Social inequalities in health in the UK persist despite attempts to reduce them. We argue that work and pensions constitutes an area of intervention where there is potential to make change happen. We propose that workers who are exposed to significant health risks through their occupation should be allowed to draw their state pension earlier, based on a minimum number of years in the workforce. We model this proposal on similar policies in other European countries. In our modification, the pension (...) age and the retirement age would be separated, such that workers can receive a state pension whether or not they choose to continue working. This arrangement may encourage workers either to reduce their working hours or to change to less demanding or harmful work. The health of these workers would thereby benefit from reduced exposure to a harmful work environment, reduced stress and more opportunities for rest and relaxation. However, it has also been suggested that retirement is bad for mental health. In response, our proposal enables workers to phase in full retirement over a period of part-time work, and we believe that this would counter any potential negative effects on health caused by retirement. (shrink)

Political philosophers have become increasingly interested in questions of justice as applied to health. Much of this literature works from a distributive understanding of justice. In the recent debate, however, ‘relational’ egalitarians have proposed a different way of conceptualising equality, which focuses on the quality of social relations among citizens and/or how social institutions ‘treat’ citizens. This paper explores some implications of a relational approach to health, with particular focus on health care, health inequalities and health policy. While the relational (...) account can add interesting perspectives to current debates on justice and health, we also highlight some tensions and difficulties relational egalitarians might encounter and some discontinuities between the implications of a relational account and current discourse on health equity. (shrink)

Relational views of equality put forward a social and political ideal of equality that aims at being a better interpretation of what social justice requires than the prevailing distributive conceptions of equality, especially luck egalitarian views. Yet it is unclear what social justice as relational equality demands in distributive terms; Elizabeth Anderson's view seems to vacate a large part of the terrain of distributive justice in favor of a minimalist, sufficiency view. Against that, this paper argues that relational equality, properly (...) understood, requires setting stringent limits to distributive inequality, for both intrinsic and instrumental reasons. First, the relational egalitarian conception of society as a cooperative enterprise among equals gives rise to a presumption of equality in socially produced goods (and bads); inequalities in these goods have to be justified by justice-relevant reasons. Second, relational egalitarianism also delivers instrumental reasons to limit inequalities in income, wealth, and opportunities, because such inequalities may generate both opportunities for domination and inegalitarian status norms that threaten the social bases of self-respect of the worse off. (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)

Numa sociedade democrática, as regras sociais são impostas a cada um por todos. Como “recebedores” de tais regras, tendemos a pensar que elas deviam ser designadas para engendrar a melhor distribuição possível de bens e males ou qualidade de vida. Enquanto autores das regras, tendemos a pensar que os malefícios por nós impostos através de tais regras têm maior peso moral que os danos que nós meramente deixamos de evitar ou mitigar. Embora as atuais teorias sejam dominadas pela primeira perspectiva, (...) uma concepção adequada da justiça exige um balanceamento de ambas tendências. O tema da equidade na saúde é bem apropriado para mostrar como concepções da justiça puramente dirigidas aos recebedores estão fadadas ao fracasso e como esboçar uma alternativa mais promissora. (shrink)

Much contemporary egalitarian theorizing is broadly divided between luck egalitarians, such as G. A. Cohen, Richard Arneson, and John Roemer, and relational egalitarians, such as John Rawls, Samuel Scheffler, Josh Cohen, and me. The two camps disagree about how to conceive of equality: as an equal distribution of non-relational goods among individuals, or as a kind of social relation between persons - an equality of authority, status, or standing.This disagreement generates a second, about when unequal distributions of non-relational goods are (...) unjust. Luck egalitarians claim that inequality is unjust when it is accidental: when it is caused by morally arbitrary factors such as circumstances of birth. Relational egalitarians claim that inequality is unjust when it disadvantages people: when it reflects, embodies, or causes inequality of authority, status, or standing. (shrink)

Much of the philosophical literature on health inequalities seeks to establish the superiority of one or another conception of luck egalitarianism. In recent years, however, an increasing number of self-avowed egalitarian philosophers have proposed replacing luck egalitarianism with alternatives that stress the moral relevance of distinct relationships, rather than the moral relevance of good or bad luck. After briefly explaining why I am not attracted to luck egalitarianism, I seek in this chapter to distinguish and clarify three views that have (...) been characterized in the philosophical literature as forms of relational egalitarianism. I call these three relational views equality of treatment, equality of concern, and social egalitarianism. I will explain why each claims to be a form of egalitarianism and why these three views should not be seen as competitors. I will argue that each brand of relational egalitarianism describes a plausible plank of distributive justice that bears on the evaluation of health inequalities and on the political institutions that create, sustain, or exacerbate them. To illustrate this pluralistic relational egalitarian approach, I will draw on a case study by Horton and Barker (this volume) to discuss how each of the three planks might be brought to bear on the evaluation of oral health disparities among the children of migrant Latino farmworkers in California. (shrink)

Social factors have a powerful influence on human health and longevity. Yet the social dimensions of health are often obscured in public discussions due to the overwhelming focus in health policy on medical care, individual-level risk factor research, and changing individual behaviours. Likewise, in philosophical approaches to health and social justice, the debates have largely focused on rationing problems in health care and on personal responsibility. However, a range of events over the past two decades such as the study of (...) modern famines, the global experience of HIV/AIDS, the international women’s health movement, and the flourishing of social epidemiological research have drawn attention to the robust relationship between health and broad social arrangements. In Health Justice, Sridhar Venkatapuram takes up the problem of identifying what claims individuals have in regard to their health in modern societies and the globalized world. Recognizing the social bases of health and longevity, Venkatapuram extends the ‘Capabilities Approach’ of Amartya Sen and Martha Nussbaum into the domain of health and health sciences. In so doing, he formulates an inter-disciplinary argument that draws on the natural and social sciences as well as debates around social justice to argue for every human being’s moral entitlement to a capability to be healthy. An ambitious integration of the health sciences and the Capabilities Approach, Health Justice aims to provide a concrete ethical grounding for the human right to health, while advancing the field of health policy and placing health at the centre of social justice theory. With a foreword by Sir Michael Marmot, chair of the WHO Commission on the Social Determinants of Health. (shrink)

What does it mean to be disadvantaged? Is it possible to compare different disadvantages? What should governments do to move their societies in the direction of equality, where equality is to be understood both in distributional and social terms? Linking rigorous analytical philosophical theory with broad empirical studies, including interviews conducted for the purpose of this book, Wolff and de-Shalit show how taking theory and practice together is essential if the theory is to be rich enough to be applied to (...) the real world, and policy systematic enough to have purpose and justification. The book is in three parts. Part 1 presents a pluralist analysis of disadvantage, modifying the capability theory of Sen and Nussbaum to produce the 'genuine opportunity for secure functioning' view. This emphasises risk and insecurity as a central component of disadvantage. Part 2 shows how to identify the least advantaged in society even on a pluralist view. The authors suggest that disadvantage 'clusters' in the sense that some people are disadvantaged in several different respects. Thus identifying the least advantaged is not as problematic as it appears to be. Conversely, a society which has 'declustered disadvantaged' - in the sense that no group lacks secure functioning on a range of functionings - has made considerable progress in the direction of equality. Part 3 explores how to decluster disadvantage, by paying special attention to 'corrosive disadvantages' - those disadvantages which cause further disadvantages - and 'fertile functionings' - those which are likely to secure other functionings. In sum this books presents a refreshing new analysis of disadvantage, and puts forward proposals to help governments improve the lives of the least advantaged in their societies, thereby moving in the direction of equality. (shrink)