In ethics and political philosophy, the concepts of equity, equality, need satisfaction, and justice are significant for the fulfilment of underlying requirements of human rights, and the attainment of peace in societies. Studies show these as potential frames for defining processes, distributing resources, sharing responsibilities, allocating rewards, demonstrating respect and dispensing with unequal treatments. Justice, as the ideal that impels us to impartially adjudicate between competent claims, is linked to equality. But as the moral force that propels actions (...) for needs’ satisfaction, it is linked to equity. Hence, equality and equity are two elements of the theory of justice: both are grounded on the principles of distributive justice. This ‘common grounding’ apparently obfuscates their distinctive features, and over time, has elicited their equiparation. This essay highlights the archetypal frames of the notions of equity and equality as indispensable principles of social justice. It identifies the skewed distribution of resources in Nigeria as arising from a legal framework that removes the power of personal/group autonomy from the people. The essay notes the misleading tendency in the insulated use of equality for justice, and accepts the primacy of distributive justice amongst rival pathways to national cohesive living. (shrink)

In John Rawls’s theory, the role of the principles of justice is to regulate the basic structure of society—its major social, political and economic institutions—and to specify the fair terms of cooperation for free and equal persons. Some have interpreted Rawls as excluding contract law, and perhaps the private law as a whole, from the basic structure. However, this interpretation of Rawls is untenable, given the motivations for his emphasis on the basic structure and the highly inclusive characterisations he (...) gives of it. Yet if he includes private law within the basic structure, he seems committed to holding that its design and operations should be regulated by his two principles of justice, which govern the distribution of basic liberties, economic resources and opportunities. This would leave it unclear whether there was any room for values other than distributive values to inform the design of private law. Leaving no role for other values might be unproblematic if distributive justice were a master normative category with equal regulative authority over all basic social institutions. But we should not assume that this ‘distributivist paradigm’ gives the best interpretation either of private law or of the fair terms of cooperation for a society of free and equal people. We need to think further about how non-distributive values may inform the principles of justice that regulate the institutional structure of society. And we need to ask how much of law, whether public or private, is regulated solely by principles of justice that focus on the distribution of basic liberties, economic resources and opportunities. (shrink)

Given resource constraints in healthcare, demands justice and equity require the constant development of material principles for resource distribution. In many cases, such material principles are formulated as mid-level principles, well-adapted to handle healthcare distribution but suffering from aspects outside the healthcare context that affect their application. In healthcare, factors outside the healthcare system will sometimes affect patients’ equal opportunity to receive treatment and achieve health. Examples of such factors might include an individual’s economic means, the cost (...) of drugs, geography, etc. This article explores whether the formal equality principle could help us address such problems. It is argued that the traditional (thin) formal equality principle can aid in priority setting, both as a heuristic tool to aid in consistency and also in handling under-determined cases. However, it appears to be too ‘thin’ to handle problems caused by factors outside the healthcare context. In the article, I explore a more robust version of the formal equality principle and argue that such a principle can be used to address such cases. However, even a more comprehensive formal equality principle will need to consider whether some other actors have a moral responsibility to address the problem or whether the issue could be solved more effectively by others. Furthermore, such a principle needs to consider whether the opportunity cost of achieving ‘thick’ formal equality is acceptable, given the material principles of distribution. (shrink)

In theory and practice, the notion of fairness is far from simple. The principle is often elusive and subject to confusion, even in institutions of law, usage, and custom. In Fairness, Nicholas Rescher aims to liberate this concept from misunderstandings by showing how its definitive characteristics prevent it from being absorbed by such related conceptions as paternalistic benevolence, radical egalitarianism, and social harmonization. Rescher demonstrates that equality before the state is an instrument of justice, not of social utility or (...) public welfare, and argues that the notion of fairness stops well short of a literal egalitarianism. Rescher disposes of the confusions arising from economists' penchant to focus on individual preferences, from decision theorists' concern for averting envy, and from political theorists' sympathy for egalitarianism. In their place he shows how the idea of distributive equity forms the core of the concept of fairness in matters of distributive justice. The coordination of shares with valid claims is the crux of the concept of fairness. In Rescher's view, this means that the pursuit of fairness requires objective rather than subjective evaluation of the goods being shared. This is something quite different from subjective equity based on the personal evaluation of goods by those laying claim to them. Insofar as subjective equity is a concern, the appropriate procedure for its realization is a process of maximum value distribution. Further, Rescher demonstrates that in matters of distributive justice, the distinction between new ownership and preexisting ownership is pivotal and calls for proceeding on very different principles depending on the case. How one should proceed depends on context, and what is adjudged fair is pragmatic, in that there are different requirements for effectiveness in achieving the aims and purposes of the sort of distribution that is intended. Rescher concludes that fairness is a fundamentally ethical concept. Its distinctive modus operandi contrasts sharply with the aims of paternalism, preference-maximizing, or economic advantage. Fairness will be of interest to philosophers, economists, and political scientists. "[Fairness is] one of the most forceful conceptual analysis of fairness yet produced." -Ludwig Beckman, The Review of Metaphysics Nicholas Rescher is University Professor of Philosophy and vice chairman of the Center for Philosophy of Science at the University of Pittsburgh. He has written more than seventy books in various areas of philosophy, including Complexity: A Philosophical Overview and Inquiry Dynamics, both published by Transaction. (shrink)

