The American Journal of Bioethics, Volume 11, Issue 7, Page 24-25, July 2011.

Facing the impending rationing in health care and consequently necessary priorisation, this article pleads for primarily following the capability approach of justice. The decent minimum of just health care is onentated to the capability of leading a personally responsible life, functioning in its respective society. The capability approach is on the one band semantically justified by considering different ideas of humankind; on the other band, its capability of application is structurally checked by a network of further criteria conceming (...) justice. (shrink)

This article tries to analyze the meaning of a decent minimum of health care, by confronting the idea of decent care with the concept of justice. Following the ideas of Margalith about a decent society, the article argues that a just minimum of care is not necessarily a decent minimum. The way this minimum is provided can still humiliate individuals, even if the end result is the best possible distribution of the goods (...) as seen from the viewpoint of justice. This analysis is combined with an analysis from the perspective of solidarity, particularly of reflective solidarity, as a way to develop decent care, which is care that does not humiliate individuals and maintains their dignity. (shrink)

This article tries to analyze the meaning of a decent minimum of health care, by confronting the idea of decent care with the concept of justice. Following the ideas of Margalith about a decent society, the article argues that a just minimum of care is not necessarily a decent minimum. The way this minimum is provided can still humiliate individuals, even if the end result is the best possible distribution of the goods (...) as seen from the viewpoint of justice. This analysis is combined with an analysis from the perspective of solidarity, particularly of reflective solidarity, as a way to develop decent care, which is care that does not humiliate individuals and maintains their dignity. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 16-18, July 2011.

(2001). Justice and Healthcare: The Right to a Decent Minimum, Not Equality of Opportunity. The American Journal of Bioethics: Vol. 1, No. 2, pp. 1a-3a.

Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. (...) This account is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested. (shrink)

Isaiah Berlin’s political thought consistently combines tragic value pluralism with moral priority for a minimum sphere of individual liberty which is defined and protected by a core set of basic human rights. His fundamental concept of a common moral minimum includes multiple components, including the idea that there is a common moral world of plural and conflicting incommensurable objective values and the idea that humans share a common nucleus of needs and interests centered on the overriding goal of (...) human survival. The basic human rights have priority over competing values because the rights are essential for human survival. They determine a common threshold of human decency: decent societies must respect the rights, which are in principle mutually harmonious under ordinary conditions, although emergencies can arise in which some of the rights must be sacrificed to respect others. Berlin’s focus is on decency, which he insists can be maintained without a commitment to political democracy. (shrink)

The book theoretically examines the recent and topical debates over democracy and social rights, arguing that there are four fundamental rights that should be constitutionalized; minimum income; housing; healthcare; and education. The theoretical discussion is explored within an analysis of important legal cases.

Dating back to the 1930s, President Franklin D. Roosevelt argued that workers were entitled to a wage that allowed them to enjoy a decent standard of living—a conviction that led the president to propose the first federally-mandated minimum wage. Mr. Roosevelt’s proposal was met with highly partisan resistance in congress and the courts—reactions not different in kind from the highly partisan resistance former President Obama experienced in his proposal to increase the federal minimum wage from its current (...) level of $7.25 per hour. Reflecting President Roosevelt’s convictions, it is clear that many low wage workers today are not, and cannot, enjoying a decent standard of living at current minimum wage levels. Further, many of the economic arguments raised in opposition to increasing the minimum wage have been thoroughly discredited: empirical evidence suggests that increased minimum wages would not lead to dramatic spikes in unemployment, massive substitutions of capital for labor, business closings, and significantly increased consumer prices. However, as compelling as arguments for increasing the minimum wage may be, the reality is that this may not be sufficient to alleviate the plight of low income workers, particularly given the political nature of minimum wage adjustments. Indeed, it may be time to shift the national focus away from the minimum wage to an emphasis on viable living wage legislation, a proposition consistent with the social justice perspective of contemporary ethicists. (shrink)

We argue that human rights are best conceived as norms arising from a fiduciary relationship that exists between states and the citizens and noncitizens subject to their power. These norms draw on a Kantian conception of moral personhood, protecting agents from instrumentalization and domination. They do not, however, exist in the abstract as timeless natural rights. Instead, they are correlates of the state's fiduciary duty to provide equal security under the rule of law, a duty that flows from the state's (...) institutional assumption of irresistible sovereign powers. (shrink)

Arguing that the state and its people stand in a fiduciary relationship, Sovereignty's Promise puts forward a bold new account of political authority and its legal limits. In doing so it presents a fresh argument for common law constitutionalism and a novel theoretical framework for understanding the requirements of the rule of law.

