Public health ethicists face two difficult questions. First, what makes something a matter of public health? While protecting citizens from outbreaks of communicable diseases is clearly a matter of public health, is the same true of policies that aim to reduce obesity, gun violence or political corruption? Second, what should the scope of the government’s authority be in promoting public health? May government enact public health policies some citizens reasonably object to or policies that are paternalistic? Recently, some theorists have (...) attempted to address these questions by arguing that something is a matter of public health if and only if it involves a health-related public good, such as clean water or herd immunity. Relatedly, they have argued that appeals to the promotion of public health should only be used to justify the provision of health-related public goods. This public goods conception of public health (PGC) is meant to enjoy advantages over its rivals in three respects: it provides a better definition of public health than rival views, it respects moral disagreement, and it avoids licensing objectionably paternalistic public health policies. We argue, however, that the PGC does just as poorly, or worse, than its rivals in all three respects. (shrink)

This discussion revises and extends Jonny Anomaly's ‘public goods’ account of public health ethics in light of recent criticism from Richard Dees. Public goods are goods that are both non-rival and non-excludable. What is significant about such goods is that they are not always provided efficiently by the market. Indeed, the state can sometimes realize efficiency gains either by supplying such goods directly or by compelling private purchase. But public goods are not the only goods that the market may fail (...) to provide efficiently. This point to a way of broadening the public goods account of public health to accommodate Dees' counterexamples, without abandoning its distinctive appeal. On the market failures approach to public health ethics, the role of public health is to correct public health-related market failures of all kinds, so far as possible. The underlying moral commitment is to economic efficiency in the sense of Pareto: if we can re-allocate resources in the economy so as to raise the welfare of some without lowering the welfare of any other, we ought to do so. (shrink)

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can ‘take responsibility’ for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms (...) of moral responsibility should be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents have prudential reasons to maintain their health, in order to pursue those things which make their lives go well—i.e. that maintenance of a certain level of health is rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion. (shrink)

The notion of individual responsibility has gained prominence in recent debates about health care. First, responsibility has been proposed as a rationing criterion; second, some policies use rewards and sanctions to encourage individuals to ‘take responsibility’ for their health; finally, acting responsibly within the health care system is portrayed as a requirement of reciprocity. The aim of this paper is two-fold. First, I assess these different kinds of appeal to individual responsibility from the perspective of equality. The literature has identified (...) important concerns about equality and fairness with proposals to use individual responsibility as a rationing criterion; I suggest that there are similar concerns about incentive schemes and reciprocity-based appeals to individual responsibility. The analysis will draw on luck egalitarian accounts of equality, which emphasise the importance of individual responsibility. This allows me to pursue the second objective for paper: to reconsider the luck egalitarian perspective on these different appeals to responsibility. Applying the arguments of recent contributions to the luck egalitarian literature to the health arena suggests that luck egalitarians need not support the use of responsibility as a rationing criterion, and they can also identify problems with incentives and reciprocity-based arguments. However, the language of individual responsibility and its prominence in public debates may have implications for individuals’ health and well-being, which raises challenging issues for luck egalitarians as they attempt to apply their theory to the real world. (shrink)

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health – should be considered a social primary (...) good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient. -/- . (shrink)

Citizens in wealthy liberal democracies are typically expected to see to basic needs like food, clothing, and shelter out of their own income, and those without the means to do so usually receive assistance in the form of cash transfers. Things are different with health care. Most liberal societies provide their citizens with health care or health care insurance in kind, either directly from the state or through private insurance companies that are regulated like public utilities. Except perhaps for small (...) co-pays or deductibles, citizens are not expected to see to their health needs out-of-pocket, at least for some basic level of care. Instead, when a citizen gets sick, the state or her insurance company foots the... (shrink)

This article considers attempts to include the issues of ageing and ill health in a Rawlsian framework. It first considers Norman Daniels’ Prudential Lifespan Account, which reduces intergenerational questions to issues of intrapersonal prudence from behind a Rawslian veil of ignorance. This approach faces several problems of idealisation, including those raised by Hugh Lazenby, because it must assume that everyone will live to the same age, undermining its status as a prudential calculation. I then assess Lazenby's account, which applies Rawls’ (...) general theory of justice more directly to healthcare. Lazenby suggests that we should apply Rawls’ difference principle – which claims that any inequalities in social goods must benefit the worst off – to conclude that we should significantly prioritise treatment of young patients. I argue first that the existence of young terminally ill patients undermines a number of Rawlsian arguments for the difference principle. I then argue that the structure of ageing undermines the Rawlsian decision mechanism of the ‘veil of ignorance’ on which Lazenby relies. I conclude that age and terminal illness present significant problems for any comprehensive Rawlsian account of justice. (shrink)

I critically examine a common liberal egalitarian view about the justification for, and proper content of, mandatory health insurance. This view holds that a mandate is justified because it is the best way to ensure that those in poor health gain health insurance on equitable terms. It also holds that a government should mandate what a representative prudent individual would purchase for themselves if they were placed in fair conditions of choice. I argue that this common justification for a mandate (...) is incomplete. A further reason for mandated insurance is that it helps secure social egalitarian public goods that would be underprovided if insurance were optional. I also argue that rather than mandating what a representative individual would choose for themselves, we should design the mandatory package by appealing to a pluralistic egalitarian view, which cares about improving people’s well-being, reducing unfair inequality, and maintaining egalitarian social relations. (shrink)