We present a vignette study conducted with a quota sample of the German population (n = 400). Subjects had to redistribute a good between two hypothetical persons who contributed equally to the available amount but differed in quantity needed and the reason for their neediness. On a within-subjects level, we tested for the effects of need, accountability, and resource availability on their third-party distribution decisions. Between subjects, we further varied the kinds of needs: The persons either needed the good (...) as a means to survive, to live a decent life, to participate in society, or to be autonomous. Despite equal productivity, the mean share allocated to the needier person was significantly higher than an equal share. However, this share turned out significantly smaller when the needier person was accountable for needing more than the other. Nonetheless, even if accountable, the needier person still got a share larger than their contribution would suggest. When there was a surplus of resources, the needier person got an even higher share than when resources were scarce. (shrink)

This conceptual paper revisits the concept of equality as a base of distributive justice and contends that it is underspecified, both theoretically and in terms of its ethical and pragmatic application to human resource management (HRM) within organizations. Prior organizational literature focuses primarily upon distributive equality of remunerative outcomes within small groups and implicitly employs an equity-based conception of inputs to define equality. In contrast, through exposition of the philosophical roots of equality principles, we reconceptualize inputs (...) as de facto equal and consider the systemic application of distributive equality in the form of status leveling practices. Ethical ramifications of distributive equality so viewed are explored. We conclude by arguing that, to implicitly insert a stronger ethics focus into the study and practice of HRM, perhaps there should be "equality theory" competing with equity theory for recognition in managerial and scholarly discourse. (shrink)

(2013). Hobbes's Account of Distributive Justice as Equity. British Journal for the History of Philosophy: Vol. 21, No. 1, pp. 13-33. doi: 10.1080/09608788.2012.689749.

This book sets forth a novel theory of distributive justice premised on the fundamental moral equality of persons. It argues that, subject to certain limitations on personal sacrifice, no one should have less valuable resources and opportunities available to him than anyone else, simply invirtue of some chance occurrence the risk of which he did not choose to incur. Applying this principle to the distribution of wealth and income, the specification of property rights, and the allocation of scarce (...) medical resources, Professor Rakowski reaches challenging, often unconventional,conclusions. He further criticizes the economic analysis of law as a normative theory, and develops an alternative account of tort law.Among the topics discussed are the principles by which earnings, wealth, and gifts should be taxed; whether the compulsory removal of organs for transplantation can be justified; how doctors and public officials should make life-or-death decisions when all those endangered cannot be saved; and themorality of killing human beings and nonhuman animals. (shrink)

The core of this book is a novel theory of distributive justice premised on the fundamental moral equality of persons. In the light of this theory, Rakowski considers three types of problems which urgently require solutions-- the distribution of resources, property rights, and the saving of life--and provides challenging and unconventional answers. Further, he criticizes the economic analysis of law as a normative theory, and develops an alternative account of tort and property law.

There is at present a divide in the geographical literature between those interested in distributive justice as a social value and those who seek to implement distributive plans on the basis of efficiency of resource use. The former are 'social geographers' interested in equity as a social value, and the latter are 'practical' economic and locational geographers. This divide mirrors one existing elsewhere in social science between Rawlsian liberalism and utilitarian planners. Here we argue that equality (...) and efficiency are related values that cannot be separated easily in the analysis of practical problems. Data on the distribution of transplantable human organs are considered in a practical consideration of this approach. The case-study suggests that inequality of distribution appears to effect adversely the general organ supply. Stated positively, the data suggest that, to the extent that equality of service is an objective, that goal may positively impact on organ supply. More generally, the conclusion argues for a conjoining of theoretical and practical geographical approaches where a scarce resource must be allocated across a dispersed population. (shrink)

In this paper I argue that individuals are, prior to the existence of just institutions requiring that they do so, bound as a matter of global distributive justice to restrict their use, or share the benefits fairly of any use beyond their entitlements, of the Earth’s capacity to absorb greenhouse gases (EAC) to within a specified justifiable range. As part of the search for an adequate account of climate morality, I approach the task by revisiting, and drawing inspiration (...) from, two prominent models from classical political philosophy for thinking about norms (rights, permissions, limits, etc.) regarding “pre-institutional” appropriation of unowned resources; Locke and Kant, respectively. The basic resources they develop—connected to fundamental norms of equality and rights to self-preservation and freedom—in order to generate their particular schema for distributive shares prior to the existence of just institutions can be usefully and plausibly connected up with the scarce, valuable, rival, non-excludable, global, and unowned resource that is EAC in order to undergird a picture of individual climate duties in the contemporary world. It is a picture that comes with some fairly radical implications, especially for the well-off. (shrink)

Distributive justice is achieved when entitlements to economic goods are allocated to people as they ought to be. Throughout most of the history of political philosophy, the attempt to specify the principles of distributive justice so conceived has been pitched at the domestic level: it has been concerned with distribution between the inhabitants of a city, the citizens of a country, the members of a society. But as the ‘globalization’ of communication and economic activity started being (...) perceived, conceptualized and named, there were fewer and fewer people whose city was their world, and more and more for whom the world had become their city. From grassroots activists to armchair philosophers, serious thought started being given to the idea that the demands of distributive justice should be pitched primarily at the global level, at the level of mankind as a whole. For those following this track, it would seem natural that whatever conception of justice was deemed plausible for the distribution of resources between members of a particular society should also provide a suitable characterization of global distributive justice. Yet, this view, as we shall see, turns out to be very controversial. (shrink)