The fundamental interaction that triggers a fiduciary obligation is the exercise by one party of discretionary power of an administrative nature over another party's interests, where the latter party is unable, as a matter of fact or law, to exercise the fiduciary's power. The goal of this paper is to demonstrate that there is something "deeply fiduciary" about the interaction between a state and its subjects. The fiduciary nature of this relationship provides the justification for the state's legal authority and (...) its obligation to act in the interests of its subjects. The practical manifestation of the state's overarching fiduciary obligation to its subjects is the rule of law. (shrink)

A broad range of scholars contend that the rule of law is indifferent to human rights. I call this view the "no-rights thesis," and attempt to unsettle it. My argument draws on the work of Lon L. Fuller and begins with the idea that the fundamental justification of the rule of law rests on a juridical conception of human agency, one that finds expression in the legal and moral claims that can arise from human agency within the context of legal (...) relationships. I argue that the state and its legal subjects are in a particular kind of legal relationship with one another, a fiduciary relationship, and that the content of the state's ensuing fiduciary obligation is the rule of law. Because the rule of law is intelligible in terms of the right, and independently of the good, it follows that compliance with the rule of law necessarily makes a moral difference regardless of how poorly the state lives up to the demands of the good. This is a conceptual rather than an empirical claim, and it leads to the conclusion that respect for human agency in the context of the state-subject fiduciary relationship necessarily entails respect for human dignity, respect for human dignity entails respect for human rights, and therefore a commitment to the rule of law entails a commitment to human rights. (shrink)

The prevailing view in Canada of the Crown-Native fiduciary relationship is that it arose as a consequence of the Crown taking on the role of intermediary between First Nations and British settlers eager to acquire Aboriginal lands. First Nations are sometimes deemed to have surrendered their sovereignty in exchange for Crown protection. The author suggests that the sovereignty-for-protection argument does not supply a compelling account of how Aboriginal peoples lost their sovereignty to the Crown. Furthermore, Aboriginal treaties compel the courts (...) to take seriously Aboriginal peoples' sovereign authority to treat with the Crown. First Nations did not intend to surrender their sovereignty through the treaty process, but courts assume that this is the result. Against this background, the author argues that the Supreme Court of Canada has imposed fiduciary obligations on the Crown in order to legitimise the Crown's assertions of sovereignty over Canada's Aboriginal peoples. (shrink)

Parliamentary privilege immunises certain activities of legislative bodies and their members from the ordinary law and judicial scrutiny. The rule of law, on the other hand, insists that everyone - including public officials - is subject to the law. Moreover, the rule of law is usually understood to involve judicial review of executive rather than legislative action. Thus, parliamentary privilege seems to establish a public sphere that is beyond the rule of law. Notwithstanding the tension that appears between these two (...) ideas, I argue that parliamentary privilege and the rule of law, properly understood, support rather than oppose one another. However, the ideas can be reconciled only if we reject the jurisdictional and categorical approach to parliamentary privilege adopted recently by the Supreme Court of Canada in Canada (House of Commons) v. Vaid [2005] 1 S.C.R. 667, 2005 SCC 30. This approach should be rejected because it trades on an unsustainable distinction between review of the scope of an asserted privilege and review its actual exercise, with the Court finding that only issues of scope are subject to review, even if important human rights are at stake. (shrink)

The relationship between Canadian administrative law and the Canadian Charter of Rights and Freedoms is complex and still unfolding. If a decision touches a Charter right, frontline decision-makers and reviewing courts alike determine the requirements of legality using the Charter, administrative law principles, or some combination of the two. There is an emerging consensus that the Charter does not replace the common law, but rather embodies and supplements fundamental legal principles contained within it.This chapter sets out various ways in which (...) judicial review at common law has influenced understandings of the Charter, as well as the manner in which the Charter has influenced review of administrative decisions when a Charter right is clearly at stake. The influence runs in both directions, and has significant implications for judicial review of both the procedure and substance of administrative action. In the realm of procedure, the courts rely on the common law doctrine of procedural fairness to interpret the principles of fundamental justice set out in s. 7 of the Charter. However, when courts review the substance rather than the procedural aspects of a decision that engages a Charter right, they tend to review the decision using the analytical framework developed in R. v. Oakes for testing the validity of legislation. Taken together, these general features of the relationship between Charter jurisprudence and administrative law suggest that each is porous and open-textured to the other. Put another way, the relationship between the Charter and administrative law exhibits a cross-fertilization of principles and approaches which inform judicial review of administrative action. (shrink)

The self-ownserhip thesis claims that people are the rightful owners of themselves, and that as a consequence that are entitled to do as they please, and appropriate what they will, just so long as they do not harm others. I argue that this no-harm proviso is problematic in that our best conception of harm is not that A harms B if, and only if, A makes B worse off, but rather that A harms B if, and only if, A's action (...) makes B worse off than B ought to be under the lights of our best political and moral theory. A consequence of this analysis of harm is that the self-ownership thesis turns out to be too crude to serve as a foundational principle of any political theory concerned with the distribution of scarce resources. (shrink)

