Temkin asks how we should distribute resources between the social determinants of health and health care; Sreenivasan argues that if our goal is fair opportunity, funding universal health coverage is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly than he claims: it applies to any argument for UHC based on health (...) equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given what Sen calls the multidimensional nature of health equity and the role of UHC in cost containment, UHC may not be a threat to health equity. I also argue against Sreenivasan's claim that the data he discusses should not trouble sufficientists and prioritarians. The worst-off are not simply lagging in improvement; rather, their health status is stagnating or worsening. (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)

The article presents two main arguments. First, we claim that in contemporary societies, insurance enacts peculiar kinds of solidarities as well as inequality and exclusion. Especially important in this respect are life, health, disability and old age pension insurance, both in compulsory and voluntary forms. Second, the article maintains that the ideas of solidarity, inequality and exclusion are transformed by the machinery of insurance. In other words, the concrete ways in which insurance relations are practically arranged have an effect on (...) the ways in which the related moral and political concepts are perceived. We elaborate on three different forms of insurance solidarity, which we call chance, risk and income solidarity. The existence of multiple forms of solidarity relevant to insurance is significant because practices of insurance require decisions concerning what kind of solidarity is emphasised, when it is emphasised, and on what grounds. Moreover, what is solidarity for some can entail exclusion and inequality for others. Showing these internal tensions within insurance practice underlines the inherently political and moral nature of insurance. (shrink)

This article sets out the moral failure of single-tier basic healthcare. Single-tier basic healthcare has been advocated on the grounds that the provision of healthcare should be divorced from ability to pay and unequal access to basic healthcare is morally intolerable. However, single-tier basic healthcare encounters a host of catastrophic moral failings. Given the fact of human pluralism it is impossible to objectively define “basic” healthcare. Attempts to provide single-tier healthcare therefore become political processes in which interest groups compete for (...) control of scarce resources with the most privileged possessing an inherent advantage. The focus on outputs in arguments for single-tier provision neglects the question of justice between individuals when some people provide resources for others without reciprocal benefits. The principle that only healthcare that can be provided to everyone should be provided at all leads to a leveling-down problem in which advocates of single-tier provision must prefer a situation where some individuals are made worse-off without any individual being made better-off compared to plausible multi-tier alternatives. Contemporary single-tier systems require the exclusion of noncitizens, meaning that their universalism is a myth. In the light of these pathologies, it is judged that multi-tier healthcare is morally required. (shrink)

John Broome; V*—Fairness, Proceedings of the Aristotelian Society, Volume 91, Issue 1, 1 June 1991, Pages 87–102, https://doi.org/10.1093/aristotelian/91.1.87.

Needs, Values, Truth brings together of some of the most important and influential writings by a leading contemporary philosopher, drawn from twenty-five years of his work in the broad area of the philosophy of value. The author ranges between problems of ethics, meta-ethics, philosophy of mind, and philosophy of logic and language, looking at questions relating to meaning, truth and objectivity in judgements of value. For this third edition he has added a new essay on incommensurability, in addition to making (...) minor revisions to the existing text. The volume will stand as a definitive summation of his work in this area. (shrink)

In recent years there has been a good deal of discussion of equality’s place in the best account of distribution or distributive justice. One central question has been whether egalitarianism should give way to a principle requiring us to give priority to the worse off. In this article, I shall begin by arguing that the grounding of equality is indeed insecure and that the priority principle appears to have certain advantages over egalitarianism. But I shall then claim that the priority (...) principle itself is ungrounded and that the priority principle should itself give way to a sufficiency principle based — indirectly, via the notion of an impartial spectator — on compassion for those who are badly off. (shrink)

Solidarity is a significant but poorly understood feature of political life. It is typically conceived, in “associative and teleological” terms, as working together for common political aims. But this conception misses the fact that solidarity requires individuals to will collective ends despite incompletely shared interests. Careful consideration of these elements reveals four “dynamics of solidarity”: its characteristic duties, the durability of commitments made in solidarity, the deference it involves, and its effects over time on agents’ habits and capacities. In this (...) article I describe these dynamics, first contrasting solidarity-given duties with duties of beneficence, justice, and loyalty. These contrasts lay bare the distinctive durability of solidarity, which differs from both the liberal’s commitment to justice and the loyalist’s commitment to the group. I then discuss deference, a feature of solidarity that has implications for individual engagement in political life more generally. Finally, I discuss the effects of solidarity on agents’ intellectual and physical capacities. I conclude by drawing out implications of these dynamics, challenging Tommie Shelby’s influential conception and justification of black solidarity and buttressing Philip Soper’s rejection of the Principle of Autonomy. (shrink)

