Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

I investigate whether tobacco health warnings’ interference with autonomy is ethically justifiable in order to deter people from smoking. I dissociate first the informational role and the persuasive role of tobacco health warnings and show that both roles enable typical addicted smokers to better rule themselves, fostering their autonomy. The fact that some messages address people’s non-deliberative faculties is therefore compensated by a larger positive influence on their autonomy. However, misleading messages are not ethically justified and should be (...) avoided. Tobacco health warnings’ effect on autonomy highlights an important difference between libertarian paternalism and classical paternalism. (shrink)

Cigarette smoke is by far the leading preventable cause of death and disease in the United States. It has been estimated to kill between 419,000 and 589,000 smokers and up to 65,000 non-smokers each year. This premier status is hardly a new development, having been true for most of the last century, and known to be true at least since the first Surgeon General’s Report in 1964.Why then are tobacco products exempt from any significant federal oversight or control? Why (...) do cigarette advertisements, pitched to young smokers and non-smokers, continue to be plastered on every available surface inside and outside many convenience stores and to adorn the pages of popular magazines? Why, decades since the makers of far less dangerous products began to be held accountable in tort law, was the first payment by a cigarette company on a products liability judgment not made until 2001? (shrink)

Cigarette smoke is by far the leading preventable cause of death and disease in the United States. It has been estimated to kill between 419,000 and 589,000 smokers and up to 65,000 non-smokers each year. This premier status is hardly a new development, having been true for most of the last century, and known to be true at least since the first Surgeon General’s Report in 1964.Why then are tobacco products exempt from any significant federal oversight or control? Why (...) do cigarette advertisements, pitched to young smokers and non-smokers, continue to be plastered on every available surface inside and outside many convenience stores and to adorn the pages of popular magazines? Why, decades since the makers of far less dangerous products began to be held accountable in tort law, was the first payment by a cigarette company on a products liability judgment not made until 2001? (shrink)

This paper argues that there are instances in which tobacco control litigation is strengthening the justiciability of the right to health and health-related rights. This is happening in different parts of the world, but in particular in Latin America. In part this is because, to a certain extent, tobacco control litigation based on fundamental rights overcomes the traditional arguments against economic, social and cultural rights adjudication: the anti-democratic argument, the lack of technical competency argument, the problem of the (...) misallocation of scarce public resources and the problem of the implementation of judicial decisions. As we analyzed in this paper, tobacco control cases based on fundamental rights are allowing courts to elaborate on broader standards of judicial adjudication of social rights, e.g., expand notions of standing, progressive realization, and state obligations enshrined in the right to health. Key to this judicial trend is the Framework Convention on Tobacco Control, which provides a legal standard — supported by scientific evidence — defining concrete measures states should take to address the tobacco epidemic, and thus giving content to the right to health as it relates to tobacco control. (shrink)

There is perhaps no area of law that so effectively protects human health and thereby advances the right to the highest attainable standard of health, as tobacco control. Globally, tobacco is responsible for 1 in 10 adult deaths, and is on track to kill 10 million people per year, mostly in developing countries, representing a US$200 billion drain on the global economy. Yet experience in recent decades has shown that a range of tobacco control measures, such as (...) comprehensive bans on smoking in public places, tobacco taxes, and limits on tobacco advertising, can greatly reduce smoking prevalence. These measures have slowly curtailed the epidemic, despite strong opposition from various sectors led by the tobacco industry. It is fitting that tobacco control is the focus of a recent, widely ratified global treaty and of increasing national litigation, often directly linked to countries’ human rights commitments. (shrink)

Although the effectiveness of some tobacco programs and policies has been clearly demonstrated in reducing the overall population smoking prevalence, the health benefits are not equally distributed across all socio-economic classes; a situation that clearly runs against the equalitarian ethos of most modern states. In this article, we evaluate the benefits of using Sen’s Capability Approach as a theory of social justice to guide public health program and policy development in a way that would prevent the further increase of (...) inequalities in health outcomes. Starting from four consensual goals of tobacco control practice (i.e. that individuals live a smoke-free life, that smokers quit smoking, that non-smokers are protected from exposure to second-hand smoke and that smoking cessation support is accessible) we found that besides the standard interventions (e.g. education on the harms of smoking, policies to reduce exposure to SHS) an iniquity-proof tobacco control program needs also to address the lack of options of underprivileged people in affordable smoke-free settings and in leisure activities. We conclude that an ethical tobacco prevention program needs to address the broader social determinants of health such as the socio-economic policies that put a strain on people’s capacity to shun or quit smoking. (shrink)