For several decades, international law has recognized certain norms such as the prohibitions against genocide, slavery, and military aggression as "jus cogens"- peremptory law which supersedes conflicting international treaties and customs. Despite widespread acceptance of the jus cogens concept, legal theorists continue to debate whether peremptory norms derive their legal authority from state consent, natural law, or the demands of international public order. Anxiety over peremptory norms' legal basis has frustrated efforts to clarify the scope and content of jus cogens, (...) as well as placing peremptory norms on a collision course with inherited notions of state sovereignty. Drawing on Immanuel Kant 's conception of fiduciary relations, this Article develops a new theory of jus cogens based on the idea that states are fiduciaries of their people. According to the fiduciary theory, peremptory norms do not stand in opposition to state sovereignty; rather, they are constitutive of state sovereign authority because all states owe their subjects a fiduciary obligation to comply with such norms. The fiduciary model of the state resolves the longstanding tension in international legal theory between peremptory norms and state sovereignty and points to discrete formal and substantive criteria for identifying peremptory norms. (shrink)

We explore two special challenges indigenous peoples pose to the idea of sovereigns as trustees for humanity. The first challenge is rooted in a colonial history during which a trusteeship model of sovereignty served as an enabler of paternalistic colonial policies. The challenge is to show that the trusteeship model is not irreparably colonial in nature. The second challenge, which emerges from the first, is to specify the scope and nature of indigenous peoples’ sovereignty within the trusteeship model. Whereas the (...) interaction between states and foreign nationals is the locus of cosmopolitan law, the relationship between states and indigenous peoples is distinctive. In the ordinary cosmopolitan case, foreign nationals do not purport to possess legal authority. Indigenous peoples often do make such a claim, pitting their claim to authority against the state’s. We discuss how international law has attempted to come to grips with indigenous sovereignty by requiring states to include indigenous peoples in decision-making processes that affect their historical lands and rights. A crucial fault line in the jurisprudence, however, separates a duty to consult indigenous peoples from a duty to acquire their free, prior and informed consent. The latter but not the former recognizes that indigenous peoples possess a veto over state projects on their lands, in effect recognizing in them a limited co-legislative power. We focus on recent jurisprudence from the Inter-American Court of Human Rights, and consider whether either the duty to consult or FPIC are enough to dispel the shadow of the trusteeship model’s colonial past. We suggest that they are a move in the right direction, and that implicitly they represent international law’s recognition that states are no longer the sole bearers of sovereignty at international law. In limited circumstances, international law recognizes indigenous peoples as sovereign actors. (shrink)

In international law, the term "jus cogens" refers to norms that are considered peremptory in the sense that they are mandatory and do not admit derogation. Although the jus cogens concept has achieved widespread acceptance, international legal theory has yet to furnish a satisfying account of jus cogens's legal basis. We argue that peremptory norms are inextricably linked to the sovereign powers assumed by all states. The key to understanding international jus cogens lies in Immanuel Kant 's discussion of the (...) innate right of children to their parents' care. Drawing on Kant 's account, our theory of jus cogens posits that states exercise sovereign authority as fiduciaries of the people subject to their power. An immanent feature of this state-subject fiduciary relationship is that the state must comply with jus cogens. The fiduciary theory clarifies jus cogens's content by generating discrete criteria for identifying peremptory norms. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more modest and limited topic of (...) medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

One of the most prevalent rationales for public healthcare policies is a human right to healthcare. Governments are the typical duty-bearers, but they differ vastly in their capacity to help those vulnerable to serious health problems and those with severe disabilities. A right to healthcare is out of the reach of many developing economies that struggle to provide the most basic services to their citizens. If human rights to provision of such goods exist, then governments would be violating rights without (...) doing anything wrong. I argue that such variable ability to provide healthcare depends not only on financial resources, but on institutional capacity, and that the latter represents a more fundamental challenge to the existence of a human right to healthcare than previously recognized. This challenge does not imply that government has no obligations to protect and improve the health of their citizens, but that it is best to think of such obligations as generated by conventional rights, namely rights arising from local legal and social conventions, which require governments to pursue health-related moral goals such as reducing suffering, closing opportunity gaps for the disadvantaged, and preventing the spread of contagious diseases. We need not think of such moral goals in terms of human rights. (shrink)

This volume engages with post-humanist and transhumanist approaches to present an original exploration of the question of how humankind will fare in the face of artificial intelligence. With emerging technologies now widely assumed to be calling into question assumptions about human beings and their place within the world, and computational innovations of machine learning leading some to claim we are coming ever closer to the long-sought artificial general intelligence, it defends humanity with the argument that technological 'advances' introduced artificially into (...) some humans do not annul their fundamental human qualities. Against the challenge presented by the possibility that advanced artificial intelligence will be fully capable of original thinking, creative self-development and moral judgement and therefore have claims to legal rights, the authors advance a form of 'essentialism' that justifies providing a 'decent minimum life' for all persons. As such, while the future of the human is in question, the authors show how dispensing with either the category itself or the underlying reality is a less plausible solution than is often assumed. (shrink)