According to robert nozick's theory of distributive justice, We are forced to choose between a commitment to the kantian principle that no one may be used as a means to the purposes of others and the socialist view that the benefits of land and natural resources should be distributed on the basis of an end-State standard of equity. However, We face no such dilemma. A careful look at nozick's argument reveals that the kantian imperative does not clearly entail (...) the right of individuals to own land and natural resources. Indeed a very plausible application of the imperative is compatible with the doctrine that land and resources are communal property. Therefore, Nozick's theory fails to justify economic distributions produced by a system in which natural resources are privately owned. (shrink)

This paper discusses Philippe Van Parijs’ claim that men’s lack of female longevity constitutes an injustice, whether this is caused by asocial factors or by gendered lifestyles. This response argues that, like others, such as John Kekes and Shlomi Segall, Van Parijs underestimates the resources of egalitarian liberalism to avoid this implication. One explanation treats individuals as liable for gendered life-shortening behavior, for example, when they value either life-shortening lifestyles or the choice between lifestyles, and one ca nnot say society (...) has not “done enough” for them. A second explanation claims a trait is not a relative advantage when it is systematically part of a package of traits that do not constitute a relative advantage. A third explanation claims a trait is not an advantage when its value to the trait bearer is conditional, and the relevant conditions are unlikely to be fulfilled. (shrink)

This introductory chapter provides an overview of the recent debate about responsibility and distributive justice. It traces the recent philosophical focus on distributive justice to John Rawls and examines two arguments in his work which might be taken to contain the seeds of the focus on responsibility in later theories of distributive justice. It examines Ronald Dworkin's ‘equality of resources’, the ‘luck egalitarianism’ of Richard Arneson and G. A. Cohen, as well as the criticisms (...) of their work put forward by Elizabeth Anderson, Marc Fleurbaey, Susan Hurley, and Jonathan Wolff. Key concepts such as responsibility (individual and collective), luck (thin and thick; brute and option), control, desert, and equality of opportunity are delineated, and the implementation of responsibility-sensitive accounts of justice is considered. The chapters of this book are positioned in relation to the wider literature on responsibility and distributive justice, and a brief outline of the chapters is provided. (shrink)

Between 1787, and the end of his life in 1832, Bentham turned his attention to the development and application of economic ideas and principles within the general structure of his legislative project. For seventeen years this interest was manifested through a number of books and pamphlets, most of which remained in manuscript form, that develop a distinctive approach to economic questions. Although Bentham was influenced by Adam Smith's An Inquiry into the Nature and Causes of the Wealth of Nations, he (...) neither adopted a Smithian vocabulary for addressing questions of economic principle and policy, nor did he accept many of the distinctive features of Smith's economic theory. One consequence of this was that Bentham played almost no part in the development of the emerging science of political economy in the early nineteenth century. The standard histories of economics all emphasize how little he contributed to the mainstream of late eighteenth and early nineteenth-century debate by concentrating attention on his utilitarianism and the psychology of hedonism on which it is premised. Others have argued that the calculating nature of his theory of practical reason reduced the whole legislative project to a crude attempt to apply economics to all aspects of social and political life. Put at its simplest this argument amounts to the erroneous claim that Bentham's science of legislation is reducible to the science of political economy. A different but equally dangerous error would be to argue that because Bentham's conception of the science of legislation comprehends all the basic forms of social relationships, there can be no science of political economy as there is no autonomous sphere of activity governed by the principles of economics. This approach is no doubt attractive from an historical point of view given that the major premise of this argument is true, and that many of Bentham's ‘economic’ arguments are couched in terms of his theory of legislation. Yet it fails to account for the undoubted importance of political economy within Bentham's writings, not just on finance, economic policy, colonies and preventive police, but also in other aspects of his utilitarian public policy such as prison reform, pauper management, and even constitutional reform. All of these works reflect a conception of political economy in its broadest terms. However, this conception of political economy differs in many respects from that of Bentham's contemporaries, and for this reason Bentham's distinctive approach to problems of economics and political economy has largely been misunderstood. (shrink)

This paper proposes a novel egalitarian answer to the question: what initial distribution of the world’s resources could possibly count as just? Like many writers in the natural rights tradition, I take for granted that distributive justice consists in conformity to pre-political principles that apply to property regimes. Against the background of that assumption, the paper distinguishes between broadly Lockean and broadly Grotian conceptions of distributive justice in the state of nature. After an extended critique of (...) various versions of the Lockean approach, it argues for a particular, egalitarian version of the Grotian view. My position is based on what I call the common ownership formula, which says: each human being, as an equal co-owner of the world’s resources, may use those resources provided that the terms of their use are in conformity with principles that no co-owner could reasonably reject as the basis of an informed, unforced general agreement between all of the world’s co-owners who sought to find equitable principles of resource division. Using this principle, I suggest how an unequivocally egalitarian view of pre-political entitlement can be justified without recourse to any alleged duty to ameliorate the effects of brute bad luck on people’s lives. (shrink)

