The vision of global health with justice which Larry Gostin articulates in his book Global Health Law envisages a switch to ‘upstream’ priority-setting for expenditure on health, with a focus upon social determinants and a goal of redressing health inequalities. This article explores what is meant by this proposal and offers a critical evaluation of it. It is argued that difficulties arise in respect of the ethical and evidential bases for such an approach to the setting of priorities, while significant (...) challenges may also arise in the necessary modification of structures of governance. (shrink)

Socialism is dead, though many of its academic proponents take no notice of its demise. With its death, private property in the means of production is not generally in dispute, and the action in political philosophy centers on the justification of the welfare state. The heart of the welfare state is social insurance programs, such as government managed and subsidized health insurance, retirement pensions, and unemployment insurance. The arguments about health insurance will arguably be among the most ferocious, difficult, and (...) important of the welfare-state debates: Ferocious, because proposals to alter government managed or subsidized health care strike at people's fears and concerns in a way matched by few other proposals. Difficult, because people can often not even conceive of a market alternative to the status quo in health insurance, and there is no real existing alternative to hold up as a model. Important, because if an intellectually solid case for market health insurance can be established, then supporters of the welfare state should be on the defensive, since social health insurance is an institution central to their vision of the just or good society. (shrink)

While in America most people think of “welfare” as means-tested programs such as Aid to Families with Dependent Children, in reality in the United States and other affluent democracies the heart of the welfare state is social insurance programs, such as health insurance, old-age or retirement pensions, and unemployment insurance. They are insurance programs in the sense that they protect against common risks of a loss of income if and/or when certain events come to pass ; they are “social” because (...) unlike market insurance they are not run on a sound actuarial basis, the premiums are not voluntarily incurred but compulsory, and there is very limited choice or flexibility concerning the type of policy one can purchase. Why have social insurance rather than market insurance? In this essay, I take up this question with regard to old-age or retirement pensions, which at present absorb around 9 percent of the gross domestic product and 25 percent of government spending of the affluent industrial countries comprising the Organization for Economic Cooperation and Development. My aim is to show that old-age or retirement social insurance is worse in virtually every relevant normative respect than its alternative, some form of market or private pensions. By relevant normative respect, I mean those values or principles which are used by contemporary political philosophers in their discussions and justifications of welfare-state policies, and which are applicable to assessments of different systems of old-age or retirement pensions. (shrink)

Many think that equality is an intrinsic value. However, this view, especially when based on a consequential foundation, faces familiar objections related to the claim that equality is sometimes good for none and bad for some: most notably the levelling down objection. This article explores a unique (consequential) conception of equality, as part of a more general conception of fairness concerning the resolution of interpersonal conflicts, which is not exposed to these objections.

Decision-makers face severe uncertainty when they are not in a position to assign precise probabilities to all of the relevant possible outcomes of their actions. Such situations are common—novel medical treatments and policies addressing climate change are two examples. Many decision-makers respond to such uncertainty in a cautious manner and are willing to incur a cost to avoid it. There are good reasons for taking such an uncertainty-averse attitude to be permissible. However, little work has been done to incorporate it (...) into an egalitarian theory of distributive justice. We aim to remedy this lack. We put forward a novel, uncertainty-averse egalitarian view. We analyse when the aims of reducing inequality and limiting the burdens of severe uncertainty are congruent and when they conflict, and highlight practical implications of the proposed view. We also demonstrate that if uncertainty aversion is permissible, then utilitarians must relinquish a favourite argument against egalitarianism. (shrink)

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in jeopardy of falling beneath the threshold has (...) a legitimate claim to justice. People's entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold). (shrink)

According to outcome welfarism, roughly, the value of an outcome is fundamentally a matterof the individual welfare it contains. I assess various suggestions as to how to spell out this idea more fully on the basis of some basic intuitions about the content and implications of welfarism. I point out that what are in fact different suggestions are often conflated and argue that none fully captures the basic intuitions. I then suggest that what this means is that different doctrines of (...) welfarism may be appropriate in different contexts and that when deciding on a particular doctrine, we need to consider which intuitions it does accommodate. Finally, I consider the issue of just how a benefit must be related to an outcome in order to contribute to its value. (shrink)

