Public deliberation about health policy in the United States often hinges on two untenable basic assumptions about political legitimacy. The first assumption, common in public debate throughout the United States, is that federal oversight of health care is justified under a federal compact binding all citizens. This assumption is false because the federal compact precludes such oversight. Indeed, the ascendancy of national government (and demise of federalism) over the past 70 years was engineered through the subversion of the federal compact, (...) creating an expansive legitimation gap. The second assumption—that political legitimacy can be established through appeals to expert consensus about fundamental conceptions of justice or human rights—is prevalent among bioethicists. I argue that this assumption is illicit because it hinges on a weak, rationalistic form of majoritarian democracy that conflates public acquiescence with public approval. If the public mission of academic bioethics involves protecting the integrity of public deliberation, then these two basic assumptions should be challenged. (shrink)

Principles of sufficiency are widely discussed in debates about distributive ethics. However, critics have argued that sufficiency principles are vulnerable to important objections. This paper seeks to clarify the main claims of sufficiency principles and to examine whether they have something distinctive and plausible to offer. The paper argues that sufficiency principles must claim that we have weighty reasons to secure enough and that once enough is secured the nature of our reasons to secure further benefits shifts. Having characterized sufficientarianism (...) in this way, the paper shows that the main objections to the view can be avoided; that we can examine the plausibility of sufficiency principles by appealing to certain reasons that support a shift; and that we should be optimistic about the prospects for sufficientarianism because many of our strongest reasons seem to be of this sort. This shift, I claim, is the overlooked grain of truth in sufficientarianism. (shrink)

A growing body of empirical research examines the effects of the so-called “social determinants of health” on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the fairness of particular health inequalities; and second, the policy recommendations issued on (...) this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended—such as improving people's living conditions and reducing inequalities in wealth and power—are justified in their own right, the way these recommendations are tied to health is problematic. (shrink)

In bioethics, discussions of justice have tended to focus on questions of fairness in access to health care: is there a right to medical treatment, and how should priorities be set when medical resources are scarce. But health care is only one of many factors that determine the extent to which people live healthy lives, and fairness is not the only consideration in determining whether a health policy is just. In this pathbreaking book, senior bioethicists Powers and Faden confront foundational (...) issues about health and justice. How much inequality in health can a just society tolerate. The audience for the book is scholars and students of bioethics and moral and political philosophy, as well as anyone interested in public health and health policy. (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)

Efficiency and equity are central concepts for the normative assessment of health policy. Drawing on the work of academic philosophers and philosophically sophisticated economists, this article identifies important philosophical questions implicated by the notions of efficiency and equity and then summarizes influential answers to them. Promising avenues for further philosophical research are also highlighted, especially in the context of health equity and its elusive ethical foundations.

The infant mortality rate in Liberia is 50 times higher than it is in Sweden, whilst a child born in Japan has a life expectancy at birth of more than double that of one born in Zambia. 1 And within countries, we see differences which are nearly as great. For example, if you were in the USA and travelled the short journey from the poorer parts of Washington to Montgomery County Maryland, you would find that ‘for each mile travelled life (...) expectancy rises about a year and a half. There is a twenty-year gap between poor blacks at one end of the journey and rich whites at the other’. (Marmot, 2004, p.2). There are two types of questions which it is important to ask about inequalities in health such as these. The first are social scientific questions about the extent of inequalities in health and the factors which are causally responsible for these inequalities. Examples of social scientific questions to ask might be: how do infant mortality rates in the UK differ according to social class? What is the difference in life expectancy between Japanese who emigrate to the US and those who remain in Japan? Why do civil servants in higher ranked jobs tend to live longer than civil servants in lower ranked jobs? The second type are normative questions about the reasons we have to care about inequalities in health. Important normative questions to answer are: which inequalities in health should we care about (all inequalities or merely some of them)? When is an inequality in health unjust? How should we weigh our concern for equality in health against other factors such as maximising the.. (shrink)