The evidence linking tobacco product advertising to adolescent smoking initiation and resulting long-term addiction, premature death, and disability is well established. Each link in the causal chain has been substantiated: children and adolescents are especially vulnerable to advertising; point-of-sale advertising comprises 92.1% of cigarette advertising and marketing expenditures by manufacturers and 71.3% of smokeless tobacco advertising; tobacco companies have targeted youth through advertising; advertising exposure causes adolescents to start and to continue smoking; among adults who become daily (...) smokers, nearly all first use of cigarettes occurs by 18 years of age; adolescents who smoke are at high risk for long-term addiction because their brains are still developing; and long-term addiction results in the tremendous personal, social and financial costs of tobacco-related illnesses. (shrink)

This article challenges the use of social deprivation as a punishment, and offers a preliminary examination of the human rights implications of exile and solitary confinement. The article considers whether a human right against coercive social deprivation is conceptually redundant, as there are recognised rights against torture, extremely cruel, inhumane, or degrading treatment as well as rights to basic health care, education, and security, which might encompass what this right protects. The article argues that the right is not (...) conceptually redundant, but that, even if it were, there would be significant reasons to articulate it. (shrink)

The tobacco industry has used corporate social responsibility tactics to improve its corporate image with the public, press, and regulators who increasingly have grown to view it as a merchant of death. There is, however, an intractable problem that corporate social responsibility efforts can mask but not resolve: the tobacco industry's products are lethal when used as directed, and no amount of corporate social responsibility activity can reconcile that fundamental contradiction with ethical corporate citizenship. This study's focus is (...) to better understand the tobacco industry's corporate social responsibility efforts and to assess whether there has been any substantive change in the way it does business with regard to the issue of exposure to secondhand smoke. The results show that the industry has made no substantial changes and in fact has continued with business as usual. Although many of the tobacco companies' tactics traditionally had been defensive, they strove for a way to change to a more offensive strategy. Almost without exception, however, their desire to appear to be good corporate citizens clashed with their aversion to further regulation and jeopardizing their legal position, perhaps an irreconcilable conflict. Despite the switch to offense, in 2006 a federal judge found the companies guilty of racketeering. (shrink)

Should tobacco be banned? The answer depends largely on two further questions. How much are smokers benefitted by being made to stop, or to not start? And what is the moral cost of their being made to stop by their government, as opposed to stopping due to the influence of policies that fall short of coercion? Grill and Voigt provide one answer to the first question. They argue that the benefits of cessation are high enough to justify a ban (...) on tobacco products.1 I partly agree: I share their view that the harms of tobacco consumption are great enough to justify at least some policies that force (rather than merely encourage) people to not smoke.i But the differences between policies of this sort are large enough that any general conclusion in favour of ‘a ban’ is incomplete.ii By not elaborating on what a ban might come to, Grill and Voigt leave the second question rather unaddressed. Of course, the authors hardly mean to say that anything goes when it comes to forming policies that force people to not smoke. Nevertheless, it is appropriate to build on their defence of the benefits of forced cessation by comparing different sorts of bans, and by comparing bans with other sorts of coercive policies. I will pick up, therefore, where they leave off: granting that a ban's effects on well-being would be overall positive, a principal moral cost of a ban can be measured in terms of its infringement of smokers’ autonomy. Comparisons, then, can be sought in terms of how different policies infringe autonomy in different ways. What exactly might it mean, however, to speak of smokers’ autonomy? According to Grill and Voigt, autonomy should be thought of as a sort of ‘self-direction’ which obtains given ‘the absence of external …. (shrink)