Scholarship aiming to describe the wrongness of exploitation, especially when it is voluntary and mutually beneficial, has increased greatly in recent years. In this paper, I expand the scope of this discussion by highlighting a set of additional ethical concerns associated with many cases of mutually voluntary and beneficial exploitation. Specifically, I argue that the phenomenon of persons desperately seeking out and gratefully accepting exploitative interactions raises special moral concerns. The element of voluntariness is key to understanding how and why (...) some exploitative interactions are degrading to exploitees. When an exploitative offer does not allow the exploitee sufficient progress toward a decent minimum of human functioning, these offers can create what I call a 'demeaning choice', where the exploitee may either accept the status quo or accept an offer that improves the exploitee's insufficiently. In these cases, the exploitee's participation in the interaction contributes to its demeaning quality, creating a form of `surface endorsement' of the treatment that she receives. (shrink)

: Free-market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate the basic (...) needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement. (shrink)

Contemporary accounts of medical ethics and professionalism emphasize the importance of social justice as an ideal for physicians. This ideal is often specified as a commitment to attaining the universal availability of some level of health care, if not of other elements of a “decent minimum” standard of living. I observe that physicians, in general, have not accepted the importance of social justice for professional ethics, and I further argue that social justice does not belong among professional norms. (...) Social justice is a norm of civic rather than professional life; professional groups may demand that their members conform to the requirements of citizenship but ought not to require civic virtues such as social justice. Nor should any such requirements foreclose reasonable disagreement as to the content of civic norms, as requiring adherence to common specifications of social justice would do. Demands for any given form of social justice among physicians are unlikely to bear fruit as medical education is powerless to produce this virtue. (shrink)

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled (...) to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants. (shrink)

In the newly emerging debates about genetics and justice three distinct principles have begun to emerge concerning what the distributive aim of genetic interventions should be. These principles are: genetic equality, a genetic decent minimum, and the genetic difference principle. In this paper, I examine the rationale of each of these principles and argue that genetic equality and a genetic decent minimum are ill-equipped to tackle what I call the currency problem and the problem of weight. (...) The genetic difference principle is the most promising of the three principles and I develop this principle so that it takes seriously the concerns of just health care and distributive justice in general. Given the strains on public funds for other important social programmes, the costs of pursuing genetic interventions and the nature of genetic interventions, I conclude that a more lax interpretation of the genetic difference principle is appropriate. This interpretation stipulates that genetic inequalities should be arranged so that they are to the greatest reasonable benefit of the least advantaged. Such a proposal is consistent with prioritarianism and provides some practical guidance for non-ideal societies–that is, societies that do not have the endless amount of resources needed to satisfy every requirement of justice. (shrink)

This essay discusses human rights from the standpoint of five outlooks dominant in our time by imaging five stylist ideal-typical countries. First, three countries in which the principle of defending human rights is unknown: Utilitaria, Communitaria and Proletaria. Each rejects human rights for a distinct set of reasons: the first because they conflict with utilitarian calculation, the second because they abstract from correct ways of living, the third because they soften hearts and are superfluous in a classless world. Accepting human (...) rights means departing from each of these standpoints in a given respect. First, we restrain the pursuit of social advantage, however enlightened or benevolent that pursuit. Second, we accept and protect the abstraction or distance of persons from specific, concrete ways of life. Third, we hold that the conditions of human life will never surmount scarcity, conflict of interests, moral divergences and limited rationality to render human rights superfluous. Next, two further countries are imagined in which human rights might be said to be respected: Libertaria and Egalitaria. The first represents a context of market freedoms, property rights, equal opportunity and civil rights but generates basic inequalities of condition and the sanctification of self-interest. The second is committed to rendering civil rights of equal worth to all and maintaining decent minimum standards for all, while striving for growth and improvement. But is Egalitaria feasible and viable? The incentives needed for growth give rise to inequalities, and the ideal of equal individual treatment conflicts with the communitarian goal of treating cultural identities as equal. These difficulties lead some away from Egalitaria back to Libertaria or Communitaria, but the essay concludes by suggesting that there is an »egalitarian plateau« that should not be abandoned for any of the other four possibilities. (shrink)

The ethics of firefighting is a seriously underexplored field. This is unfortunate, since firefighting raises issues of great social importance and has the potential to inform moral theorizing. In the first part of this paper, I explore possible reasons why firefighting ethics has received so little academic attention and argue that it warrants study in its own right. I do so primarily by comparing firefighting ethics to medical ethics, demonstrating their close relationship yet pointing out important differences: firefighting is less (...) professionalized than medicine, the caregiver-patient relationship is not central in firefighting, firefighters need to concern themselves with other values than life and limb, they face greater and qualitatively different risks than medical personnel, and they have to make almost every operative decision under conditions of temporal stress. In the second part of the paper, I argue that some elements from medical ethics may be adapted for use in firefighting ethics. I illustrate this by applying four mid-level principles from mainstream medical ethics to firefighting – the principles of autonomy, non-maleficence, beneficence, and justice. I argue that they are indeed applicable in firefighting ethics, but that they need modification and their relative weight is different. Respect for autonomy is of limited importance in firefighting. Non-maleficence is important, and beneficence is central. The special principle of beneficence for firefighters is best thought of as grounded in firefighters’ contractual obligations rather than in a general principle that one should help someone in peril. As regards the principle of justice, there is a case for applying a utilitarian principle of justice on the operative level and a principle of a decent minimum aid on the policy level. The latter can be brought about by comparatively simple and low-cost means, such as a volunteer fire service and subsidized fire equipment. (shrink)

