Health policy sometimes hinges on claims about the responsibility borne by people or corporations for health outcomes. We don't want these claims to be arbitrary, so we construe them as discoveries of plain fact. But we're mistaken. They are interwoven with our values and social institutions. Recognizing that they are allows us to debate them more honestly and thoroughly.

This study is concerned with john R0emer’s Equality of Opportunity} I argue that his theory is committed to compatibilism but that one of its central claims is plausible only within a libertarian view on the free-will problem. Thus Roemer’s theory is troubled by a deep structural inco— herence and should be rejected as an account of equality of opportunity? Let me briefly introduce some background to Roemer’s theory. Contemporary egalitarians face two major challenges: first, they need..

A number of egalitarians have reached the conclusion that inequalities are just provided that they are the outcome of holding people appropriately responsible for their choices, and that only inequalities which can be traced back to the circumstances in which people happen to find themselves are objectionable. But this form of egalitarianism needs to be supplemented with an account of when it is appropriate to hold people responsible for their choices that is properly sensitive to the profound effects of socialisation. (...) Two of the most promising attempts to develop such an account-those of Ronald Dworkin and John Roemer-are found to be problematic in the light of a range of cases where gender socialisation influences values and aspirations. (shrink)

This paper considers issues raised by Elizabeth Anderson’s recent critique of the position she terms ‘luck egalitarianism’. It is maintained that luck egalitarianism, once clarified and elaborated in certain regards, remains the strongest egalitarian stance. Anderson’s arguments that luck egalitarians abandon both the negligent and prudent dependent caretakers fails to account for the moderate positions open to luck egalitarians and overemphasizes their commitment to unregulated market choices. The claim that luck egalitarianism insults citizens by redistributing on the grounds of paternalistic (...) beliefs, pity and envy, and by making intrusive and stigmatizing judgments of responsibility, fails accurately to characterize the luck egalitarian’s rationale for redistribution and relies upon luck egalitarians being insensitive to the danger of stigmatization. The luck egalitarian position is reinforced by the fact that Anderson’s favoured conception of equality, ‘democratic equality’, is counterintuitively indifferent to all unchosen inequalities, including intergenerational inequalities, once bare social minima are met. (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)

Two models of the relationship between individual behaviour and health status are examined. On the Freedom Model, the individual is presumed to be capable of free choices including many that have important health consequences. Freedom entails accountability. Thus individuals can be held responsible for health conditions that result from choices they have made. To hold otherwise—to refuse to acknowledge the freedom and responsibilities of individuals—is bad faith. On the Facticity Model, behaviour is a result of facts—genetic and environmental—beyond an individual's (...) control. There is little or no freedom; people are the bodies and roles they inherit. Important among these facts is socio-economic position since it determines much of behaviour and resulting health status. Many people who are poor and lack education also suffer from poor health. To blame their poor health on their behaviour is to blame people already victimised by their circumstances. The relationships of these two models to health promotion are explored. Though conflicting in theory, some justice can be done to each model in the practical world of health promotion by appealing to the freedom in individuals in health education and to the facts that shape individuals in other health promotion and health care contexts. (shrink)

The article addresses the issue of rationing health care services, a topic currently being hotly debated in many countries. The author argues that the aspect of causal responsibility ought to play a decisive role in the allocation of limited medical resources. Starting out from Ronald Dworkin's distinction between option luck and brute luck, the appropriate and meaningful uses of the term causal responsibility are clarified first. A discussion of the conditions which might justify giving lower priority to patients whose illnesses (...) are the result of unhealthy behavior, like e.g. alcohol abuse, follows. Causal responsibility is then viewed in the context of private health insurance and the club model of organ donation. It is argued that individuals themselves are basically responsible for their decisions regarding insurance coverage and membership in organ donors' clubs. Causal responsibility is shown to be a more suitable criterion for rationing scarce medical resources than other criteria which might alternatively be considered, such as patients' age. (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?

Autonomy is good for you. A strong sense of competent self-control and effective choice-making promotes both physical and psychological well-being. Loss of autonomous control—and a sense of helplessness—causes depression, increased sensitivity to pain, greater vulnerability to disease, and death. Well established by a wide range of psychological and physiological studies, the positive effects of patient autonomy are well known to competent physicians, nurses, and therapists. Conscientious caregivers are thus moving beyond grudging acceptance of informed consent toward clinical respect for patient (...) autonomy. (shrink)

When does behavior trigger a lesser claim to medical resources? When does chronic drinking, for example, mean that one has a lesser claim to a liver transplant? Only when one's behavior becomes a callous indifference to others' needs—when one knows the consequences of heavy drinking and knows that by drinking one may end up depriving someone else of a liver.

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)

abstract This article defends luck egalitarianism as an interpretation of the egalitarian ideal against two major criticisms levelled against it by Elizabeth Anderson — that it is trapped in the distributive paradigm, and that it treats the victims of bad option luck too harshly to be considered an egalitarian theory. Against the first criticism, I argue that luck egalitarianism will condemn non‐material inequalities and injustices if an appropriate conception of well‐being is adopted. I demonstrate this by showing how the approach (...) is sensitive to the five faces of oppression developed by Iris Young. Although the second criticism is more troubling, it does not defeat luck egalitarianism, either. I will show that few of the inequalities that arise in the real world result from option luck. Further, if cases do occur, rather than abandoning the theory, the best response is to combine luck egalitarianism with another egalitarian principle that will ensure that the basic needs of all citizens are satisfied. The paper concludes by defending the appeal of the distinction between option luck and brute luck, in light of the preceding discussion. (shrink)