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)

Structural Injustice advances a theory of what structural injustice is and how it works. Powers and Faden present both a philosophically powerful, integrated theory about human rights violations and structural unfairness, alongside practical insights into how to improve them.

In this article, we address the relevance of J.S. Mill’s political philosophy for a framework of public health ethics. In contrast to some readings of Mill, we reject the view that in the formulation of public policies liberties of all kinds enjoy an equal presumption in their favor. We argue that Mill also rejects this view and discuss the distinction that Mill makes between three kinds of liberty interests: interests that are immune from state interference; interests that enjoy a presumption (...) in favor of liberty; and interests that enjoy no such presumption. We argue that what is of focal importance for Mill in protecting liberty is captured by the essential role that the value of self-determination plays in human well-being. Finally, we make the case for the plausibility of a more complex and nuanced Millian framework for public health ethics that would modify how the balancing of some liberty and public health interests should proceed by taking the thumb off the liberty end of the scale. Mill’s arguments and the legacy of liberalism support certain forms of state interference with marketplace liberties for the sake of public health objectives without any presumption in favor of liberty. (shrink)

Articles by Lyn Horn and Alison Thompson highlight several points crucial to understanding how our theory figures in wider debates about social justice as well as the particular relevance of our theory for assessing the overall practice of public health (Horn, 2013; Thompson, 2013). We begin with these two articles, first to respond to and concur with many of their central points, and second to set the stage for dealing more efficiently with some points raised in the other articles.

: The increasing reliance upon, and perhaps the growing public and professional skepticism about, the special expertise of bioethicists suggests the need to consider the limits of moral expertise. For all the talk about method in bioethics, we, bioethicists, are still rather far off the mark in understanding what we are doing, even when we may be going about what we are doing fairly well. Quite often, what is most fundamentally at stake, but equally often insufficiently acknowledged, are inherently political, (...) essentially contested visions of the most compelling and attractive forms of life for individuals and social organization. The current situation in bioethics parallels similar debates in eighteenth-century jurisprudence, especially Jeremy Bentham's withering critique of the prevalent forms of judicial argument and his own, equally unsuccessful, attempt to develop a decision-making procedure in ethics that would operate on a plane above politics. The risk, both then and now, is that we will fail to appreciate the wide range of reasonable disagreement that will remain past the point of extended reflection and discussion. (shrink)

The goal of this article is to explore how a social justice framework can help illuminate the role that consent should play in health and science policy. In the first section, we set the stage for our inquiry with the important case of Henrietta Lacks. Without her knowledge or consent, or that of her family, Mrs. Lacks’s cells gave rise to an enormous advance in biomedical science—the first immortal human cell line, or HeLa cells.

What determines whether an action is right or wrong? Morality, Rules, and Consequences: A Critical Reader explores for students and researchers the relationship between consequentialist theory and moral rules. Most of the chapters focus on rule consequentialism or on the distinction between act and rule versions of consequentialism. Contributors, among them the leading philosophers in the discipline, suggest ways of assessing whether rule consequentialism could be a satisfactory moral theory. These essays, all of which are previously unpublished, provide students in (...) moral philosophy with essential material and ask key questions on just what the criteria for an adequate moral theory might be. (shrink)

Modern life is full of examples of environmentally-mediated “group harms” – what Derek Parfit describes as harms produced by “what we all do together.” Typically, the harms are unintended and arise from the uncoordinated actions of many individuals. Their actions ordinarily are not inherently wrong, no one’s action causes harm to an identifiable individual, and prevention of the expected harm is unlikely unless all, or nearly everyone, reduce or cease to engage in activities that collectively and cumulatively result in harm. (...) Unless the individual’s action is likely to make a difference to the outcome, it is often argued that it is not clear what, if anything, makes it wrong or a breach of personal moral responsibility. Activities that result in climate change and agricultural practices commonly employed within the global system of food production are prominent examples. There are several well-known strategies for dealing with such cases, but often they rest on idealized assumptions regarding the impact that one individual can have, provide answers suitable only in counterfactual circumstances, or rely on the kinds of principles of justice that make it difficult to identify clearly and address directly many important moral problems. The task of this chapter is to examine these strategies and propose alternative freestanding practical principles that can guide our efforts to address the world as we find it and explain the sense of wrongness individuals often experience. (shrink)