Deprivations normally give rise to undeserved inequality. It is commonly thought that one way of improving a situation with respect to equality is by reducing the incidence of deprivations. In this paper I argue that there is at least one respect in which reducing the incidence of deprivations can make things worse from the point of view of equality. While eliminating deprivations leads to the elimination of inequalities, reducing the incidence of deprivations leads to an uneven distribution of the pairwise (...) relations of inequality of a population, which leads to the concentration of pairwise relations of inequality in the worse off. If my argument is correct, egalitarians have reasons to broaden their dimensions of concern: egalitarians should not only be concerned about the unequal distribution of goods, but also about the unequal distribution of pairwise relations of inequality of a population. (shrink)

I here settle a recent dispute between two rival theories in distributive ethics: Restricted Prioritarianism and the Competing Claims View. Both views mandate that the distribution of benefits and burdens between individuals should be justifiable to each affected party in a way that depends on the strength of each individual’s separately assessed claim to receive a benefit. However, they disagree about what elements constitute the strength of those individuals’ claims. According to restricted prioritarianism, the strength of a claim is determined (...) in ‘prioritarian’ fashion by both what she stands to gain and her absolute level of well-being, while, according to the competing claims view, the strength of a claim is also partly determined by her level of well-being relative to others with conflicting interests. I argue that, suitably modified, the competing claims view is more plausible than restricted prioritarianism. (shrink)

We analyse three moral dilemmas involving resource allocation in care for HIV-positive patients. Ole Norheim and Kjell Arne Johansson have argued that these cases reveal a tension between egalitarian concerns and concerns for better population health. We argue, by contrast, that these cases reveal a tension between, on the one hand, a concern for equal *chances*, and, on the other hand, both a concern for better health and an egalitarian concern for equal *outcomes*. We conclude that, in these cases, there (...) is much less tension than Norheim and Johansson claim between egalitarian concerns and concerns for better population health. (shrink)

The Levelling-Down Objection is a standard objection to monistic egalitarian theories where equality is the only thing that has intrinsic value. Most egalitarians, however, are value pluralists; they hold that, in addition to equality being intrinsically valuable, the egalitarian currency in which we are equal or unequal is also intrinsically valuable. In this paper, I shall argue that the Levelling-Down Objection still minimizes the weight that the intrinsic badness of inequality could have in the overall intrinsic evaluation of outcomes, given (...) a certain way of measuring the badness of inequality, namely, the Additive Individual-Complaints Measure. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 44-46, December 2011.

In this paper I criticize the standard argument for deontological egalitarianism, understood as the thesis that there is a moral claim to have an equal share of well-being or whatever other good counts. That argument is based on the idea that equals should be treated equally. I connect the debate over egalitarianism with that over comparative justice. A common theme is a general skepticism against comparative claims. I argue (i) that there can be no claim to equality based simply on (...) the fact of equal worth as that fact itself does not have any value for the supposed claim holder; and (ii) intuitions that suggest otherwise can be explained away without appealing to comparative claims. (shrink)

The exposure of doctors, nurses and other medical professionals to risks in the context of epidemics is significant. While traditional medical ethics offers the thought that these dangers may limit the extent to which a duty to care is applicable in such situations, it has less to say about what we might owe to medical professionals who are disadvantaged in these contexts. Luck egalitarianism, a responsibility-sensitive theory of distributive justice, appears to fare particularly badly in that regard. If we want (...) to maintain that medical professionals are responsible for their decisions to help, cure and care for the vulnerable, luck egalitarianism seems to imply that their claim of justice to medical attention in case of infection is weak or non-existent. The article demonstrates how a recent interpretation of luck egalitarianism offers a solution to this problem. Redefining luck egalitarianism as concerned with responsibility for creating disadvantages, rather than for incurring disadvantage as such, makes it possible to maintain that medical professionals are responsible for their choices and that those infected because of their choice to help fight epidemics have a full claim of justice to medical attention. (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)