Corporate social responsibility has become a potential path to legitimacy and improved public relations for both companies that produce mainstream products and those that sell vice, such as the tobacco industry. Since the early 1990s, the tobacco industry has sought to bridge the gap between the public perception it has earned as a merchant of death and its goal of gaining corporate legitimacy and normality by promoting programs, positions, and policies it hopes the general public will believe are (...) aimed at preventing or mitigating some of the societal ills that smoking causes, such as youth smoking. There is, however, an intractable problem that corporate social responsibility efforts can mask but not resolve: the tobacco industry’s products are lethal when used as directed, and no amount of public relations or funding of ineffective youth smoking prevention programs can reconcile that fundamental contradiction with ethical corporate citizenship. The focus of this study is to better understand the tobacco industry’s corporate social responsibility efforts and to assess whether there has been any substantive change in the way it does business with regard to the issue of exposure to secondhand smoke. (shrink)

Tobacco, divine, rare superexcellent tobacco, which goes far beyond all panaceas, potable gold and philosopher's stones, a sovereign remedy to all diseases.Although most of the toxicity, including cancerogenicity, of tobacco is related to a mix of components other than nicotine present in cigarettes (U.S. Surgeon General 2010), it is indeed nicotine that causes addiction to smoking (Benowitz 2010; Russo et al. 2011).In 1988, the U.S. Surgeon General's Report concluded that cigarettes and other forms of tobacco are (...) addictive as a result of their nicotine content, and that the processes determining tobacco addiction "are similar to those that determine addiction to drugs such as heroin and cocaine." Previously, in .. (shrink)

Epicurus argued that death can be neither good nor bad because it involves neither pleasure nor pain. This paper focuses on the deprivation account as a response to this Hedonist Argument. Proponents of the deprivation account hold that Epicurus’s argument fails even if death involves no painful or pleasurable experiences and even if the hedonist ethical system, which holds that pleasure and pain are all that matter ethically, is accepted. I discuss four objections that have been raised against (...) the deprivation account and argue that this response to Epicurus’s argument is successful once it has been sufficiently clarified. (shrink)

Over the past few decades, “Big Tobacco” has spread its tentacles across the developing world with devastating results. The global incidence of smoking has increased exponentially in Africa, Asia and South America and it is leading to an equally rapid increase in the incidence of smoking-induced morbidity and mortality on these continents. The World Health Organization (WHO) has tried to respond to this crisis by devising a set of regulations to limit the spread of smoking, and many countries have (...) bound themselves to follow the WHO’s guidelines. This article provides an overview of these regulatory measures and the authors attempt to defend them from the perspective of liberty and autonomy. Their motivation is to countermand any attempt by the tobacco industry to attack the regulations on the grounds that they infringe the liberty rights of producers and consumers. It is also argued, however, that a blanket ban of the production, sale and consumption of tobacco cannot be justified on the grounds of autonomy alone. (shrink)

There remains no consensus among social scientists as to how to measure and understand forms of information deprivation such as misinformation. Machine learning and statistical analyses of information deprivation typically contain problematic operationalizations which are too often biased towards epistemic elites' conceptions that can undermine their empirical adequacy. A mature science of information deprivation should include considerable citizen involvement that is sensitive to the value-ladenness of information quality and that doing so may improve the predictive and explanatory (...) power of extant models. (shrink)

The tobacco industry first began to promote the idea that a minority of smokers are 'genetically predisposed' to lung cancer in the 1950s. We used tobacco industry documents available as a result of litigation to investigate the role of the tobacco industry in funding the 'scientific bandwagon' described by Fujimura, in which genetics has come to dominate the cancer research agenda. From 1990-1995 inclusive, 52% of the project funding allocated by British American Tobacco's Scientific Research Group (...) went to genetic research, mainly based in universities and at one cancer charity. The largest project involved a pharmacogenetic research unit, based in a UK medical school, which was established with the help of tobacco industry PR consultants in 1988. The unit received half its project funding from the industry in 1992. Its main aim was to identify a minority of smokers who are supposedly 'genetically susceptible' to lung cancer, so that smoking cessation measures could be targeted at them. This aim was adopted and promoted by influential scientists at the US National Institutes of Health and the UK Medical Research Council in the late 1980s, in the run up to the Human Genome Project.BAT's research funds were also used to counter claims by others to have identified a unique 'genetic fingerprint' for tobacco smoke in lung cancer cells. We conclude that the tobacco industry has played a significant role in shaping research agendas, in particular, by promoting the idea that individual genome screening would be of benefit to public health. (shrink)

