Is Health (Really) Special? Health Policy between Rawlsian and Luck Egalitarian Justice

In recent work, Norman Daniels extends the application of Rawls's principle of ‘fair equality of opportunity’ from health care to health proper. Crucial to that account is the view that health care, and now also health, is special. Daniels also claims that a rival theory of distributive justice, namely luck egalitarianism (or ‘equal opportunity for welfare’), cannot provide an adequate account of justice in health and health care. He argues that the application of that theory to health policy would result in an account that is, in a sense, too narrow, for it denies treatment to imprudent patients (e.g. lung cancer patients who smoked). In a different sense, Daniels argues, luck egalitarian health policy would be too wide: it arguably tells us to treat individuals for such brute‐luck conditions as shyness, stupidity, ugliness, and having the ‘wrong’ skin colour. I seek to advance three claims in response to Daniels's revised theory, and in defence of a luck egalitarian view of health policy. First, I question Daniels's assertion regarding the specialness of health. While he is right to abandon his insistence on the specialness of health care, it is doubtful that health proper can be depicted as special. Second, I try and meet Daniels's objections to luck egalitarianism. Luck egalitarian health policy escapes being too narrow for it does not in fact require denying basic care to imprudent patients. As for it being allegedly too wide, I try to show that it is not, after all, counterintuitive to rid individuals of unfortunate and disadvantageous biological traits (say, a disadvantageous skin colour). And third, I question whether Daniels's own Rawlsian account is in fact wide enough. I argue that fair equality of opportunity fails to justify some standard medical procedures that many health systems do already practice.     

Distributive Luck

Abstact

This article explores the Rawlsian goal of ensuring that distributions are not influenced by the morally arbitrary. It does so by bringing discussions of distributive justice into contact with the debate over moral luck initiated by Williams and Nagel. Rawls’ own justice as fairness appears to be incompatible with the arbitrariness commitment, as it creates some equalities arbitrarily. A major rival, Dworkin’s version of brute luck egalitarianism, aims to be continuous with ordinary ethics, and so is (a) sensitive to non-philosophical beliefs about free will and responsibility, and (b) allows inequalities to arise on the basis of option luck. But Dworkin does not present convincing reasons in support of continuity, and there are compelling moral reasons for justice to be sensitive to the best philosophical account of free will and responsibility, as is proposed by the revised brute luck egalitarianism of Arneson and Cohen. While Dworkinian brute luck egalitarianism admits three sorts of morally arbitrary disadvantaging which correspond to three forms of moral luck (constitutive, circumstantial, and option luck), revised brute luck egalitarian-ism does not disadvantage on the basis of constitutive or circumstantial luck. But it is not as sensitive to responsibility as it needs to be to fully extinguish the influence of the morally arbitrary, for persons under it may exercise their responsibility equivalently yet end up with different outcomes on account of option luck. It is concluded that egalitarians should deny the existence of distributive luck, which is luck in the levels of advantage that individuals are due.     

Luck And Equality: Susan Hurley

I argue that the aim to neutralize the influence of luck on distribution cannot provide a basis for egalitarianism: it can neither specify nor justify an egalitarian distribution. Luck and responsibility can play a role in determining what justice requires to be redistributed, but from this we cannot derive how to distribute: we cannot derive a pattern of distribution from the 'currency' of distributive justice. I argue that the contrary view faces a dilemma, according to whether it understands luck in interpersonal or counterfactual terms.     

Luck and Decision

abstract Much recent work on moral responsibility and on distributive justice has addressed the concept of luck. Very little attention has been given to the relation of luck to rationality. How does luck bear on our choices? Can beliefs about luck lead to unwise decisions? These questions have particular relevance for understanding gambling behaviour, and for public policy on gambling. In this paper I argue that no one is reliably lucky, and that projecting luck can undermine rational decision‐making. I give various examples to show the conceptual connection between luck and unpredictability. I present an a posteriori conception of projectibility, and argue that because lucky events are rationally unexpected, regularity statements about luck fail to satisfy the conditions of projectibility. I reject the claim that ‘lucky’ is a dispositional term, and thus projectible, on the ground that a dispositional interpretation leads to contradiction. I then defend my claim that luck is not projectible against three objections. I conclude with some thoughts about rational responses to luck, using gambling as an illustration.     