The paper begins by drawing a distinction between “allocation” — the distribution of resources between different categories, and “rationing” — the distribution of scarce resources within a single category. I argue that the current allocation of funds to health care makes some form of rationing unavoidable. The paper next considers proposals by Daniel Callahan and Norman Daniels supporting age rationing publicly-financed life-extending medical care. I provide reasons for doubting that either argument succeeds. The final section of the paper sets forth (...) an alternative approach which holds that if people have any rights to health care, then they have a right to a decent minimum. (shrink)

A basic human right to the delivery of health care, even to the delivery of a decent minimum of health care, does not exist. The difficult with talking of such rights should be apparent. It is difficult if not impossible both to respect the freedom of all and to achieve their long-range best interests. -/- Rights to health care constitute claims against others for either their services or their goods. Unlike rights to forbearance, which require others to refrain (...) from interfering, rights to beneficence require others to participate actively in a particular understanding of the good life. Rights to health care, unless they are derived from special contractual agreements, depend on the principle of beneficence rather than that of autonomy, and therefore may conflict with the decisions of individuals who may not wish to participate in realizing a particular system of health care. If the resources involved in the provision of health care are not fully communal, private owners of resources may rightly have other uses in mind for their property than public care….[T]he principles of autonomy and beneficence that lie at the foundations of justice will spawn conflicts within any portrayal of a just allocation of health care resources. (shrink)

Carson Strong's article “Cloning and Infertility” has initiated a conversation in this journal about the ethical and policy issues surrounding the question of who, if anyone, should be allowed access to human reproductive cloning technology, should somatic cell nuclear transfer ever become technically feasible and safe. Strong's position in that article is that infertile opposite sex couples for whom cloning is the last resort for having a genetically related child are the only people who should be granted access to such (...) technology, primarily because this need to have a genetically related child would give such couples respectable reasons for cloning themselves. Also, every child has a basic right to a “decent minimum opportunity for development.” Thus it would be morally wrong, other things being equal, to clone a person with cystic fibrosis or spina bifida but morally permissible to clone a nearsighted person, because nearsightedness is not sufficiently disabling to violate the child's birthright. With this caveat, he concludes that protecting reproductive freedom requires that physicians be allowed to provide cloning services only to that small subset of infertile opposite sex couples who would need it as a last resort, should human reproductive cloning ever become safe and feasible. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to drop their (...) financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care, the issue of who provides health care has evolved as individual rights have (...) trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a ‘negative right to health care’, to various forms of a ‘positive right to health care’. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a ‘right’, which is unconditional, a ‘privilege’ has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one’s health must for elevated. To have access to health care in the future will mean some loss of personal rights and an increase in personal responsibility for gaining or maintaining one’s health. (shrink)