In an ongoing class action suit against large tobacco companies, including Philip Morris, Inc., and R.J. Reynolds Tobacco Co., Judge Jack B. Weinstein of the U.S. District Court for the Eastern District of New York issued an opinion on October 15, 2002 making statistical proof available to address plaintiffs’ common questions and prove required elements of consumer fraud.The dilemmas inherent in tobacco litigation as a mass tort action include overcoming the collective action problem, mobilizing appropriate and persuasive (...) legal theories for recovery, and meeting the standards of proof, all in a timely and cost-effective manner. While some tobacco cases have proceeded on products liability theories of defective or negligent design, many recent cases are grounded in consumer fraud laws. (shrink)

In an ongoing class action suit against large tobacco companies, including Philip Morris, Inc., and R.J. Reynolds Tobacco Co., Judge Jack B. Weinstein of the U.S. District Court for the Eastern District of New York issued an opinion on October 15, 2002 making statistical proof available to address plaintiffs’ common questions and prove required elements of consumer fraud.The dilemmas inherent in tobacco litigation as a mass tort action include overcoming the collective action problem, mobilizing appropriate and persuasive (...) legal theories for recovery, and meeting the standards of proof, all in a timely and cost-effective manner. While some tobacco cases have proceeded on products liability theories of defective or negligent design, many recent cases are grounded in consumer fraud laws. (shrink)

Government’s responsibility to safeguard the public’s health through law has been part of the social contract since ancient times. Cicero declared salus populi suprema lex esto - “the safety of the people is the supreme law”. Disraeli proclaimed that protecting the public’s health is the first duty of the statesman. Of the ten most important public health achievements of the 20th century in the US., seven are directly related to legal interventions, including legislative interventions. As new and existing risks to (...) health risks emerge internationally, governments have consistently used the law as a tool to define the goals of public health, direct public health authorities to accomplish these goals, and equip them with the power and resources to do so.Tobacco control represents a salient example of how law can be used to ensure health. Like other public health laws, tobacco control laws have historic grounds. Government and other policymakers have enacted laws to control tobacco use for hundreds of years. The Russian church forbade tobacco use as an “abomination.”. (shrink)

Government’s responsibility to safeguard the public’s health through law has been part of the social contract since ancient times. Cicero declared salus populi suprema lex esto - “the safety of the people is the supreme law”. Disraeli proclaimed that protecting the public’s health is the first duty of the statesman. Of the ten most important public health achievements of the 20th century in the US., seven are directly related to legal interventions, including legislative interventions. As new and existing risks to (...) health risks emerge internationally, governments have consistently used the law as a tool to define the goals of public health, direct public health authorities to accomplish these goals, and equip them with the power and resources to do so.Tobacco control represents a salient example of how law can be used to ensure health. Like other public health laws, tobacco control laws have historic grounds. Government and other policymakers have enacted laws to control tobacco use for hundreds of years. The Russian church forbade tobacco use as an “abomination.”. (shrink)

A long history of research has revealed many neurophysiological changes and concomitant behavioral impacts of sleep deprivation, sleep restriction, and circadian rhythms. Little research, however, has been conducted in the area of computational cognitive modeling to understand the information processing mechanisms through which neurobehavioral factors operate to produce degradations in human performance. Our approach to understanding this relationship is to link predictions of overall cognitive functioning, or alertness, from existing biomathematical models to information processing parameters in a cognitive architecture, (...) leveraging the strengths from each to develop a more comprehensive explanation. The integration of these methodologies is used to account for changes in human performance on a sustained attention task across 88 h of total sleep deprivation. The integrated model captures changes due to time awake and circadian rhythms, and it also provides an account for underlying changes in the cognitive processes that give rise to those effects. The results show the potential for developing mechanistic accounts of how fatigue impacts cognition, and they illustrate the increased explanatory power that is possible by combining theoretical insights from multiple methodologies. (shrink)

The renewed interest in the fate of endangered languages has led to the adoption by the Permanent International Committee of Linguists (CIPL) of a major project on such languages and the publication of Endangered Languages, edited by R.H. Robins and E.M. Uhlenbeck (1991). This book contains not only a discussion of the conditions that lead to language death but also case studies of endangered languages around the world.