The Machinations of Luck

Luck is at issue when it is a matter of pure chance that a result of significant positive of negative value ensues for someone. Luck differs from fate, which pivots on an individual's condition, and from fortune, which pivots on an individual's talent and effort. It is by luck that you are rich when you win the lottery, by fortune if your wealth comes from talent and hard work, and by fate if you inherit those millions. On this basis luck lies beyond anyone's rational control. With risk (R) as the probability of failure in a chancy situation and the stake (S) as the difference between a favorable and an unfavorable outcome, luck (L) can be measured as the product of these quantities: L = R × S. The condition of humankind in an uncertain world being as it is, luck cannot be eliminated as a key factor of our existence, be it in cognitive, practical, or ethical regards.     

The Coherence of Luck Egalitarianism

One of the foremost egalitarian theories in recent years, luck egalitarianism, has recently been subjected to the charge that it is in fact incoherent. This charge is brought by David Miller who highlights two dimensions of luck egalitarianism: on the one hand a commitment to the justice of certain inequalities arising from responsible choices; on the other a commitment to injustice of brute inequalities. The putative incoherence emerges in cases where the inequalities that justice requires on the basis of individuals' responsible choices also entail brute luck inequalities for which there are the very same grounds of justice to condemn. Here I argue that the charge of incoherence against luck egalitarianism fails. In service of this I clarify the quite specific sense in which luck egalitarianism requires inequalities and demonstrate the coherence of this with its condemnation of other inequalities.     

Luck and the Domain of Distributive Justice

相似文献   

Justice as Fairness: Luck Egalitarian, Not Rawlsian

I assess G. A. Cohen’s claim, which is central to his luck egalitarian account of distributive justice, that forcing others to pay for people’s expensive indulgence is inegalitarian because it amounts to their exploitation. I argue that the forced subsidy of such indulgence may well be unfair, but any such unfairness fails to ground an egalitarian complaint. I conclude that Cohen’s account of distributive justice has a non-egalitarian as well as an egalitarian aspect. Each impulse arises from an underlying commitment to fairness. Cohen’s account of distributive justice is therefore one of justice as fairness.     

Disability as a test of justice in a globalising world

This paper shows how most modern theories of justice could require or at least condone international aid aimed at alleviating the ill effects of disability. Seen from the general viewpoint of liberal egalitarianism, this is moderately encouraging, since according to the creed people in bad positions should be aided, and disability tends to put people in such positions. The actual responses of many theories, including John Rawls's famous view of justice, remain, however, unclear. Communitarian, liberal egalitarian, and luck egalitarian thinkers alike have to consider their attitude towards cosmopolitan ideals before they can extend their theories across national borders. The only view of justice that automatically rejects the obligation of international aid based on disability is libertarianism. This is significant for two reasons. Libertarianism is arguably the economic doctrine of globalisation; and its moral appeal to voluntary charity draws attention to the foundations of voluntary corporate social responsibility. Is the latter a prompt for greater or lesser social and political responsibility in global matters?     