When the President’s Commission of 1983 concluded that there is an “ethical obligation” to secure universal access to a decent minimum of health care, some hoped that this standard would be achieved in the United States within a few years. Nearly 30 years later, when we began work on this issue of the Journal of Medicine and Philosophy (JMP), that standard had yet to be achieved, although the bills that would later become the Affordable Care Act (ACA) were (...) then working their way through Congress. Now, the ACA has been passed and signed into law. The provisions of that bill aim at achieving universal access to an “essential health benefits (EHBs) package". (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 25.1 (2001) 171-173 [Access article in PDF] Book Review Literary Lives: Biography and the Search for Understanding Literary Lives: Biography and the Search for Understanding, by David Ellis; ix & 195 pp. New York: Routledge, 2000, $35. In his discussion of biography as a form, Ellis points to his study as a response to the scarcity of "monographs on biography... and [that] none of them are (...) particularly satisfactory" (p. 2). He further points out that "the comparative dearth of analytic enquiry into biography is surprising" (p. 3). In short, his first pages get off to a rocky start in their tatty justification of a critical study. Though a critic of D. H. Lawrence, Ellis uses the English writer sparingly, pointing out in his "Preface" what he feels is a need "to keep illustration involving Lawrence to a decent minimum" (p. viii) while concentrating on those problems which face the biographer. That said, he sets about to characterize biography as an integration of "a disinterested enthusiasm for information... [fashioning a]... compelling story in which many details with no direct relevance to the life of his subject can be considered as contributing successfully to a period atmosphere" (p. 35). Ellis is thinking specifically of Norman Sherry's biography of Graham Greene through which he has brought to the discussion his intent of pointing to an approach which concerns itself with chapters on "Ancestors," "Primal Scenes," "Body Matters," "the Sociological [End Page 171] Imagination," "History, Chance and Self-determination," "Compatibility, Sartre and Long Biographies." All are aspects of biography.As well as the approach he suggests by these areas of concentration, Ellis draws broadly from many subjects of biography, always keeping a critical eye on its form. Anne Stevenson's approach "is towards psychological determinism" (p. 135); Ackroyd in his biography of Dickens raises "through a degree of intellectual play" the questions of when "lineage" is appropriate, that is, the extent to which it has any productive consequence. He also uses Hawthorne and Virginia Woolf as examples. Writing of the role of the historian raises difficulties for writers creating biographies from such an early period as that of Chaucer; Ellis points to Derek Pearsall's "excellent Life of Geoffrey Chaucer" (p. 121).Ellis neither can nor should ignore Lawrence and what better chapter to include him in than "Body Matters" in its concentration on illness. Here Ellis draws on Lawrence's concern with the harm of his health on his work (p. 78). He also considers Flaubert, Sartre, and Woolf. Briefly he mentions Stendhal's imagination of his "future audience" after his death (p. 109), sensibly rejects the long ago depleted and so, parenthetically, apparently permanent speculation on what Keats's might have become had he lived a full life "in a time of drugs for treatment of tuberculosis" (p. 123) and the equally mined issue of what prompted Hemingway's suicide (pp. 132-33). Certainly he is aware of the danger that such a use of material may pander to the pleasure of mere name-hunters (what if there were no index!). At the same time, if the effect of his range of examples invites additions of our own, while keeping before us that his study is about biography as form, it is successful.In "Primal Scenes," the fourth chapter of his book, Ellis gives what he feels is necessary space to Freud, the creator of the term. He points to Wordsworth's "spots of time" as only one indication of the difficulty--if not impossibility--of capturing biographically those moments in childhood by which the individual written about might be defined (p. 57). (Such an impossibility should not be surprising to those of us readers who recognize the nearly impossible task for ourselves in our own lives.) Surely both the biographer and autobiographer share this ignorance and frustration. In a very interesting move, Ellis points to Compton Mackenzie's discussion of a critical event in his six-year old life surrounding the interruption of an Easter evening with his parents and siblings, interrupted by the arrival of friends. Ellis writes... (shrink)

In this article, I maintain that the social process of labour commodification, through which the individual capability to uphold a decent welfare is bound to participation in the labour market, poses a problem of justice from the republican prospective on freedom as non-domination. I first discuss the reasons we might hold that capitalism brings a form of systemic domination by virtue of one of its intrinsic features: unequal access to the means of production. Then, I argue for a (...) class='Hi'>minimum de-commodification of labour power as a criterion of justice, adding that it should be conceived as a cosmopolitan proviso because states unfairly suffer from their limited economic capacity to neutralize capitalist systemic domination. Lastly, I compare the normative account of global justice that I am proposing in this article with sufficientarianism, with the capability approach, and with Thomas Pogge’s ‘Global Resources Dividend’. (shrink)

The question whether distributive justice is at bottom practice-dependent or practice-independent has received much attention in recent years. I argue that the problem of intergenerational justice resolves this dispute in favor of practice-independence. Many believe that we owe more to our descendants than leaving them a world in which they can merely lead minimally decent lives. This thought is particularly convincing given the fact that it is us who determine to a significant extent what this future world will look (...) like. However, no practices that would trigger distributive obligations exist between distant generations. Thus, if we have to leave more than a minimum for future generations, we cannot conceive of distributive justice in terms of the justification of ongoing social interactions. Rather we have to think of the entire concept as an idea based on persons’ legitimate interests and capacity for well-being, and which abstracts from participation in particular practices. (shrink)

One major objection to social rights is a failure of determining which precise social and economic claims should be granted rights status. The social rights debate has grappled with this ‘indeterminacy problem’ for quite some time, and a number of proposals have emerged aimed at fixing the content of these rights. In what follows I examine three distinct approaches to fleshing out the idea of a minimum threshold: social rights as the fulfilment of basic needs, social rights as the (...) securing of a minimally decent life and social rights as a requirement of citizenship. Each of these proposals progressively expands on what the minimum threshold of social rights requires and, conversely, what obligations they generate on part of the state. I will show that none of these approaches is entirely satisfactory and suggest that the social rights debate look elsewhere to determine its content. (shrink)

Israel Scheffler views moral education as having two major objectives: inculcating minimum standards of decent conduct and developing rationality in moral deliberation and judgment. The latter is to be achieved by engaging students in discussions of moral issues in such a way that they come to appreciate and follow standards of rational deliberation and judgment – standards that Scheffler explicates primarily in terms of impartiality. This paper argues that the conception of rational moral deliberation and discussion underlying Scheffler's (...) approach to moral education is inadequate, and suggests an alternative conception that gives far more prominence to the problem of interpreting the meaning of substantive moral concepts and determining how they apply to particular cases. (shrink)