Much effort and many resources have been expended in enacting smoking bans for private businesses catering to adult-only clientele. Although the arguments in favor of bans leave much to be desired, many people believe that banning smoking in the hospitality industry is justified.What is puzzling is the lack of attention on banning smoking around children in cars, houses, and other private property. After all, if such prohibitions are justified for autonomous adults, then they must be for non-autonomous minors as well. (...) A good case can be made out for banning smoking around children in the best interests of their health. (shrink)

In order to at least begin addressing the extensive the problem of moral clarity in aiding the deprived to some degree, I first argue that the duty to aid the deprived is not merely a charitable one, dependent on the discretion, or the arbitrary will, of the giver (1). Then, before further analysing the individual duty to aid, I critically examine whether deprivation is better alleviated or remedied through the duties of corrective justice. I argue that the perspective of (...) corrective justice is important, but not sufficient when it comes to dealing with deprivation (2). I then argue that non-domination cannot serve as a first-order principle of justice. It is too minimalistic, since it would not require duties of justice where deprivation exists, but dominating relations and institutions do not. (3). Going back to the individual duty to help, I argue that the duties to aid the needy must be assessed according to the situation at hand (4). In order to avoid meaninglessness and morality’s excessive demands, one should be able to identify the responsible agents by constructing a shared and, in the last resort, institution-based duty to help (5). The institutional approach in this paper argues that we should create and reform institutions in order to realize the pre-existing requirement to alleviate global deprivation. This is a form of “global political justice” that does not start with politics, but ends with global political institutions. (shrink)

Previous research showed that fear-inducing graphic warning labels can lead to cognitive dissonance and defensive responses. Less threatening, social-related warning labels do not elicit these defensive responses, making them more effective in preventing smoking in adults. Given that smoking numbers are still too high among youngsters, it is crucial to investigate how warning labels should be designed to prevent teenagers from starting smoking in the first place. In two studies, we investigated whether comparable effects of social-related warning labels could be (...) observed in a group of teenagers (14-17 years) who are not yet legally allowed to smoke. In addition, we tried to replicate earlier findings with smoking and non-smoking adults. Participants were presented with either health warning labels, social warning labels, or no warning labels. Subsequently, their explicit cognitions (i.e., risk perception, attitude towards smoking) and their implicit associations of smoking with healthiness/unhealthiness (Study 1a and Study 1b) and with positivity/negativity (Study 2a and Study 2b) were assessed. Results showed that in both studies, adult smokers had a higher risk perception and a more positive attitude towards smoking than adult non-smokers. Additionally, social warning labels lead to stronger implicit associations between smoking and negativity in Study 2 in the adult groups. In the teenage group, social warning labels lead to more positive attitudes than health warning labels in Study 2. No further effects on risk perception or implicit associations were found in the teenage group. Possible explanations are discussed. (shrink)

The author defends himself against an attack by Smith and Bopp on his views on smoking and taxation. The theory that, on the grounds of equity and/or fairness, smokers should pay via taxation on tobacco for the health care costs of treating smoking-related medical conditions is discussed and shown to be defective. It is argued that the fundamental mistake that Smith and Bopp make is to confuse and conflate the separate issues of whether particular taxes are fair and whether (...) they are justifiable. The conclusion is reached that an excise duty on tobacco is a good tax. It is a non-fair or even an unfair tax but it is justified on grounds other than fairness. (shrink)

Deprivation of liberty in psychiatric hospitals is common world-wide. The aim of this study was to find out whether patients had experienced deprivation of their liberty during psychiatric hospitalization and to explore their views about it. Patients (n = 51) in two acute psychiatric inpatient wards were interviewed in 2001. They were asked to describe in their own words their experiences of being deprived of their liberty. The data were analysed by inductive content analysis. The types of (...) class='Hi'>deprivation of liberty in psychiatric hospital care reported by these patients were: restrictions on leaving the ward and on communication, confiscation of property, and various coercive measures. The patients' experiences of being deprived of their liberty were negative, although some saw the rationale for using these interventions, considering them as part of hospital care. (shrink)