The Right to Health Care as a Right to Basic Human Functional Capabilities

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

Why epistemologists are so down on their luck

It is nearly universally acknowledged among epistemologists that a belief, even if true, cannot count as knowledge if it is somehow largely a matter of luck that the person so arrived at the truth. A striking feature of this literature, however, is that while many epistemologists are busy arguing about which particular technical condition most effectively rules out the offensive presence of luck in true believing, almost no one is asking why it matters so much that knowledge be immune from luck in the first place. I argue that the best explanation for the consensus that luck undermines knowledge is that knowledge is, complications aside, credit-worthy true believing. To make this case, I develop both the notions of luck and credit, and sketch a theory of knowledge in those terms. Furthermore, this account also holds promise for being able to solve the “value problem” for knowledge, and it explains why both internal and external conditions are necessary to turn true belief into knowledge. The arguments and ideas in this paper have been in development for a while, and I would like to thank a number of people for their contribution to that development. For many helpful discussions on these topics, In d’like to thank Steve Ellis, Linda Zagzebski and the students in my graduate epistemology seminar—Mary Gwin, Ben Hagy, Matthew Hodge, Robert Johnson and Shyam Patwardhan. And thanks to Karen Antell for her comments on an earlier draft     

INFINITE REGRESS ARGUMENTS

Abstract

Gerald Cohen's critique of John Rawls's theory of justice is that it is concerned only with the justice of social institutions, and must thus arbitrarily draw a line between those inequalities excluded and those allowed by the basic structure. Cohen claims that a proper concern with the interests of the least advantaged would rule out ‘incentives’ for ‘talented’ individuals. I argue that Rawls's assumption that the subject of justice is the basic structure of society does not arbitrarily restrict the concerns of political justice, as Cohen claims. Further, I argue that it does not allow ‘deep’ inequalities within a just basic structure. When properly understood, Rawls's theory of justice is strongly egalitarian, taken as a theory of fairness in the way the burdens and benefits of social cooperation are distributed, even if it is not as egalitarian as Cohen wishes.     

Paradigms and possibilities

This paper is a excursus into a philosophy of science for deployment in the study of sport. It argues for the virtues of Thomas Kuhn's account of the philosophy of science, an argument conducted strategically by contrasting that account with one derived from views of Karl Popper. In particular, it stresses, first, that Kuhn's views have been widely misunderstood; second, that a rectified Kuhnianism can give due weight to truth in science, while recognising that social sciences differ in crucial ways from natural sciences. For, as Kuhn recognised, social sciences do not function in the paradigm-relative way characteristic of natural sciences. Yet there Kuhn's jargon, and especially misguided talk of ‘paradigms’, is almost ubiquitous.

These thoughts have relevance for three groups. First, as both sports scientists and exercise scientists come to grips with the claims to scientificity of their work, they will need increasingly to locate it within an epistemological framework provided by philosophy of science. So they must begin to take Kuhn's view seriously. Second, social scientists of sport – faced with the predominant scientism of colleagues in sport and exercise science – must also recognise alternatives to a postmodernist rejection of the concept of truth, where Kuhn's picture of natural science clarifies one such. Finally, philosophers writing on sport must not let antipathy to scientism close off the options they present or the terms in which they (we!) present them. And that may require debate among ourselves on abstract issues not immediately connected with sport.     

Luck And Equality: Richard J. Arneson

Does it make sense to hold that, if it is bad that some people are worse off than others, it is worse if those who are worse off come to be so through sheer bad luck that it is beyond their power to control? In her contribution to this symposium, Susan Hurley cautions against a closely related fallacy: from the fact that people have come to an unequal condition through unchosen bad luck, it does not follow that, if we aim to undo the influence of unchosen luck, we ought to institute equality of condition. Forswearing the fallacy that Hurley analyses is compatible with answering the question affirmatively, and more generally with holding that principles of distributive justice should be sensitive to the distinction between chosen and unchosen bad luck. This essay explores how this might be done.     

Précis of Justice,Luck, and Knowledge*

Justice, Luck, and Knowledge (JLK) contributes to recent developments in two areas, moral responsibility and distributive justice. Prominent luck‐neutralizing approaches to distributive justice, exemplified in work by Cohen and by Roemer, argue that justice requires equal distribution of goods for which people aren't responsible. Such views of justice haven't focused attention on responsibility itself. Meanwhile, responsibility has been illuminat‐ingly articulated in work including, and influenced by, Frankfurt's seminal essays. My book brings these separate lines of work, on justice and on responsibility, into contact, examining how the new articulation of responsibility constrains the roles responsibility can play in distributive justice. Part I focuses on responsibility and its inverse correlate, luck; Part II assesses responsibility‐based approaches to justice in light of preceding arguments about responsibility. (See JLK, 4–5 on responsibility, reactive attitudes, and accountability.)     