: The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed the philosophical landscape and encouraged some in (...) bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice. (shrink)

Many of the contemporary disagreements regarding privacy are conceptual in nature. They concern the meaning or definition of privacy and the analytic basis of distinguishing privacy rights from other kinds of rights recognized within moral, political, or legal theories. The two main alternatives within this debate include reductionist views, which seek a narrow account of the kinds of invasions or intrusions distinctly involving privacy losses, and anti-reductionist theories, which treat a much broader array of interferences with a person as separate (...) and irreducible kinds of privacy invasions. Other theorists have expressed doubts about the prospects for achieving greater analytical precision even within a fairly expansive anti-reductionist approach. However, a reductionist privacy definition is defended in this article, and its primary theoretical virtues are its ability to unify and explain the insights of several competing definitions and its role in developing an account of privacy rights that is both internally coherent and consistent with a plausible understanding of the theoretical basis for a number of related rights. (shrink)

New biotechnologies have the potential to both dramatically improve human well-being and dramatically widen inequalities in well-being. This paper addresses a question that lies squarely on the fault line of these two claims: When as a matter of justice are societies obligated to include a new biotechnology in a national healthcare system? This question is approached from the standpoint of a twin aim theory of justice, in which social structures, including nation-states, have double-barreled theoretical objectives with regard to human well-being. (...) The first aim is to achieve a sufficient level of well-being in each of six core dimensions. In the special case of healthcare systems, this aim is focally but not exclusively attentive to achieving health sufficiency as one of the core dimensions. The second aim is to combat the emergence and persistence of densely woven patterns of systematic disadvantage that tend to undermine the achievement of a sufficient level of health and the other core elements of well-being of some persons and groups. Judgments about entitlements to health related resources, including new biotechnologies, are made in light of a threshold notion of health sufficiency. What is enough or sufficient health? The answer that is defended here is that sufficient health is enough health for a decent human life, understood as enough health to live a full life course without preventable, significant functional disability or decrement in health, or treatable pain or suffering. When a state must include a new biotechnology in its national healthcare system is also influenced by ancillary concerns about the connection between health and other core dimensions of well-being. What counts as a significant functional impairment or health decrement is thus explicated, in part, in relation to the theory’s sufficiency aim for the other essential dimensions of well-being, and thus for a decent life, overall. Those elements of health that play a critical role in the experience of sufficient reasoning, affiliation, security, respect and self determination are especially important; any loss of health function or capacity that threatens the individual’s prospects for sufficiency in these other dimensions, including the relational egalitiarian concerns they entail, constitutes a significant functional impairment. Within national borders, individuals are thus entitled to those health-related goods and services that are essential for a sufficiency of each of the dimensions of well-being; with regard to self determination and respect, what is sufficient by way of guaranteed access to specific goods and services is going to depend on the implications of such access for where an individual stands in relation to her co-nationals. The content of any entitlement to health-related goods and services is also necessarily dynamic. What can be done for health and the other core dimensions of well-being as a function of technological innovation and diffusion is in constant flux. The paper concludes by considering the implications of this analysis for the conditions under which states are obligated to include access in their healthcare systems to one biotechnology, deep brain stimulation. (shrink)

: Justice is widely thought to consist in equality. For many theorists, the central question has been: Equality of what? The author argues that the ideal of equality distorts practical reasoning and has deeply counterintuitive implications. Moreover, an alternative view of distributive justice can give a better account of what egalitarians should care about than can any of the competing ideals of equality.