While many theories of well-being are able to capture some of our central intuitions about well-being, e.g. avoiding alienation worries, they typically do so at the cost of not being able to capture others, e.g. explaining deprivation. However, both of these intuitions are important and any comprehensive theory of well-being ought to attempt to strike the best balance in responding to both concerns. In light of this, I develop and defend a theory of well-being which holds that our well-being (...) depends, in part, on the nature of our well-being qua person, a class whose members are defined by their possessing certain cognitive and volitional capacities including those capacities constitutive of autonomy. I argue that this theory of well-being is able to address concerns about alienation and deprivation, along with capturing the importance of autonomy to well-being, better than many popular subjective and objective theories of well-being. (shrink)

Deprivation offers a plausible explanation for the badness of death, so fear is not unreasonable. But horror at the prospect of one's death is not just extreme fear because horror is structurally different than fear. Horror requires a different explanation. For Sartre, horror is possible only in unique circumstances. I argue that Sartre's view, when combined with the subjective incomprehensibility of one's annihilation, can explain horror and other negative emotions that are not contingent on deprivation. Further, I argue (...) that while fear can be reasonable if one's death will deprive, Lucretius's Symmetry Argument shows that horror is unreasonable. (shrink)

There is no more striking public health triumph than the demise of the “brown plague.” The cigarette was once the accoutrement of a good life, but smoking is now a tragic habit of the poor. By the mid‐1960s, half of all men and a third of women in the United States smoked. Today the national prevalence is 18 percent, with rates in major cities below 15 percent. A suite of policies drove down smoking rates—antismoking campaigns, taxation, clean air laws, package (...) labeling, and marketing curbs. These policies, and the resultant behavior changes, however, have diminishing returns. Is it possible that tobacco rates will remain relatively stagnant? If so, what “endgame” strategies might drive rates to negligible levels, say, lower than 5 percent? And if society does achieve such an audacious goal, how attentive should it be to the problems of social justice? (shrink)

Two recent discussions concerning punishment of the socially deprived reach conflicting conclusions. Andrew von Hirsch and Andrew Ashworth argue that we should sympathize with the predicament of the poor and therefore mitigate their sentences. Peter Chau disputes von Hirsch and Ashworth’s conclusion, contending that having to face strong temptations is not an appropriate ground for reducing anyone’s punishment for their crimes. I argue that neither von Hirsch and Ashworth’s account nor Chau’s critique of it is persuasive. I then take up (...) the challenge of showing why social deprivation renders punishment problematic. I contend that it establishes a perverse incentive structure that is persistent and powerful, requiring the disadvantaged to exercise self-control on an ongoing basis. Repeated acts of self-control are difficult, especially for youths whose skills at it are not yet fully developed. Also, in a variety of more and less subtle ways, social deprivation reduces the incentives for self-control and may work to stunt its development. In closing, I briefly consider the options for responding to the crimes of the chronically disadvantaged. (shrink)

In my essay, Why abortion is immoral, I criticised discussions of the morality of abortion in which the crucial issue is whether fetuses are human beings or whether fetuses are persons. Both argument strategies are inadequate because they rely on indefensible assumptions. Why should being a human being or being a person make a moral difference? I argued that the correct account of the morality of abortion should be based upon a defensible account of why killing children and adults is (...) wrong. I claimed that what makes killing us wrong is that our premature deaths deprive us of our futures of value, that is, the goods of life we would have experienced had we survived. This account of the wrongness of killing explains why killing is one of the worst of crimes and how killing greatly harms the victim. It coheres with the attitudes of those with cancer or HIV facing premature death. It explains why we believe it is wrong to kill infants. It does not entail that it wrongs a human being to end her life if she is in persistent vegetative state or if her future must consist only of unbearable physical suffering and she wants to die. This account of the wrongness of killing implies that abortion is immoral because we were fetuses once and we know those fetuses had futures of value. Mark Brown claims that this potential future of value account is unsound because it implies that we have welfare rights to what we need to stay alive that most people would reject. I argue that Brown is incorrect in two ways: a welfare right to what we need to stay alive is not directly implied by my account and, in addition, most of us do believe that dependent human beings have substantial welfare rights to what they need to stay alive. Brown argues that depriving us of a future of value of which we have mental representations both is a better explanation of the wrongness of killing and does not imply that abortion is immoral. I reply that if Brown's arguments against my view were sound, those arguments could be easily adapted to show that his view is unsound as well and Brown's view is both ambiguous and unsound on any interpretation. The most popular class of pro-choice argument strategies appeals to the view that some or all fetuses lack either a mental state or function or a capacity for a mental state or function necessary for possession of the right to life. Desires, interests, sentience, various concepts, moral agency, and rationality have all been suggested as candidates for this crucial mental role. Brown's analysis is one member of this class of strategies. I believe that it is possible to show that none of these strategies is reasonable. However, there are so many of these strategies that the required argument demands something more like a book and less like a short essay. The argument of the following essay is a piece of this larger argument. (shrink)