A theory of justice for the basic structure of society may constrain though not directly govern colleges. The principle of "equal opportunity" commonly applied to jobs either does or does not apply to varsity opportunities. If it applies, it interdicts sex discrimination but, one fallacious argument notwithstanding, it states no obligation to expend resources on new teams. If it does not apply, an analogue of Rawls's difference principle may appropriately constrain inequalities between the sexes. In either case the preferences (...) of a majority of the sex affected by any inequality are pivotal in fashioning any tenable distributive policy. Those preferences are neglected by a government policy that assimilates equal opportunity to equality of (i) the ratio of male:female varsity athletes and (ii) the ratio of male:female students. It is argued that such policy rests on affirming the consequent. Its effects include misallocations of resources and overvaluation of athletics. It is argued that what should approximately be equal is competitive access, the ratio of available positions to aspirants, for each sex. Two versions of a principle of equal competitive access are proposed, the recommended one of which pertains to teams whose net consumption of resources is positive. (shrink)

Cosmopolitans argue that the account of human rights and distributive justice in John Rawls's The Law of Peoples is incompatible with his argument for liberal justice. Rawls should extend his account of liberal basic liberties and the guarantees of distributive justice to apply to the world at large. This essay defends Rawls's grounding of political justice in social cooperation. The Law of Peoples is drawn up to provide principles of foreign policy for liberal peoples. (...) Human rights are among the necessary conditions for social cooperation, and so long as a decent people respect human rights, a common good, and the Law of Peoples, it is not the role of liberal peoples to impose upon well-ordered decent peoples liberal liberties they cannot endorse. Moreover, the difference principle is not an allocative or alleviatory principle, but applies to design property and other basic social institutions necessary to economic production, exchange and consumption. It presupposes political cooperation—a legislative body to actively apply it, and a legal system to apply it to. There is no feasible global state or global legal system that could serve these roles. Finally, the difference principle embodies a conception of democratic reciprocity that is only appropriate to cooperation among free and equal citizens who are socially productive and politically autonomous. a Footnotesa I am grateful to K. C. Tan for many helpful discussions and criticisms of this essay. I am also grateful to the other contributors to this volume for their comments, and to Ellen Paul for her many helpful suggestions in preparing the final version of this essay. (shrink)

An ongoing tension exists within the Lockean tradition in political philosophy between the claim that each individual is the “Proprietor of his own Person” and the claim that nature is “that which God gave to Mankind in common.” The former claim points to a realm of discrete individual entitlements only formally equal in the sense of each individual having jurisdiction over his own person and not over any other person, while the latter points either to a collective entitlement to nature (...) or to individual entitlements to substantively equal shares of nature. Were the two realms, that of persons and that of extra-personal nature, separate and independent, no tension would arise from the union of these two claims. But the realms are manifestly interconnected. Individuals acquire, use, labor upon, invest their time and energy on, and transform, more or less in accordance with their purposes, elements of extra-personal nature. And Locke and his followers believe that at least certain of these interactions with segments of nature give rise to individual property rights to the segments thereby appropriated, labored upon, transformed, or whatever. The traditional bridging notion is each person's right to his own labor which is seen as part of each person's proprietorship over himself. According to this tradition, if the right of each individual over his own person is to be respected, individual titles to appropriated, labored upon, or transformed nature must also be respected. The task for anyone seeking to embrace all the strands within this Lockean heritage is to reconcile, a) this right to one's own labor and the system of private property rights tied to it plus the right of self-ownership which lies behind the right to one's own labor, with b) some distributionist ideal, at least with regard to natural resources. (shrink)

Proceeding on a limited number of general, widely accepted equity criteria, we develop a proposal for distributing common resources. In particular, the proposed fair division mechanism is individually rational, envy-free, Pareto-efficient and satisfies the stand alone test, which follows as a minimum requirement from the resource and population monotonicity criteria. Applied to international climate policy, the thrust of this proposal is that the South should initially be fully compensated for the greenhouse gas abatement measures it is to undertake as (...) a result of efficiency considerations. (shrink)

Aristotle is critical of the political egalitarianism advocated by ancient participatory democracies on the grounds that serious inequalities exist among citizens. Nevertheless, when he constructs his own complete political ideal in his Politics, he advocates an egalitarianism that is even stronger and wider in scope than the democratic one; it goes beyond equal political shares, proposing equality in many other things, including resources and wealth. Such strong egalitarianism is motivated by the kind of complete political ideal he aims to delineate—a (...) city possessing the best constitution and all the other good-making characteristics of a polis. To ground such characteristics, Aristotle makes several ideal assumptions about the human and non-human resources necessary for a polis. Some of these assumptions secure the kind of equality in political capacities and virtue among the citizens Aristotle needs for justifying, by the application of his principle of distributive justice, numerically equal shares in political office, resources, and other goods or burdens. Ideal, albeit negative, assumptions about indispensable non-citizen groups enable Aristotle to specify the features of those necessary for securing some private and civic goods essential to his complete political ideal and to justify certain extreme inequalities within his polis. This paper explores the nature of these assumptions, the role they play in the distribution of goods and burdens, and some of the problems they give rise to within Aristotle’s complete political ideal. (shrink)