John Broome; V*—Fairness, Proceedings of the Aristotelian Society, Volume 91, Issue 1, 1 June 1991, Pages 87–102, https://doi.org/10.1093/aristotelian/91.1.87.

n this paper, I argue that political solidarity is important to justice. At its core, political solidarity is a relational concept. To be in a relation of political solidarity, is to be in a relation of connection or unity with one’s fellow citizens. I argue that fellow citizens can be said to stand in such a relation when they have attitudes of collective identification, mutual respect, mutual trust, and mutual support and loyalty toward one another. I argue that political solidarity, (...) so conceived, is an integral element of a theory of justice. I argue that there are distinctly social bases for political solidarity and that justice requires that we promote these. Furthermore, as an example of the sort of social and political arrangements that might encourage political solidarity, I discuss Canada’s response to the recent H1N1 pandemic and the failings of this response with respect to members of the Aboriginal community within Canada. I argue that ensuring that members of the Aboriginal community had equal access to the goods they needed to protect themselves against H1N1 infection would have promoted relations of political solidarity and, in turn, would have promoted justice more effectively. (shrink)

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the conceptual specification of health system boundaries and (...) on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries. (shrink)

Recent work has stressed the importance of the concept of solidarity to bioethics and social philosophy generally. But can and should it feature in documents such as the Universal Declaration on Bioethics and Human Rights as anything more than a vague notion with multiple possible interpretations? Although noting the tension between universality and particularity that such documents have to deal with, and also noting that solidarity has a political content, the paper explores the suggestion that solidarity should feature more centrally (...) in international regulations. The paper concludes with the view that when solidarity is seen aright, the UDBHR is an implicitly solidaristic document. (shrink)

abstract The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this (...) account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting‐point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs‐based priority setting to social welfare maximisation. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two (...) distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

The principle that people's lives and fundamental interests are of equal value and that they must therefore be given equal weight has immense intellectual appeal and intuitive force. It is often enough to discredit a theory or proposal simply to show that it violates this principle. When measures are said to be discriminatory or unfair it is this principle which is in play. Recent philosophers of widely differing schools and outlooks give versions of this principle a central role in their (...) theories. (shrink)

Recognising and responding to injustices that benefit us is a pervasive problem of contemporary life, and arguably a mark of moral seriousness in anyone who presumes to take moral stands at all. In response, a number of authors have defended the view that such benefits normally bring with them prima facie obligations of compensation. This ‘wrongful-benefits’ approach has considerable intuitive plausibility, much of it founded in the financial metaphor that gives it an appearance of precision. Yet while the compensation scenario (...) works reasonably well in one-off cases such as receiving stolen property, it yields incoherent results when facing ongoing structural injustices. In such cases ‘innocence’ is ambiguous and our status as beneficiaries and victims is complex. In contrast, solidarity — understood as a principle of equity requiring that we side with the least well off — provides a better account of duties to respond to structural injustice. In solidarity the agent follows the lead of organised out-groups and defers to their judgment about collective actions to overcome injustice. Solidarity leads us to support the organised group that suffers from the greatest inequity. Solidarity does not use a financial metaphor and thus it neither requires full disgorgement, nor absolves us of further action when we reach the point of net-zero benefit. Rather, solidarity is a principal means for ordinary citizens to promote equity by affirming the equal status of the victims, and to atone for having benefited from injustice, whether they did so willingly or otherwise. (shrink)

This paper explores how medical practice ought to be conducted, in the face of scarcity, if our objective is to maximise the benefits of health. After explaining briefly what the cost-per-QALY criterion means, a series of ethical objections to it are considered one by one. The objectors fall into four groups: a. those who reject all collective priority-setting as unethical; b. those who accept the need for collective priority-setting, but believe it is contrary to medical ethics; c. those who accept (...) the need for collective priority-setting, and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it; d. those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. -/- The purpose of this discussion paper is to give each group a hard time! (shrink)