An important objection to many utilitarian theories is that their conceptions of utility may count as morally relevant contributions to individual well-being items which are morally or rationally suspect. For example, if the conception of utility is pleasure, or alternatively, the fulfilment of actual desire or satisfaction of preferences, then greater individual utility may be produced by whatever increases pleasure, fulfils desire, or satisfies someone's preferences. This is true no matter how disgusting or vile we may think such pleasures are, (...) or how irrational or distasteful we find the fulfilment of a desire or the satisfaction of some preference. (shrink)

The coming decades will present an immense challenge for the planet: sustainably feeding nearly ten billion people that are expected to be alive by 2050. This is no small task, and one that intersects with climate change, geopolitics, the increased globalization of agricultural markets, and the emergence of new technologies. The world faces a challenge of increased demand, propelled by an expanding world population and a global shift in dietary patterns toward more resource-intensive foods. Moreover, changes in demand occur in (...) the context of declining soil fertility and freshwater availability, agriculture's growing contribution to water pollution and climate change, and the emerging threats to agricultural productivity caused by climate disruption. (shrink)

Persons infected with the Human Immunodeficiency Virus often experience intermittent life-threatening infections, a progressive decrease in cognitive abilities, and a loss of capacity to communicate their wishes to their family and medical care providers. Accordingly, AIDS patients are among those most likely to benefit from the increased availability of legally recognized forms of advance care planning. Although the three countries examined in this article differ greatly in the prevalence of HIV infection, the legal status of advance directives, and in the (...) attitudes toward their use, a collection of case studies is used to demonstrate that an ability to address the specific needs, values and goals of individual patients is promoted by the availability of a variety of options for implementing advance directives or health care proxies. The conclusion of the analysis is that the best option in a specific context will depend upon differences in individual values and medical objectives of the sort discussed in the case studies. Das mit der HIV-Infektion verbundene Krankheitsbild ist durch wechselnde lebensbedrohliche Infektionen und den fortschreitenden Verfall kognitiver Fähigkeiten gekennzeichnet. Es führt zudem häufig zum Verlust der Möglichkeit, Behandlungswünsche gegenüber Ärzten und Angehörigen zu äußern. Deshalb gehören besonders AIDS-Patienten zu denjenigen, die von rechtlich anerkannten vorsorglichen Patientenverfügungen profitieren werden.In diesem Artikel werden drei Länder betrachtet, die sich hinsichtlich der Häufigkeit des Auftretens der HIV-Infektion sowie des rechtlichen Status von und der Einstellung zu Patientenverfügungen erheblich unterscheiden. Fallstudien belegen allerdings, daß nicht allein die kulturellen und sozialen Bedingungen für die jeweils beste Form der Patientenverfügung ausschlaggebend sind. Voraussetzung für die Möglichkeit, den Bedingungen, Wert- und Zielvorstellungen des individuellen Patienten zu entsprechen, ist auf jeden Fall die Verfügbarkeit unterschiedlicher Formen von Patienten- und Betreuungsverfügungen. Auch innerhalb eines Kulturkreises müssen daher verschiedene Formen vorsorglicher Willensäußerungen des Patienten rechtlich anerkannt werden. Welche Art von Verfügung jeweils die beste Option darstellt, ist dabei abhängig von medizinischen Bedingungen und persönlichen Wertvorstellungen, wie sie in den Fallstudien diskutiert werden. (shrink)

John Broome’s Climate Matters is a timely, elegant, and accessible book. His book is deliberately interdisciplinary, as is much of his work in moral philosophy more generally. The discussion of what should be done, and by whom, to prevent the adverse effects of climate change is informed by many years of philosophical engagement with economic theory, especially problems arising in the conceptualization and technical implementation of cost-benefit analysis.The central arguments in the book are informed as well by a longstanding engagement (...) with climate change science. Broome brings to bear a perspective forged in the work of his role as a lead author—and occasional critic—of the report of Working Group III of the .. (shrink)

: In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care plans developed in the absence of comprehensive health care reform (...) work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability. (shrink)