A normative account of epistemic luck

This paper develops a normative account of epistemic luck, according to which the luckiness of epistemic luck is analyzed in terms of the expectations a subject is entitled to have when she satisfies the standards of epistemic justification. This account enables us to distinguish three types of epistemic luck—bad, good, and sheer—and to model the roles they play e.g. in Gettierization. One controversial aspect of the proposed account is that it is non‐reductive. While other approaches analyze epistemic luck in non‐epistemic terms—either in modal terms (lack of safety) or in agential terms (lack of creditworthiness)—I argue that the non‐reductive nature of the normative account is actually a selling‐point relative to its competitors.     

On the Moral Value of Physical Activity: Body and Soul in Plato's Account of Virtue

It is arguable that some of the most profound and perennial issues and problems of philosophy concerning the nature of human agency, the role of reason and knowledge in such agency and the moral status and place of responsibility in human action and conduct receive their sharpest definition in Plato's specific discussion in the Republic of the human value of physical activities. From this viewpoint alone, Plato's exploration of this issue might be considered a locus classicus in the philosophy of sport. Indeed, it is in this place that Plato offers a highly distinctive account of the value of physical education in terms of its vital contribution to the development of a part of the soul that he characterises in terms of ‘spirit’, ‘energy’ and/or ‘initiative’. Drawing on more recent work in ethics and philosophy of action, this paper sets out to revisit and evaluate Plato's argument. While concluding that Plato's case ultimately flounders on fundamental uncertainty regarding the logical role of spirit in the explanation of agency, the paper concludes that there is much to be learned – in the philosophy of sport and elsewhere – from the instructive failures of Plato's argument.     

The “Meta” Level of Integrity: Integrity in the Context of Structural Injustice

This essay argues for a new, “meta,” level of integrity that is created by the context of structural injustice. The essay will draw from Margaret Walker to bring out a defining social value of integrity, namely, its ability to facilitate reliable response to harms caused by “moral luck.” The essay will then argue that, when bad luck is caused by complex social‐structural function, traditional advice for maintaining one's integrity fails to provide adequate guidance; following such advice facilitates unjust social‐structural function, and so unreliability in response to harm. The essay will address this problem by arguing that in the context of structural injustice, a “meta‐level” meaning of integrity emerges. This new meta‐level of integrity, unlike the more traditional first‐level integrity, does not instruct an individual to disassociate herself from structural harms; instead, it instructs an individual to manage the way in which she participates in unjust social structures. Meta‐level integrity, unlike first‐level integrity, does not facilitate an end to structural harm, but it does promote a reliable presence of social‐justice movements within unjust structures.     

Beyond Skills and Structure: Justice Dispositions as Antecedents of Young Citizens' Volunteering and Political Participation

Community involvement is usually attributed to opportunity structures and individuals' ability to be involved. Building on psychological justice research, this paper proposes that justice dispositions add to explaining why young citizens become active in their communities or not. Furthermore, it is argued that justice dispositions help to understand why most studies find only moderate relationships between youth volunteering and forms of political involvement. In a sample of 321 young Swiss volunteers, this study shows justice centrality and belief in a just world to predict the extent of volunteering and political participation, even after controlling for civic skills and opportunity structures. However, scrutinising the motivations to volunteer, self‐oriented motivations (enhancement, social, career and understanding) more strongly affected the level of volunteering than motivations related to justice dispositions (political responsibility and social responsibility). These findings have implications for the attraction and retention of volunteers as well as for the politics of volunteering and community development in general. Copyright © 2013 John Wiley & Sons, Ltd.