosophers. McKerlie develops a comprehensive view of fairness between age groups that applies the egalitarian values of equality, or priority for the badly off, to temporal parts of lives -- not just to complete lives. (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)

This article explores the problem of justice between age-groups. Specifically, it presents a challenge to a leading theory in this field, Norman Daniels' Prudential Lifespan Account. The challenge relates to a key assumption that underlies this theory, namely the assumption that all individuals live complete lives of equal length. Having identified the roles that this assumption plays, the article argues that the justifications Daniels offers for it are unsatisfactory and that this threatens the foundation of his position, undermining his claim (...) that ‘the fact that we all age’ makes age a special problem of distributive justice. This shows that the problem of justice between age-groups is not special in the way Daniels proposes; rather it involves the same irreducibly interpersonal distributive decisions as other problems of justice. The consequences of this argument are several-fold. Most importantly, it shows that the Rawlsian account of justice to which Daniels hopes to attach his theory to requires significantly greater benefits to be conferred on those in earlier age-groups relative to those in later age-group, not a distribution similar to simultaneous equality as Daniels proposes. (shrink)

ABSTRACT For a distribution of health care resources to be fair, it should consider the consequences for the whole lives of the affected persons and not just how badly off they are at the present moment. Since, other things being equal, a person is worse off if he dies young than if he dies old, it is fair to give scarce vital health care resources to young rather than to old persons. In the paper this ageist view is restated and (...) defended against a number of objections raised by John Harris. According to Harris' so‐called anti‐ageist argument the only relevant consideration in the distribution of vital health care resources is people's desire to go on living. On reflection, this is highly counterintuitive. Instead, it is argued that both present desires to go on living and possible future happiness should weigh together with considerations of fairness. Both fairness and possible future happiness will in most cases speak in favour of saving the young before the old. A number of other problems for the ageist view are discussed, and solutions are suggested. (shrink)

ABSTRACT For a distribution of health care resources to be fair, it should consider the consequences for the whole lives of the affected persons and not just how badly off they are at the present moment. Since, other things being equal, a person is worse off if he dies young than if he dies old, it is fair to give scarce vital health care resources to young rather than to old persons. In the paper this ageist view is restated and (...) defended against a number of objections raised by John Harris. According to Harris' so‐called anti‐ageist argument the only relevant consideration in the distribution of vital health care resources is people's desire to go on living. On reflection, this is highly counterintuitive. Instead, it is argued that both present desires to go on living and possible future happiness should weigh together with considerations of fairness. Both fairness and possible future happiness will in most cases speak in favour of saving the young before the old. A number of other problems for the ageist view are discussed, and solutions are suggested. (shrink)

Societal aging raises challenging ethical questions regarding the just distribution of health care between young and old. This article considers a proposal for age-based rationing of health care, which is based on the prudential life span account of justice between age groups. While important objections have been raised against the prudential life span account, it continues to dominate scholarly debates. This article introduces a new objection, one that develops out of the well-established disability critique of social contract theories. I show (...) the implications of this critique for the prudential life span account and for the special case of age-group justice. The result is that age-based rationing based on the prudential life span approach is not supported, and that the prudential life span approach itself is not the best way to think about allocating health care between age groups. I propose an alternative approach that avoids the disability objection, and consider its implications for specific proposals for age-based rationing of health care. (shrink)

When Richard Lamm made the statement that old people have a duty to die, it was generally shouted down or ridiculed. The whole idea is just too preposterous to entertain. Or too threatening. In fact, a fairly common argument against legalizing physician-assisted suicide is that if it were legal, some people might somehow get the idea that they have a duty to die. These people could only be the victims of twisted moral reasoning or vicious social pressure. It goes without (...) saying that there is no duty to die. (shrink)

La présente contribution vise à offrir au lecteur une présentation de la doctrine suffisantiste de la justice, de ses justifications générales et spécifiques et de son articulation possible avec d’autres théories de la justice. Elle explore certains aspects plus particuliers tels que la place de la responsabilité en son sein, son applicabilité au domaine intergénérationnel ou son positionnement par rapport à la question des « vies-complètes ». Elle montre aussi en quoi, quelles que soient les faiblesses possibles de cette doctrine, (...) elle présente des caractéristiques la rendant non redondante, en particulier par rapport à l’égalitarisme du leximin.This paper aims at presenting sufficientarianism, its justifications, specificities and the ways in which it can be combined with other theories of justice. We also explore more specific dimensions such as the place of responsibility-sensitivity, the doctrine’s application to the intergenerational realm or its interest for « complete-life » questions. We show to what extent, despite some weaknesses, it is not redundant when compared to or combined with leximin egalitarianism. (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)

In a world of limited resources, competition between the young and old prompt difficult questions of justice. In countries with public pension and health care systems, or with aging populations, there is often a concern that members of different generations are not always treated fairly. Dennis McKerlie's monograph examines justice between age-groups with the ultimate goal of a new theory of justice that effectively grapples with those questions. In the realm of public policy and medical ethics this is an important (...) and timely topic, but surprisingly one that has received relatively little attention from moral philosophers. McKerlie develops a comprehensive view of fairness between age groups that applies the egalitarian values of equality, or priority for the badly off, to temporal parts of lives -- not just to complete lives. (shrink)

This paper provides a critical examination of the strongest defenses of the pure lifetime view, according to which justice requires taking only people's whole lives as relevant when assessing and establishing their distributive entitlements and obligations. The paper proposes that we reject a pure lifetime view and replace it with an alternative view, on which some time-specific considerations--that is to say, considerations about how people fare at specific points in time--have nonderivative weight in determining what our obligations are to them.