This study examines public health nurses’ perceptions and concerns about the implications of Japan’s new long-term care insurance law concerning care provision for elderly people and their families. Respondents voiced their primary concern about this law as access to services for all elderly people needing care, and defined their major responsibility as strengthening health promotion and illness prevention programmes. Although wanting to expand their roles to meet the health care, social and public policy advocacy needs of elderly persons and their (...) families, respondents also stated their concern for the possible lack of enough resources for this expansion to support family caregivers adequately. They viewed their first function as developing collaborative relationships with local government officials to help to assure sufficient resources to provide the necessary foundation for long-term care programmes to deliver services to all those in need. These concerns fall within the larger ethical issue of distributive justice in a society based on the obligations of the state to citizens and the family to its members, especially elderly relatives, who, according to traditional Japanese values, retain respect. (shrink)

We argue that for theorists with a post-institutional conception of property, e.g., Rawlsians, there is no principled reason to limit the domain of distributive justice to tax and transfer-both tax policy and the rules of the private law are constructed in service to distributive aims. Such theorists cannot maintain a commitment to a normative conception of private law independent of their overarching distributive principles. In contrast, theorists with a pre-institutional conception of property can derive the private (...) law from sectors of morality independent of distributive justice. Nevertheless, we argue, this does not entail that the private law, for pre-institutional theorists, must be sanitized of equity-oriented values. Non-libertarian pre-institutional theorists holding principled commitments to equity-oriented values are free to invoke either tax and transfer or the rules of the private law to attain them. Footnotesa We are grateful to John G. Bennett, Harry Dolan, Edward McCaffery, and Ellen Frankel Paul for written comments on a previous draft and to Eric Mack, Fred Miller, Jeffrey Paul, A. John Simmons, and the other contributors to this volume for valuable discussions. (shrink)

This study constitutes an ethical analysis through the lens of distributive justice in the case of the Troubled Asset Relief Program (TARP), which was enacted in the midst of the Great Recession of 2007–2009. It begins by engaging with the visions of justice constructed by John Rawls and Robert Nozick, using their insights to locate the injustices of TARP according to their moral imaginations. However, this study argues that Rawls’ and Nozick’s theories of justice primarily envision (...) the nature of law as being restrictive of vice, not as instructors of virtue. Thus, it resources the legal philosophy of St. Thomas Aquinas to demonstrate how the positive pedagogy of law can enable a more just construction of economic rescue legislation, one that not only prevents future repetitions of economic vices and injustice, but is also formative for a society that prizes economic justice and virtues. In doing so, the study proposes two criteria for a more just consideration of economic rescue legislation that embraces law’s positive pedagogy. (shrink)

The international law principle of permanent sovereignty over natural resources posits that governments bear the sovereign rights to manage natural resources on behalf of citizens. That citizens have rights over natural resources at all however detaches from governance realities showcasing citizen marginalization. This necessitates revisiting the issue of what rights citizens actually have over natural resources. Qualitatively investigating this issue reveals rights of citizens over natural resources now embedded in the doctrine of peoples-based permanent sovereignty over natural resources. However, this (...) doctrine appears to be subject to international law limitations and might not be effective within domestic jurisdictions. Alternatively, PPSNR may be domestically driven by common ownership and environmental justice claims. These two drivers may be able to advance distributive justice rights of citizens to returns from natural resources exploitation within domestic jurisdictions. These rights could be actuated through rent distribution practices. This results in functional distributive justice. (shrink)

Cosmopolitans hold that our duties of distributive justice to others do not stop at borders. Darrel Moellendorf is among those who defend the view that principles of distributive justice are applicable beyond borders. He suggests as a principle of international justice the global difference principle, which allows inequalities in the distribution of wealth and resources only if they are to the greatest advantage of the least advantaged individuals. In this paper, I try to indicate that (...) Moellendorf’s argument for the global difference principle is far from sustaining it. Instead, I argue for a minimum floor principle of distributive justice on the basis of the idea that each person ought to have an equal standard of living with respect to the fulfillment of their basic interests. I also propose the principle of contribution backed up by the principle of fair equality of opportunity, aiming to equalize background conditions of a competition for socially favored positions, as the basic principles of a complete account of global distributive justice.Kozmopolitanisti drže da se naše dužnosti distributivne pravednosti prema drugima ne zaustavljaju na granicama. Darrel Moellendorf je među onima koji brane gledište da su načela distributivne pravednosti primjenjiva s onu stranu granica. Kao načelo međunarodne pravednosti on predlaže globalno načelo razlike, koje nejednakosti u raspodjeli bogatstva i resursâ dopušta samo ako su one u najveću korist najlošije stojećih individua. U ovome članku pokušavam pokazati da Moellendorfov argument u prilog globalnog načela razlike to načelo nimalo ne potkrepljuje. Umjesto toga argumentiram u prilog načela distributivne pravednosti minimalne razine na osnovi zamisli da bi svaka osoba trebala imati jednaki standard življenja s obzirom na ispunjenje njezinih osnovnih interesa. Ujedno kao osnovna načela potpunog opisa globalne distributivne pravednosti predlažem načelo doprinosa poduprto načelom pravične jednakosti mogućnosti, koje stremi izjednačavanju pozadinskih uvjeta natjecanja za društveno favorizirane pozicije. (shrink)