This is an introductory 2001 textbook on probability and induction written by one of the world's foremost philosophers of science. The book has been designed to offer maximal accessibility to the widest range of students and assumes no formal training in elementary symbolic logic. It offers a comprehensive course covering all basic definitions of induction and probability, and considers such topics as decision theory, Bayesianism, frequency ideas, and the philosophical problem of induction. The key features of this book are a (...) lively and vigorous prose style; lucid and systematic organization and presentation of ideas; many practical applications; a rich supply of exercises drawing on examples from such fields as psychology, ecology, economics, bioethics, engineering, and political science; numerous brief historical accounts of how fundamental ideas of probability and induction developed; and a full bibliography of further reading. (shrink)

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well-being or life-prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other (...) words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality. (shrink)

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free‐Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market failure” in health insurance (...) and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. -/- . (shrink)

There is an idea, extremely common among social contract theorists, that the primary function of social institutions is to secure some form of cooperative benefit. If individuals simply seek to satisfy their own preferences in a narrowly instrumental fashion, they will find themselves embroiled in collective action problems – interactions with an outcome that is worse for everyone involved than some other possible outcome. Thus they have reason to accept some form of constraint over their conduct, in order to achieve (...) this superior, but out-of-equilibrium outcome. A social institution can be defined as a set of norms that codify these constraints.1 Simplifying somewhat, one can then say that social institutions exist in order to secure gains in Pareto-efficiency. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

In the article by Kristin Voigt in the April 2013 issue of Cambridge Quarterly of Healthcare Ethics, quotation marks around certain phrases were deleted.

Health, Luck, and Justice is the first attempt to systematically apply luck egalitarianism to the just distribution of health and health care.

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear and much-needed introduction to (...) this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

In Why Some Things Should Not Be for Sale, philosopher Debra Satz takes a penetrating look at those commodity exchanges that strike most of us as problematic. What considerations, she asks, ought to guide the debates about such markets? What is it about a market involving prostitution or the sale of kidneys that makes it morally objectionable? How is a market in weapons or pollution different than a market in soybeans or automobiles? Are laws and social policies banning the more (...) noxious markets necessarily the best responses to them? Satz contends that categories previously used by philosophers and economists are of limited utility in addressing such questions because they have assumed markets to be homogenous. Accordingly, she offers a broader and more nuanced view of markets--one that goes beyond the usual discussions of efficiency and distributional equality--to show how markets shape our culture, foster or thwart human development, and create and support structures of power. (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)

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)

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in (...) different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research. (shrink)

oise Baylis, 1234 Le Marchant Street, Halifax, Nova Scotia, Canada B3H 3P7. Tel.: (902)-494–2873; Fax: (902)-494-2924; Email: francoise.baylis{at}dal.ca ' + u + '@' + d + ' '//--> . Abstract Recently, there has been a growing interest in public health and public health ethics. Much of this interest has been tied to efforts to draw up national and international plans to deal with a global pandemic. It is common for these plans to state the importance of drawing upon a well-developed (...) ethics framework and we argue that this framework should reflect the values and insights of feminist relational theory. More specifically, we argue that pandemic planning must be squarely situated in the larger realm of public health and that an ethics framework for public health will be one that recognizes the need to pay particular attention to the vulnerability of subpopulations lacking in social and economic power. We propose an ethics framework for public health that builds on the notions of relational personhood (including relational autonomy and social justice) and relational solidarity. In this way, we aim for a public health ethics that, as appropriate, promotes the public interest and the common good. CiteULike Connotea Del.icio.us What's this? (shrink)

One widely accepted way of justifying universal access to health care is to argue that access to health care is necessary to ensure health, which is necessary to provide equality of opportunity. But the evidence on the social determinants of health undermines this argument.

: Bioethics has focused principally on ethical issues arising in clinical medicine. When it has addressed justice or equity, it has focused on access to health care and on defending a general moral right to health care. This dual focus on establishing a right to health care and on health care rather than health has left bioethics largely silent on two issues of fundamental importance for a full account of justice and health. First, the focus on establishing a right to (...) health care has contributed to a failure to address difficult issues in developing ethical standards for equitably prioritizing limited resources in health care. Second, the focus on inequalities in access to health care has ignored the much greater impact of social determinants of health, in particular socioeconomic class and inequality, on health and health inequalities. Bioethics must broaden its agenda. (shrink)

This chapter contains sections titled: Is There a Right to Health Care? What Does a Right to Health Care Include? Choice or Consent and the Exercise of our Right to Health Care References.

The goal of this article is modest. It is simply to help illuminate the nature of egalitarianism. More particularly, I aim to show what certain egalitarians are committed to, and to suggest that equality, as these egalitarians understand it, is an important normative ideal that cannot simply be ignored in moral deliberations. In doing this, I distinguish between equality as universality, equality as impartiality, and equality as comparability, and also between instrumental and non-instrumental egalitarianism. I then characterise the version of (...) egalitarianism with which I am concerned, which I call equality as comparative fairness. I discuss the relations between equality, fairness, luck, and responsibility, and defend egalitarianism against rival views that focus on subsistence, sufficiency, or compassion. I also defend egalitarianism against the Levelling Down and Raising Up Objections, and present several key examples to illustrate egalitarianism's distinct appeal, in contrast to prioritarianism's. I conclude by considering two common questions about my view: first, whether my ultimate concern is really with comparative fairness, rather than equality, so that my view is not, in fact, a substantive, non-instrumental version of egalitarianism, and second, whether my view ultimately reduces to a theory about desert. (shrink)

This 1987 book offers a critique of the liberal theory of the state, focusing on a detailed study of cooperation in the absence of the state and of other kinds of coercion. The discussion includes an analysis of collective action and of the Prisoners' Dilemma supergame. It is a revised and expanded edition of the author's classic work of rational choice theory Anarchy and Cooperation, originally published with John Wiley in 1976. The analysis has been recast and developed here to (...) make it more accessible to non-mathematical readers and to provide a more comprehensive and self-contained treatment of the theory of collective action. The book will be of interest to a range of readers in political and social philosophy and in economics. (shrink)