The Living Wage Movement (LWM) should be evaluated on whether it enables more people, or people willing to work, to lead a decent life. But, first, to the extent that it succeeds in getting some workers up to that threshold it is likely to make it harder for other workers to do the same. Second, to the extent that it succeeds in getting some workers up to that threshold it is likely to make it harder for non-workers to do (...) the same. The LWM is likely afflicted with these problems to a greater extent than is the Minimum Wage Movement. (shrink)

One way of showing respect for human dignity is providing people with a suitable level of income security. This respect can be manifested by establishing a certain financial minimum that will allow people to function independently in society and use the opportunities offered by civilisation. The awareness of the above gives special meaning to the level of incomes obtained by the elderly. The fact that pensions are the primary resource for the population to meet its financial needs makes the (...) pension insurance solutions particularly important, especially the formula used for calculating the amount of a future pension. Its final amount will affect the pensioner’s standard of living, enabling them to enjoy the same quality of life they had in the period of economic activity or gradually causing impoverishment. The levels of future pensions depend on factors related to the systemic solutions, but pensioner’s personal characteristics also exert strong influence on their amounts. With the responsibility for having decent incomes after retirement being transferred to the insured themselves, it has become necessary to promote pension awareness (the knowledge of how the new system works) that translates into pension prudence prompting people to reduce voluntarily their current consumption in favour of future consumption. The public need to understand that the income replacement rate will be high only for few of the insured persons, i.e. those boasting high earnings and long, unbroken periods of economic activity. People with poorer records of economic activity will draw lower pensions that will not always allow them to live decent lives after retirement. (shrink)

