Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive resource (...) allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics. (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 authors in ethics, economics, and political science endorse the Lottery Requirement, that is, the following thesis: where different parties have equal moral claims to one indivisible good, it is morally obligatory to let a fair lottery decide which party is to receive the good. This article defends skepticism about the Lottery Requirement. It distinguishes three broad strategies of defending such a requirement: the surrogate satisfaction account, the procedural account, and the ideal consent account, and argues that none of these (...) strategies succeed. The article then discusses and discharges some remaining grounds for resistance to these skeptical conclusions, as well as the possibility of defending a weaker version of a normative lottery principle. The conclusion is that we have no reason to believe that where equal claims conflict, we are morally required to hold a lottery, as opposed to simply picking one of the parties on more subjective grounds or out of pure whim. In addition to the practical consequences of this skeptical view, the article sketches some theoretical implications for debates about saving the greater number and about axiomatic utilitarianism. (shrink)

In recent years some moral philosophers and political theorists, who have come to be called “luck egalitarians,” have urged that the essence of social justice is the moral imperative to improve the condition of people who suffer from simple bad luck. Prominent theorists who have attracted the luck egalitarian label include Ronald Dworkin, G. A. Cohen, and John Roemer.1 Larry Temkin should also be included in this group, as should Thomas Nagel at the time that he wrote Equality and Partiality.2 (...) However, each of these theorists asserts a different position. The common ground, if any, is obscure. The idea of luck that is invoked is not transparently clear. Anyway, the term “luck egalitarianism” was coined by a critic of the doctrine, and tendentiously defined to denote an extreme version of the view that looks implausible from the start.3 With some justice Ronald Dworkin, perhaps the chief architect of the luck egalitarian position, has denied that he is a luck egalitarian. (shrink)

Luck egalitarianism is the view that equality requires the influence of luck on distributive outcomes to be neutralized. The standard version of the view, brute-luck egalitarianism, neutralizes brute luck (the upshot of non-declinable risks) while allowing option luck (the upshot of declinable risks) to stand. This article argues that this view should be rejected in favour of all-luck egalitarianism, which neutralizes brute luck and option luck alike. There are three parts to this overall argument. The first shows that brute-luck egalitarianism’s (...) reasons for neutralizing brute luck’s distributive effects should lead it to also neutralize a subset of option luck. The second demonstrates that various revisions of brute-luck egalitarianism such that it neutralizes this subset (and related ones) are ultimately unsuccessful. The third defends the remaining option of neutralizing option luck generally, as all-luck egalitarianism proposes. (shrink)

In recent work, Norman Daniels extends the application of Rawls's principle of ‘fair equality of opportunity’ from health care to health proper. Crucial to that account is the view that health care, and now also health, is special. Daniels also claims that a rival theory of distributive justice, namely luck egalitarianism (or ‘equal opportunity for welfare’), cannot provide an adequate account of justice in health and health care. He argues that the application of that theory to health policy would result (...) in an account that is, in a sense, too narrow, for it denies treatment to imprudent patients (e.g. lung cancer patients who smoked). In a different sense, Daniels argues, luck egalitarian health policy would be too wide: it arguably tells us to treat individuals for such brute-luck conditions as shyness, stupidity, ugliness, and having the ‘wrong’ skin colour. I seek to advance three claims in response to Daniels's revised theory, and in defence of a luck egalitarian view of health policy. First, I question Daniels's assertion regarding the specialness of health. While he is right to abandon his insistence on the specialness of health care, it is doubtful that health proper can be depicted as special. Second, I try and meet Daniels's objections to luck egalitarianism. Luck egalitarian health policy escapes being too narrow for it does not in fact require denying basic care to imprudent patients. As for it being allegedly too wide, I try to show that it is not, after all, counterintuitive to rid individuals of unfortunate and disadvantageous biological traits (say, a disadvantageous skin colour). And third, I question whether Daniels's own Rawlsian account is in fact wide enough. I argue that fair equality of opportunity fails to justify some standard medical procedures that many health systems do already practice. (shrink)

Lotteries have long been used to resolve competing claims, yet their recent implementation to allocate school places in Brighton and Hove, England led to considerable public outcry. This article argues that, given appropriate selection is impossible when parties have equal claims, a lottery is preferable to an auction because it excludes unjust influences. Three forms of contractualism are discussed and the fairness of lotteries is traced to the fact that they give each person an equal chance, as a surrogate for (...) their equal claim to the good. It is argued that this can be a reason to favour an artificially-constructed lottery to a 'natural' lottery where there is suspicion that the latter may be biased. (shrink)

Background The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario’s protocols were presented to the public in a democratic deliberation during the summer of 2022. Objectives (1) To explore the perspectives of Quebec and Ontario (...) citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. Methods This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. Results A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value – a less acceptable tiebreaker. Conclusion Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria. (shrink)

Rawls’s difference principle and the position dubbed ‘luck egalitarianism’ are often viewed as competing theories of distributive justice. However, recent work has emphasised that Rawlsians and luck egalitarians are working with different understandings of the concept of justice, and thus not only propose different theories, but different theories of different things. Once they are no longer seen in direct competition, there are some questions to be asked about whether these two theories can be consistently endorsed alongside one another. In this (...) essay, I (begin to) investigate whether Rawls’s theory (or elements of it) and (some form of) luck egalitarianism can be consistently endorsed. -/- I begin by outlining the main aspects of Rawls’s theory and luck egalitarianism, showing them to be different kinds of theory and therefore not in direct competition. I then propose an understanding of how these ideas came to be seen to be in direct competition. Finally, I outline five different ways in which one might consistently be (some kind of) a luck egalitarian and (some kind of) a Rawlsian, and try to say something about what is to be said for and against each of these ways of combining the theories. (shrink)

Luck egalitarianism — the theory that makes individual responsibility central to distributive justice, so that bad luck underwrites a more compelling case for redistribution than do the bad choices of the disadvantaged — has recently come under a sustained attack from critics who are deeply committed to the broader struggle for equality. These egalitarian critics object, first, that luck egalitarianism’s policy recommendations are often unappealing. Second, they add that luck egalitarianism neglects the deep political connection between equality and non-subordination, in (...) favor of a shallowly distributive regime. This Article argues that both objections to luck egalitarianism have been exaggerated. Insofar as the criticisms are accurate, they apply only to a particular, maximalist strand of luck egalitarianism, whose distributive principle does not merely adjust allocations in light of responsibility but instead proposes that allocations should precisely track responsibility. However, this responsibility-tracking view does not represent the best or truest development of the basic luck egalitarian ideal. Moreover, the pathologies of the responsibility-tracking view help to cast the appeal of more judicious luck egalitarianism into sharp relief. The redistributive policies that more moderate developments of luck egalitarianism recommend are less objectionable than critics have supposed. And, more importantly, such modest luck egalitarianism is not a purely distributive ideal but instead contains, at its core, a vision of political solidarity among free and equal citizens. (shrink)

Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account (...) is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested. (shrink)