The ideal of distributive justice as a means of ensuring fair distribution of social opportunities is a cornerstone of contemporary feminist theory. Feminists from various disciplines have developed arguments to support the redistribution of the work of care through institutional mechanisms. I discuss the limits of such distribution under the conditions of theories that do not idealize human agents as independent beings. People’s reliance on care, understood as a response to needs, is pervasive and infuses almost all human (...) interaction. I argue that the effect of care on shaping the social opportunities of all individuals is huge, although often invisible. Much of the optimism of theories of distributive justice comes from ignoring or downplaying the way in which care influences most factors of social success. Jonathan Wolff distinguished between three types of resources whose fair distribution is important: internal, external and structural. Care, I argue, does not fit well in any of these types. Inseparably interwoven with relational realities, care cuts across these categories and thus poses a challenge to the feasibility of equal chances. I focus on the under-analyzed issue of bad care and show how difficult it is to dismantle legacies of bad care. Their effect on even close-to-ideal social arrangements is too significant to be disregarded, yet very difficult to tackle through institutional mechanisms. A commitment to certain elements of individual ethics – as opposed to merely political institutions – is required in order to bridge the gap between ideal theories of justice and feasible practical aims. (shrink)

This paper suggests a strategy for constructing a contemporary Humean theory of distributive justice which would serve to ground what I call an entrepreneurial welfare state. It is argued that blending David Hume's insights about the origins and purposes of justice with Ronald Dworkin's insurance-based reasoning supporting his equality of resources model of distributive justice will yield a state which, as a matter of justice, encourages its members to engage in entrepreneurial activities and which (...) protects them from the worst extremes of market economies. (shrink)

International borders concentrate opportunities in some societies while limiting them in others. Borders also prevent those in the less favored societies from gaining access to opportunities available in the more favored ones. Both distributive effects of borders are treated here within a comprehensive framework. I argue that each state should have broad discretion under international law to grant or deny entry to immigration seekers; but more favored countries that find themselves under immigration pressure should be legally obligated to fund (...) development assistance for countries that generate immigration pressure. Funding should be subject to conditions of fair and effective use in recipient countries, and should aim at a near-term target of immigration-pressure equilibrium. Equilibrium obtains between two countries when, given appropriate background circumstances, the same proportion of individuals in each manifests a preference to migrate to the other. If meeting the equilibrium target in the short term would be to the long-term disadvantage of the worst-off countries, then a Pareto-superior alternative target supersedes. It mandates development assistance at the level that yields the most favorable human development projections for the worstoff countries. An implementable set of institutions is described that can achieve the equilibrium goal in the long term without unduly sacrificing other important ends, including economic growth, political stability, cultural integrity, the political autonomy of distinct societies, and their proper accountability for policy choices. Key Words: global justice • immigration • borders • development • distributive justice • development assistance • equality • international law • cosmopolitanism. (shrink)

Recent disputes over whether older people should pay more for health insurance, or receive lower priority for transplantable organs, highlight broader disagreements regarding the legality of using age-based criteria in health care. These debates will likely intensify given the changing age structure of the American population and the turmoil surrounding the financing of American health care. This Article provides a comprehensive examination of the legality and normative desirability of age-based criteria. I defend a distributive justice approach to age-based (...) criteria and contrast it with two prevailing theoretical approaches to age-based criteria, nondiscrimination and discretion. I propose a detailed normative framework for the use of age-based criteria in health care, the lifetime justice approach, that considers the future life patients can gain from treatment and the past years of life they already have experienced. -/- This paper is available by open access from the Boston College Law School Digital Commons. (shrink)

There is growing interest for a communitarian approach to the governance of genomics, and for such governance to be grounded in principles of justice, equity and solidarity. However, there is a near absence of conceptual studies on how communitarian-based principles, or values, may inform, support or guide the governance of genomics research. Given that solidarity is a key principle in Ubuntu, an African communitarian ethic and theory of justice, there is emerging interest about the extent to which Ubuntu (...) could offer guidance for the governance of genomics research in Africa. To this effect, we undertook a conceptual analysis of Ubuntu with the goal of identifying principles that could inform equity-oriented governance of genomics research. Solidarity, reciprocity, open sharing, accountability, mutual trust, deliberative decision-making and inclusivity were identified as core principles that speak directly to the different macro-level ethical issues in genomics research in Africa such as: the exploitation of study populations and African researchers, equitable access and use of genomics data, benefit sharing, the possibility of genomics to widen global health inequities and the fair distribution of resources such as intellectual property and patents. We use the identified the principles to develop ethical guidance for genomics governance in Africa. (shrink)

Much recent work exploring a liberal theory of equality focuses on the questions of distributive justice and is thus relevant to a narrow range of legal questions. Equality, Responsibility, and the Law redresses this imbalance, reserving a single final chapter to questions of resource allocation and spending the other seven chapters on questions of equality relating to tort and crime. The book addresses a huge set of questions and—like some of the best work in philosophy—it gives the (...) same answer to all of them at an abstract level. It thus provides a coherent interpretive scheme for some of the most vexed terrain in the philosophy of law. The aim is to provide a way of looking at questions of responsibility in relation to both civil and criminal law and then explore the implications of this theory for the distribution of scarce resources. This is a Herculean task—and it is useful to think of the author as playing the role of a Dworkinian judge attempting to find a theory that gives integrity to the legal systems of Britain and North America. The dust jacket’s emphasis on legal luck hits an important theme of the book, but also obscures the extent to which this work concerns the justification of virtually every decision within common-law systems. (shrink)