The strong correlation between people’s socioeconomic position and health within high income countries is a well-documented fact. A person’s occupation, income and education level tell us a lot about that person’s prospects on a long and healthy life, such that we can speak of a ‘social gradient in health’, or a ‘socioeconomic health gap’. This association is often perceived to be unjust. Therefore, it is generally thought that governments should aim to reduce socioeconomic health inequalities. However, this idea needs ethical (...) justification, for it is not evident if and why exactly these inequalities are unjust. For instance, are inequalities in health unjust per se? Or because the underlying socioeconomic inequalities are unjust? And does justice require equal health levels, or a minimum level of health? What complicates the issue, is that the width of the health gap, or the steepness of the social gradient, depends on what health measures are used. Overall, the more subjective the measure, the greater the inequalities appear to be. But are all these measures equally morally relevant? This dissertation aims to give a better understanding of these philosophical questions. It does so by investigating the question of what we should understand by health in the first part, after which it addresses the question of how to evaluate socioeconomic health inequalities in the light of justice. The introduction begins with a description of the phenomenon of socioeconomic health inequalities, and how it has been addressed by politicians, epidemiologists and philosophers in the past and today. The chapter continues by formulating the central question of the dissertation – that of which health inequalities should be focused in the light of a concern with social justice. It explicates how this dissertation contributes to answering that question, by discussing the potential relation between the conceptualisation of health and justice evaluations, and by discussing which questions are addressed in each of the following chapters. The chapter 2 addresses the question of how health is conceptualised in the philosophical and public heath literature, and how theoretical concepts of health differ. It proposes to approach health concepts as a Wittgensteinian family of thick concepts and argues that while theories on health generally argue in favour of one specific concept, a comparison of concepts shows that we may need different concepts of health given the variety of health practices. By explicating the differences between five concepts of health, this chapter argues that each captures aspects of health that all seem relevant when we talk and think about health. Classifying these concepts based on their distinctions reveals them as members of a conceptual family: each of the discussed concepts differs from the others in at least one respect and resembles the others in several respects. Moreover, the discussion of the concepts shows that ‘health’ always both describes a condition and values that condition at the same time. Having both descriptive and evaluative dimensions, we can see health concepts as ‘thick concepts’. Given this evaluative dimension, it is important to reflect on the question of what understanding of health guides specific practices. Moreover, the distinctions revealed by the classification can serve as a conceptual toolbox for reflection on the assumptions and purposes of health practices. How such reflection could work is illustrated by a brief exploration of what health aspects are focused upon in three specific health practices. Chapter 3 presents a study into the question of how health is conceptualised by ordinary citizens and to what extent conceptualisations of health differ between socioeconomic groups. By making use of the method of concept mapping, this study analyses how different socioeconomic groups formulate their own answers regarding the question ‘what does health mean to you?’. It presents concept maps of health for three different socioeconomic groups living in the city of Utrecht that reveal that all groups have a multidimensional understanding of health. An interpretation of the concept maps reveals nuanced differences between groups. The multiple aspects of health were also ranked by importance. It appears that each group assigned most importance to mental health. All in all, the study shows that people in lower socioeconomic groups are more likely to show a conceptualisation of health that refers to 1) the absence of health threats, 2) a person within his/her circumstances, 3) the value of functional notions, and 4) an accepting attitude towards life. Chapter 4 addresses the question of what the theoretical and empirical study to concepts of health could imply for health equity practices. It does so by exploring further the suggestions made in chapters 2 and 3. Regarding the question of which health aspects should guide health equity policies, this chapter discusses the question of whether we should primarily look at subjective or objective health measures, and whether a universal or relative standard of health should be central. While justice-related concerns of impartiality and equal treatment may seem to favour an objective perspective and a universal health standard, it appears that we have good reason to account for the subjective perspective as well. It is also argued that a concern for recognition and participatory parity gives room for relative health standards. Th room for relative health standards confronts us with the question of how to deal with mechanisms like adaptive preferences that the concept maps reveal. It proposes a way out, by arguing for society-relative health standards. Chapter 5 examines the question of whether inequalities in health should be evaluated ‘directly’, thus independently of a distribution of their social determinants. It proposes a sufficientarian perspective, such that the central question of evaluation is that of whether everyone is – or can be – healthy enough. By discussing two sufficientarian approaches to health and social justice – by Powers & Faden and by Nussbaum – this chapter distinguishes two ways of setting a threshold level for health. Both approaches appear to provide an unsatisfactory basis for justice evaluations and lead us away from direct evaluation if we try to settle health minima that are less arbitrary. In anticipation to chapters 6 and 7, it is argued that the perspective of sufficient health for relational equality escapes this arbitrariness: compared to that of a decent human life, it better helps to answer both the question of what socioeconomic health inequalities a society is due to avoid, and the question of when socioeconomic health inequalities are unjust considering their consequences. Chapter 6 discusses to what extent Daniels’s theory of health justice provides a satisfactory answer to the question of what health inequalities a society is due to avoid. Daniels proposes an indirect evaluative approach by arguing that we should evaluate socioeconomic health inequalities in the light of Rawls’s principles of justice as fairness. That is, if socioeconomic inequalities are in accordance with fair equality of opportunity and with the difference principle, the corresponding health inequalities would be just. It is shown that the suggestion that Rawls’s principles regulate the social determinants of health neglects that not all social determinants of health belong to society’s basic structure as conceived of by Rawls and are thereby not subjected to the principles of justice. To acknowledge the social mechanisms leading to socioeconomic health inequalities in their full complexity, it is argued that we should broaden our understanding of society’s structure in accordance with Young’s notion of social structural processes. This renders the question of what health inequalities a society is due to avoid into a question of what we can expect from the side of the various actors that uphold the social structures that produce socioeconomic health inequalities. Lastly, it is discussed how a shift to Young’s theory completes the shift to non-ideal theorising that seem already initiated by Daniels, and that with this, the distinction between direct and indirect evaluation dissolves. Chapter 7 discusses to what extent equality in health is of instrumental value for a society of free and equals. It thus takes up the idea proposed in chapter 5, that an evaluation of the consequences of health inequalities is also due. Taking relational equality as an evaluative framework reveals three ways in which inequalities in life expectancy threaten this ideal. That is, via unequal risks to stigmatisation, unequal risks to unemployment and the risk of unequal pension enjoyments. It is thereby shown that these risks are especially great for those lower down the socioeconomic strata. It thus concludes that equality in health is of instrumental value to relational equality. The chapter continues to argue that our instrumental approach opens a new perspective: to mitigate the identified injustices by changing society, rather than by reducing inequalities in health. This is argued to be an advantage in the light of the realistic assumption that of the socioeconomic health inequalities will persist. The paper thus offers a complementary approach to both the evaluation and the mitigation of the injustice of socioeconomic inequalities in health. The discussion chapter summarises the central findings of the analyses of health concepts and discusses questions regarding the philosophical and practical merits of comparing theoretical health concepts, the need for developing new health measures or concepts and the importance or nonsense of studying citizen’s views on health. Repeating this for the dissertation’s second part, the central findings of the chapters on justice evaluation are summarised and followed by a discussion of questions and issues that have remained unaddressed so far. Here, central points of discussion are my take on rules of distribution, the distinction of direct and indirect evaluation, the role of ideal and non-ideal theory, the idea of relational equality, and personal responsibility for health. The chapter concludes by noting that also in the light of justice evaluations, all commonly used health measures are relevant for justice. Therefore, my recommendations for policy and further research entail that inequalities in each of these measures deserve attention by both policymakers and researchers. Specifically, policymakers and researchers should give attention to how exactly each of these health inequalities come about, in such a way that a discussion about the question of who can be assigned responsibility to alleviate them is well-informed; and both should give attention to the effects of health inequalities on the opportunities for people to live on equal standing, in such a way that when these opportunities are diminished, actions can be considered to aim to restore relational equality. (shrink)