Winner of the 1975 National Book Award, this brilliant and widely acclaimed book is a powerful philosophical challenge to the most widely held political and social positions of our age--liberal, socialist, and conservative.

What is a fair distribution of resources and other goods when individuals are partly responsible for their achievements? This book develops a theory of fairness incorporating a concern for personal responsibility, opportunities and freedom. With a critical perspective, it makes accessible the recent developments in economics and philosophy that define social justice in terms of equal opportunities. It also proposes new perspectives and original ideas. The book separates mathematical sections from the rest of the text, so that the main concepts (...) and ideas are easily accessible to non-technical readers. -/- It is often thought that responsibility is a complex notion, but this monograph proposes a simple analytical framework that makes it possible to disentangle the different concepts of fairness that deal with neutralizing inequalities for which the individuals are not held responsible, rewarding their effort, respecting their choices, or staying neutral with respect to their responsibility sphere. It dwells on paradoxes and impossibilities only as a way to highlight important ethical options and always proposes solutions and reasonable compromises among the conflicting values surrounding equality and responsibility. -/- The theory is able to incorporate disincentive problems and is illustrated in the examination of applied policy issues such as: income redistribution when individuals may be held responsible for their choices of labor supply or education; social and private insurance when individuals may be held responsible for their risky lifestyle; second chance policies; the measurement of inequality of opportunities and social mobility. (shrink)

In his Tanner Lecture of 1979 called ‘Equality of What?’ Amartya Sen asked what metric egalitarians should use to establish the extent to which their ideal is realized in a given society. What aspect of a person’s condition should count in a fundamental way for egalitarians, and not merely as cause of or evidence of or proxy for what they regard as fundamental?

Commodities and Capabilities presents a set of inter-related theses concerning the foundations of welfare economics, and in particular about the assessment of personal well-being and advantage. The argument presented focuses on the capability to function, i.e. what a person can do or can be, questioning in the process the more standard emphasis on opulence or on utility. In fact, a person's motivation behind choice is treated here as a parametric variable which may or may not coincide with the pursuit of (...) self-interest. Given the large number of practical problems arising from the roles and limitations of different concepts of interest and the judgement of advantage and well-being, this scholarly investigation is both of theoretical interest and practical import. (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)

Background: Some members of the general public feel that patients who cause their own organ failure through smoking, alcohol use, or drug use should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) cause their own illness, (2) have poor transplant prognoses or, (3) are simply unworthy. We explore the role that social acceptability, personal responsibility, and prognosis play in people's judgments about transplant allocation. Methods: By random allocation, we presented 283 prospective (...) jurors in Philadelphia county with one of five questionnaire versions. In all questionnaires, subjects were asked to distribute transplantable hearts between patients with and without a history of three controversial behaviors (eating high fat diets against doctors’ advice, cigarette smoking, or intravenous drug use). Across the five questionnaire versions, we varied the relative prognosis of the transplant candidates and whether their behavior caused their primary organ Results: Subjects were significantly less willing to distribute organs to intravenous drug users than to cigarette smokers or people eating high fat diets (p le; 0.0005), even when intravenous drug users had better transplant outcomes than other patients. Subjects’ allocation decisions were influenced by transplant prognosis, but not by whether the behavior in question was causally responsible for the patients’ organ failure. Conclusion: People's unwillingness to give scarce transplantable organs to patients with controversial behaviors cannot be explained totally on the basis of those behaviors either causing their primary organ failure or making them have worse transplant prognoses. Instead, many people believe that such patients are simply less worthy of scarce transplantable organs. (shrink)

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 article defends the principle of giving a fresh start to individuals who come to consider that they have mismanaged their share of resources at an earlier stage of their life. The first part challenges the ethical intuition that it would be unfair to tax the steadfast frugal in order to help the regretful spendthrift and argues that the possibility of changing one’s mind is an important freedom. The second part examines the disincentives induced by fresh-start policies. It shows that (...) even when individuals can strategically misrepresent their preferences, there remains a significant difference between unforgiving and forgiving policies. It shows that the optimal policy does not only redistribute funds, but also puts protective constraints on early individual decisions (for example, compulsory saving through social security taxes). Key Words: fairness • freedom • fresh start • incentives • preference changes • regret. (shrink)

Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to blame, are spent on prevention or treatment of disease that could be avoided through individual lifestyle changes. This may encourage policy makers and health care professionals to opt for a criterion of individual responsibility for medical suffering when setting priorities. The following article asks whether responsibility-based reasoning should be accepted as (...) relevant for fair and legitimate healthcare rationing. The luck-egalitarian argument that inequalities in health expectancies that derive from unchosen features of people’s circumstances are unjust and should be compensated, while inequalities that reflect personal choices of lifestyle may not, is discussed. It seems that while a backward-looking interpretation of individual responsibility cannot be relevant as a criterion of priority setting, a forward-looking conception of responsibility may be approved.Within all modern societies healthcare authorities are facing difficult priority setting problems. Various criteria for rationing medical intervention have been proposed due to scarcity of resources. Until now, individual responsibility for medical suffering has been given little attention in the public or in academic debate. This is about to change. As Alexander Cappelen and Ole Norheim have pointed out in a recent article in this journal, unhealthy lifestyle contributes increasingly to the burden of disease. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge.1 In this article the following question is addressed: should responsibility-based arguments be accepted as relevant to meeting healthcare rationing fairly and legitimately? I will argue that while a backward-looking conception of individual responsibility should not be endorsed, a forward-looking notion of responsibility may be approved. (shrink)

The definition and measurement of social welfare have been a vexed issue for the past century. This book makes a constructive, easily applicable proposal and suggests how to evaluate the economic situation of a society in a way that gives priority to the worse-off and that respects each individual's preferences over his or her own consumption, work, leisure and so on. This approach resonates with the current concern to go 'beyond the GDP' in the measurement of social progress. Compared to (...) technical studies in welfare economics, this book emphasizes constructive results rather than paradoxes and impossibilities, and shows how one can start from basic principles of efficiency and fairness and end up with concrete evaluations of policies. Compared to more philosophical treatments of social justice, this book is more precise about the definition of social welfare and reaches conclusions about concrete policies and institutions only after a rigorous derivation from clearly stated principles. (shrink)

This review essay examines H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics, a contemporary nonfeminist text in mainstream biomedical ethics. It focuses upon a central concept, Engelhardt's idea of the moral community and argues that the most serious problem in the book is its failure to take account of the political and social structures of moral communities, structures which deeply affect issues in biomedical ethics.