We report the results of a vignette study with an online sample of the German adult population in which we analyze the interplay between need, equity, and accountability in third-party distribution decisions. We asked participants to divide firewood between two hypothetical persons who either differ in their need for heat or in their productivity in terms of their ability to chop wood. The study systematically varies the persons’ accountability for their neediness as well as for their productivity. We find that (...) participants distribute significantly fewer logs of wood to persons who are held accountable for their disadvantage. Independently of being held accountable or not, the needier person is partially compensated with a share of logs that exceeds her contribution, while the person who contributes less is given a share of logs smaller than her need share. Moreover, there is a domain effect in terms of participants being more sensitive to lower contributions than to greater need. (shrink)

This dissertation proposes a new reading and appraisal of an important theory of distributive justice, Ronald Dworkin's "Equality of Resources" . ER is traditional in holding that choices made by rational, ignorant and purely self-interested beings are relevant to distributive justice. ER is novel both in its use of such choices and in incorporating the idea that one's success is largely one's own responsibility into liberal egalitarianism. ;I argue that the tax-and-redistribution scheme Dworkin proposes to make (...) actual distributions just is flawed because he misconceives the role of choice. He errs in thinking that the conditions for person X to receive compensation depend on the choices of such beings, although he is right, I argue, insofar as the relevant choices include X's hypothetical choices. Dworkin errs in that ER implies that whether X meets these conditions can depend on X's irrational choices, although he is right that whether X meets these conditions can depend on some of X's actual choices. ER becomes flawed, I argue, when Dworkin derives a tax-and-redistribution scheme designed to achieve distributive justice in reality from the auction he proposes for making hypothetical distributions just. ;I then consider whether ER withstands stock objections and how plausible it is relative to rival Theories. Dworkin argues that ER, but not Rawls' Theory, meets the following condition for a Theory to be plausible: the distributions a Theory deems just must be sensitive to choices. I argue that Dworkin's argument is no longer plausible once we realize to which choice sensitivity principle he is himself committed. However, I argue, Seana Shiffrin's objection to ER fails because she misunderstands the role of choice in ER, although she is right insofar as there is a related, though superficial, objection. I also argue that ER is inconsistent and show how to resolve this inconsistency without leaving ER vulnerable to attack by G. A. Cohen's rival Theory. I trace ER's inconsistency and the failure of Dworkin's argument against Rawls' Theory to Dworkin's method of justification. (shrink)

This paper examines attempts to find a conception of justice in early Confucian contexts, focusing on the concept of yi in the Mencius. It argues against the approach of deriving principles of dividing burdens and benefits from the discussions of concrete cases employing the concept of yi and instead shows that Confucian ethical concerns are more attentive to what kinds of interpersonal relations are appropriate in specific circumstances. It questions the exclusive emphasis in justice-centred ethical discourse on assessing (...) actions, and even more narrowly actions of governments and other public institutions, and their consequences regarding distribution of rights and material resources and goods. Instead of applying some abstract principles of justice, whether of equality or some other priorities according to individual characteristics, distributive problems are approached from the perspective of the effect of any proposed distribution on interpersonal relationships. Principles of justice treat opportunities, resources, and goods that are supposed to be distributed as possessions or potential possessions of individuals always competing for resources and goods. Confucians treat them not as objects to be possessed by one and denied to others, but as facilitators of personal cultivation effecting appropriate interpersonal relationships constituting harmonious communities. The Mencius offers a different perspective on distributive problems by shifting our ethical attention from ‘who gets what?’ to ‘how should we relate to others?’ within a different conception of the good life and the ideal society or polity. (shrink)

This paper examines attempts to find a conception of justice in early Confucian contexts, focusing on the concept of yi (translated as ?appropriateness?, ?right?, ?rightness?, even ?justice?) in the Mencius. It argues against the approach of deriving principles of dividing burdens and benefits from the discussions of concrete cases employing the concept of yi and instead shows that Confucian ethical concerns are more attentive to what kinds of interpersonal relations are appropriate in specific circumstances. It questions the exclusive (...) emphasis in justice-centred ethical discourse on assessing actions, and even more narrowly actions of governments and other public institutions, and their consequences regarding distribution of rights and material resources and goods. Instead of applying some abstract principles of justice, whether of equality or some other priorities according to individual characteristics, distributive problems are approached from the perspective of the effect of any proposed distribution on interpersonal relationships. Principles of justice treat opportunities, resources, and goods that are supposed to be distributed as possessions or potential possessions of individuals always competing for resources and goods. Confucians treat them not as objects to be possessed by one and denied to others, but as facilitators of personal cultivation effecting appropriate interpersonal relationships constituting harmonious communities. The Mencius offers a different perspective on distributive problems by shifting our ethical attention from ?who gets what?? to ?how should we relate to others?? within a different conception of the good life and the ideal society or polity. (shrink)

Amartya Sen is a renowned economist who has also made important contributions to philosophical thinking about distributive justice. These contributions tend to take the form of criticism of inadequate positions and insistence on making distinctions that will promote clear thinking about the topic. Sen is not shy about making substantive normative claims, but thus far he has avoided commitment to a theory of justice, in the sense of a set of principles that specifies what facts are relevant (...) for policy choice and determines, given a full characterization of any situation in terms of these relevant facts, what ought to be done in that situation. Moreover, Sen has expressed skepticism about the existence of a fully adequate theory in this sense. According to Sen there is a plurality of moral considerations that bear on choice of action and policy and no particular reason to think that weights can be attached nonarbitrarily to each consideration to yield a theory.1 “Sen’s proposal is that distributive justice entails equalizing midfare levels across persons,” writes John Roemer.2 “Other things being equal,” one has to add by way of correction to Roemer’s formulation. Sen holds that we should be concerned with the extent of people’s capability or freedom to attain midfare as well as the midfare level actually reached. Sen holds that distributive values.. (shrink)