In 1943, a distinguished child psychiatrist at Johns Hopkins University, Leo Kanner, published what would become a landmark article: a description of 11 children who suffered from a distinct disorder he called ‘infantile autism’. While initially quite obscure, in the early 1950s Kanner’s report garnered much attention, as clinicians and researchers interpreted these case studies as exemplifying the ill-effects of maternal deprivation, a new theory that rapidly gained currency in the United States. Sensory deprivation experiments, performed in the (...) mid-1950s, further complicated the picture, as experts debated whether maternal deprivation was unique or simply a form of environmental stimulation. As experts strove to make sense of this new disorder, they relied on concepts of maternal and sensory deprivation, both to promote their own theories and to critique or refute those of their colleagues. This interplay between the two theories also informed new forms of intervention, including ‘rage reduction therapy’, which served as a precursor for controversial forms of therapy today termed as the ‘attachment therapies’. This article sheds light on a little-known aspect of the history of autism, and examines the far-reaching effect popular etiological theories have in shaping debates over emerging medical concerns. (shrink)

In the Peruvian Amazon, tobacco (Nicotiana rustica) is considered a master plant and is the main curing tool of local healers. Among its several medicinal uses, we find drinking tobacco juice with the purpose of purging in order to heal on a physical, mental, and spiritual level. This specific practice is part of the addiction treatment protocol developed at Takiwasi Center. The goal of this investigation was to focus on the effects of the tobacco purge as reported (...) by therapists at Takiwasi and to elaborate its relevance within the context of addiction treatment. In order to obtain information on this topic, we performed research fieldwork based on a participant-observation approach, and retrospective data analysis on information from interviews conducted by psychotherapists with patients. As alleged effects of the tobacco purge, therapists reported that patients experienced feelings of mental clarity with the greatest frequency (n = 80), followed by noteworthy physical effects including discomfort and intoxication (n = 63). An effect on sleep and dreams was also common (n = 36) and many found the experience directly related to addiction treatment and the desire to consume substances (n = 20). (shrink)

In his ‘The Identity Objection to the future‐like‐ours argument’ (Bioethics, 2019, 33: 287–293), Brill argues that Marquis's 'future of value' account of the wrong of abortion is still vulnerable to the identity objection—the claim that the foetus and the later person are not numerically identical, so the later person's valuable experiences are not the foetus's future experiences—even if it is conceded that the future organism, as well as the person, has experiences. This is because the organism has these experiences in (...) a different way from the person. The person has them directly, and the organism has them only derivatively. This implies, he maintains, that the organism cannot be deprived of those experiences in a way that is wrong. Only the person can be deprived in this morally relevant way. But, I argue, if the organism genuinely has those experiences, it is not at all clear why its being deprived of them would be permissible. I argue that the reason why Brill can claim that having those experiences derivatively makes this moral difference is because the sense in which the organism has experiences is not a genuine sense. But that is a problem for this theory of personal identity, not for Marquis's account of the wrong of abortion. I also argue that supposing that one cannot morally harm the human organism has various implausible implications, which cast doubt on the idea that having experiences derivatively means that the organism is not morally harmed by being deprived of them. (shrink)

Journal of Political Philosophy, EarlyView.

Scholars have addressed restrictions on individual liberty, or deprivations thereof, that do not entail prison or jail—including area restrictions, revoking driver’s licenses, and GPS bracelets. In all legal domains, the effects of these measures on the lives of targeted individuals can be significant, primarily with respect to their capability to guide their own behavior. Some are applied categorically rather than individually, do not involve a fair trial or hearing, or are applied preventively or after the targeted individual has completed a (...) prison sentence. My aim in this article is to extend our view from prison as the quintessential method of depriving individuals of their liberty to control of individuals without locking them up. I address degrees of individual liberty and inquire into legal protections for individuals who are partially free but deprived of liberty in some areas of life. (shrink)