Whether it is fair to use personal responsibility of patients for their own health as a rationing criterion in healthcare is a controversial matter. A host of difficulties are associated with the concept of personal responsibility in the field of medicine. These include, in particular, theoretical considerations of justice and such practical issues as multiple causal factors in medicine and freedom of health behaviour. In the article, personal responsibility is evaluated from the perspective of several theories of justice. It is (...) argued that in a healthcare system based on both equality of opportunity and solidarity, responsible health behaviour can—in principle—be justifiably expected. While the practical problems associated with personal responsibility are important, they do not warrant the common knee-jerk refusal to think more deeply about responsibility for health as a means of allocating healthcare resources. In conclusion, the possibility of introducing personal responsibility as a fair rationing criterion is briefly sketched. (shrink)

This paper reconsiders some themes and arguments from my earlier paper “Fairness, Respect and the Egalitarian Ethos.” That work is often considered to be part of a cluster of papers attacking “luck egalitarianism” on the grounds that insisting on luck egalitarianism's standards of fairness undermines relations of mutual respect among citizens. While this is an accurate reading, the earlier paper did not make its motivations clear, and the current paper attempts to explain the reasons that led me to write the (...) earlier paper, assesses the force of its arguments, and locates it in respect to work of Richard Arneson and Elizabeth Anderson. The paper concludes by bringing out what now appears to be the main message of the earlier paper: that the attempt to implement an “ideal” theory of equality can harm the very people that the theory is designed to help. (shrink)

In some places consumption of alcohol raises serious public health issues. One recent proposal for addressing these issues has been to set a minimum price at which a unit of alcohol can be sold. In this paper I argue that such a policy, while it may have substantial health benefits, is ethically problematic. This is primarily because it unfairly places considerable burdens on those already most disadvantaged in society. In addition, such policies are poorly targeted if our concern is with (...) preventing the harms drinkers pose to other people. (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.

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)

Geoffrey Rose's ‘prevention paradox’ occurs when a population-based preventative health measure that brings large benefits to the community – such as compulsory seatbelts, a ‘fat tax’, or mass immunisation – offers little to each participating individual. Although the prevention paradox is not obviously a paradox in the sense in which philosophers understand the term, it does raise important normative questions. In particular, should we implement population-based preventative health measures when the typical individual is not expected to gain from them? After (...) canvassing other attempts to address the paradox, I argue that what is significant about the prevention paradox is that it involves intra-personal trade-offs; the costs and benefits of the choice to implement or not implement a preventative health measure fall on the same individuals. The intra-personal nature of these trade-offs has two implications. First, the solutions to the paradox proposed by other authors are deficient. Second, the policy choice to not implement some preventative health measures can be normatively justified. (shrink)

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

The aim of this article is to argue that ontological choices in scientific practice undermine common formulations of the value-free ideal in science. First, I argue that the truth values of scientific statements depend on ontological choices. For example, statements about entities such as species, race, memory, intelligence, depression, or obesity are true or false relative to the choice of a biological, psychological, or medical ontology. Second, I show that ontological choices often depend on non-epistemic values. On the basis of (...) these premises, I argue that it is often neither possible nor desirable to evaluate scientific statements independently of non-epistemic values. Finally, I suggest that considerations of ontological choices do not only challenge the value-free ideal but also help to specify positive roles of non-epistemic values in an often neglected area of scientific practice. (shrink)

The aim of this article is to argue that ontological choices in scientific practice undermine common formulations of the value-free ideal in science. First, I argue that the truth values of scientific statements depend on ontological choices. For example, statements about entities such as species, race, memory, intelligence, depression, or obesity are true or false relative to the choice of a biological, psychological, or medical ontology. Second, I show that ontological choices often depend on non-epistemic values. On the basis of (...) these premises, I argue that it is often neither possible nor desirable to evaluate scientific statements independently of non-epistemic values. Finally, I suggest that considerations of ontological choices do not only challenge the value-free ideal but also help to specify positive roles of non-epistemic values in an often neglected area of scientific practice. (shrink)

This paper argues that societal duties of health promotion are underwritten (at least in large part) by a principle of beneficence. Further, this principle generates duties of justice that correlate with rights, not merely “imperfect” duties of charity or generosity. To support this argument, I draw on a useful distinction from bioethics and on a somewhat neglected approach to social obligation from political philosophy. The distinction is that between general and specific beneficence; and the approach from political philosophy has at (...) times been called equality of concern. After clarifying the distinction and setting out the basis of the equality of concern view, I argue that the result is a justice-based principle of “specific” beneficence that should be reflected in a society’s health policy. I then draw on this account to criticize, refine, and extend some prominent health care policy proposals from the bioethics literature. (shrink)

Geoffrey Rose’s prevention paradox points to a tension between two prima facie plausible moral principles: that we should save the greater number and that weshould save the most at risk. This paper argues that a novel moral theory, ex-ante contractualism, captures our intuitions in many prevention paradox cases, regardless of our interpretation of probability claims. However, it goes on to show that it might be impossible to square ex-ante contractualism with all of our moral intuitions. It concludes that even if (...) ex-ante contractualism cannot furnish an entire ethics of risk, it does identify important considerations for any such theory. (shrink)

Geoffrey Rose’s prevention paradox points to a tension between two prima facie plausible moral principles: that we should save the greater number and that weshould save the most at risk. This paper argues that a novel moral theory, ex-ante contractualism, captures our intuitions in many prevention paradox cases, regardless of our interpretation of probability claims. However, it goes on to show that it might be impossible to square ex-ante contractualism with all of our moral intuitions. It concludes that even if (...) ex-ante contractualism cannot furnish an entire ethics of risk, it does identify important considerations for any such theory. (shrink)

Pre-natal-diagnosis technologies allow parents to discover whether their child is likely to suffer from serious disability. One argument for state funding of access to such technologies is that doing so would be “cost-effective”, in the sense that the expected financial costs of such a programme would be outweighed by expected “benefits”, stemming from the births of fewer children with serious disabilities. This argument is extremely controversial. This paper argues that the argument may not be as unacceptable as is often assumed. (...) In doing so, it sets out a more general framework for assessing the relevance of efficiency calculations to policy-making. The final section also investigates the relationship between the paper’s arguments and claims about parental responsibility for child-bearing and rearing, with reference to Scanlon’s work on “substantive responsibility”. (shrink)

Pre-natal-diagnosis technologies allow parents to discover whether their child is likely to suffer from serious disability. One argument for state funding of access to such technologies is that doing so would be “cost-effective”, in the sense that the expected financial costs of such a programme would be outweighed by expected “benefits”, stemming from the births of fewer children with serious disabilities. This argument is extremely controversial. This paper argues that the argument may not be as unacceptable as is often assumed. (...) In doing so, it sets out a more general framework for assessing the relevance of efficiency calculations to policy-making. The final section also investigates the relationship between the paper’s arguments and claims about parental responsibility for child-bearing and rearing, with reference to Scanlon’s work on “substantive responsibility”. (shrink)

Readers of this book are sure to view the ethics of incentives in a new light.

Policy-makers must sometimes choose between an alternative which has somewhat lower expected value for each person, but which will substantially improve the outcomes of the worst off, or an alternative which has somewhat higher expected value for each person, but which will leave those who end up worst off substantially less well off. The popular ex ante Pareto principle requires the choice of the alternative with higher expected utility for each. We argue that ex ante Pareto ought to be rejected (...) because it conflicts with the requirement that, when possible, one ought to decide as one would with full information. We apply our argument in an analysis of US policy on screening for breast cancer. -/- . (shrink)