This paper considers the view that the basis of equality is the range property of being a moral person. This view, suggested by John Rawls in his A Theory of Justice (1971), is commonly dismissed in the literature. By defending the view against the criticism levelled against it, I aim to show that this dismissal has been too quick. The critics have generally failed to fully appreciate the fact that Rawls's account is restricted to the domain of distributive (...) justice. On Rawls's view distributive justice is a matter of the fair terms of cooperation among the participants of a system of social cooperation. I argue that this understanding of distributive justice can provide a compelling rationale for considering moral personality as the basis of equality for this domain of morality. That moral persons are indeed equal is further supported by an intuitive argument concerning the irrelevance of morally arbitrary factors, giving us reasons to believe that varying capacities among moral persons does not result in an unequal moral status. The dismissal of Rawls's account of equality has thus been premature, and it remains an important view to consider. (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 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)

The concept of equality is subject to many different interpretations, and it is closely connected to similar concepts such as equity, justice, fairness, and human rights. As an ideal, equality entails many aspects that are untenable. For instance, genetic and social inequalities may never be extinct, but they can both be ameliorated by proper distribution of society's resources. Likewise, within the context of health care, equality can be promoted by proper rationing of health resources, amongst which nursing care stands (...) out. In the field of nursing, the principle of equality presents itself in various forms of ethical and deontological mandates. However, beyond good intentions and abstract notions, there is a need to examine the ways in which nurses enforce this principle in practice, within the reality of modern health systems. Although there is scarcity of qualitative evidence in the nursing care rationing literature, existing studies suggest that fair treatment pertains to a largely intuitive sense of equality which involves subjective perceptions and judgements about rationing. Nurses’ initial predisposition is to view all patients as equal and treat them in an equal manner; yet, on an individual basis, each patient has a different starting point, different needs and different prospects that render rationing decisions complex and uncertain. Equality should be accepted with its unavoidable limitations in practice and be further examined within the context of nursing care rationing, in the hope that it can be advanced in a consistent way, despite the idealistic nature in many of its aspects. (shrink)

Amartya Sen is a renowned economist who has also made important contributions to philosophical thinking about distributive justice. These contributions tend to take the form of criticism of inadequate positions and insistence on making distinctions that will promote clear thinking about the topic. Sen is not shy about making substantive normative claims, but thus far he has avoided commitment to a theory of justice, in the sense of a set of principles that specifies what facts are relevant (...) for policy choice and determines, given a full characterization of any situation in terms of these relevant facts, what ought to be done in that situation. Moreover, Sen has expressed skepticism about the existence of a fully adequate theory in this sense. According to Sen there is a plurality of moral considerations that bear on choice of action and policy and no particular reason to think that weights can be attached nonarbitrarily to each consideration to yield a theory. (shrink)

Distribution of sufficient health care resources to the maximum number of people in LIC is the central theme of the book. Bangladesh is taken as a representative of low income countries (LIe. In LIC, there is scarcity of health care resources like other resources but the deserving persons are numerous. Therefore, it requires an efficient distribution of resources. Considering 'Inequality to get access to health care' as the basic problem in LIC, John Rawls' principle of fair equality of opportunity is (...) proposed to apply to give people access to health care resources. In this book it is critically analyzed how the principle fails to return a good result in LIC. Instead the principle of maximizing utility is proposed for the purpose. It is argued that maximum number of people can be provided sufficient health care by applying the principle. The principle has also been justified theoretically in concerned low income country and a fruitful result has been achieved from the test. It is claimed that applying principle of utility to provide sufficient health care to the maximum number of people is the most efficient way of health care resources distribution in LIC. (shrink)

In the context of the global COVID-19 pandemic, the fast and equitable distribution of effective vaccines worldwide is one of the challenges faced by international institutions in charge, as global equity in vaccine supply has not yet been achieved. Our paper explains the current state of ethical research on equity in global COVID-19 vaccine allocation, focusing on the COVAX Facility established by the WHO, acting as the global vaccine distributor. The article presents a detailed analysis of the first year of (...) COVAX allocation in 2021 identifying problematic aspects of its allocation framework regarding the implementation of COVAX’s fundamental allocation principles. We argue that the COVAX Facility has developed a proper concept to deal with global vaccine allocation—but to address uncovered defaults, we introduce the ‘Prioritized Distribution of Equal Shares’ model—a both ethical and practically feasible alternative allocation framework to protect the value of human lives in both high- and low-income countries through fair and fast global vaccine distribution in health emergencies. Nonetheless, we argue that the COVAX Facility remains the main organization to provide equitable access to vaccines. Yet, the global community has to consider further aspects such as patent protection, vaccine production and the lack of power of global structures to address the inequities that have arisen. Since new wars and further crises have arisen, a shift in public global attention endangers the processing of COVID-19-related issues. That is why now more than ever extensive efforts to achieve vaccine equity are needed. (shrink)