Rawlsian Justice and the Social Determinants of Health

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health – should be considered a social primary good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient.     

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.     

The Place of Self‐Respect in a Theory of Justice

This essay provides a critical examination of Rawls' (and Rawlsians') conception of self‐respect, the social bases of self‐respect, and the normative justification of equality in the social bases of self‐respect. I defend a rival account of these notions and the normative ideals at stake in political liberalism and a theory of social justice.

I make the following arguments: (1) I argue that it is unreasonable to take self‐respect to be a primary social good, as Rawls and his interpreters characterize it; (2) secondly, drawing on a distinction made by Darwall, I argue that recognition respect provides a far more suitable notion of respect for a theory of justice than Rawls' notion of appraisal respect; (3) thirdly, I argue that Rawls' treatment of self‐respect and the social bases of self‐respect as empirical conceptions should be rejected in favor of normative notions of a reasonable or justified self‐respect and equality in reasonable social bases of self‐respect; (4) I argue that Rawls' notions of political liberalism and public reason provide a way of grounding a notion of the reasonable social bases of self‐respect in political ideals of the person implicit in modern economic institutions, and family relations, ignored by Rawlsians—but as central to reasonable social bases of self‐respect and justice, as Rawlsians' ideal of persons as free and equal citizens.     

How Does the Difference Principle Make a Difference?

The paper examines the relationship between the two parts of Rawls’ second principle of justice. More specifically, it explores the ways in which the Difference Principle (DP) may constrain the range of acceptable social arrangements in light of the stated lexical priority of the requirement of fair equality of opportunity (FEO) over the DP. The paper discusses two possibilities. First, it examines the role the DP may play within an institutional scheme that satisfies the requirement of FEO. Second, it discusses the role the principle may play in selecting among different institutional schemes that satisfy FEO. The paper argues that the DP has an important role only if there is a range of institutional arrangements that are equivalent from the point of view of FEO but non-equivalent from the point of view of the DP. Next, it explores the possible sources of the variation among the different FEO-equivalent institutional schemes, and argues that on the most satisfactory reading of the requirement of FEO, there will not be much variation that is relevant from the point of view of the DP. The paper concludes that the role of the Difference Principle is at best very limited in constraining the range of social arrangements that are acceptable from the point of view of justice.     

JUSTICE,INCENTIVES AND CONSTRUCTIVISM

In Rescuing Justice and Equality, G. A. Cohen reiterates his critique of John Rawls's difference principle as a justification for inequality‐generating incentives, and also argues that Rawls's ambition to provide a constructivist defence of the first principles of justice is doomed. Cohen's arguments also suggest a natural response to my earlier attempt to defend the basic structure objection to Cohen's critique, which I term the alien factors reply. This paper criticises the reply, and Cohen's more general argument against Rawls's constructivism. 1     

JUSTICE IS NOT EQUALITY

This essay disputes G. A. Cohen's claim that John Rawls's argument for the difference principle involves an argument from moral arbitrariness to equality and then an illicit move away from equality. Moreover, the claim that an argument from moral arbitrariness establishes equality as the essential distributive justice ideal is found wanting.     

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.     

Proving the non‐existence of God

Using Rawls's theory as illustration, I argue that any conception of justice which includes a commitment to equality of opportunity eventually must collide with a commitment to the family. I then contend that the link between justice and equality of opportunity cannot be severed by showing that one powerful attempt to do so founders. Borrowing from Martin Buber, I try to show that the perspective required by justice is different from and opposed to that required for intimate relations. Moreover, I argue that the institution of the family provides the soil without which human intimacy withers. Finally, I try to suggest that the need for human. I‐You encounters is a response to aspects of the human condition quite different from those which give rise to institutions of justice and the state.     

Incentive Inequalities and Talents: A Reply to Shiffrin

In a recent article, Seana Valentine Shiffrin offers a distinctive egalitarian critique of the types of incentive inequalities that are permitted by John Rawls's difference principle. She argues that citizens of a well-ordered society, who publicly accept Rawls's two principles of justice and their justifications, may not demand incentives to employ their talents in productive ways since such demands are inconsistent with a major justification for the difference principle: the moral arbitrariness of talent. I argue that there is no such inconsistency. Citizens can publicly accept the claim that talent is morally arbitrary and accept incentives to employ their talents productively without inconsistency. In the standard case that Rawls envisions, citizens who do so take their preferences to be a reason for a higher salary, not their talents.     

Equality of whom? a genetic perspective on equality (of opportunity)

Rawls’ principle of fair equality of opportunity has been regularly discussed and criticized for being inadequate regarding natural inequalities. In so far as this egalitarian goal is sound, the purpose of the paper is to see how the prospect of radical genetic intervention might affect this particular inadequacy. I propose that, in a post-genetic setting, an appropriate response would be to extend the same rules regulating societal inequalities to a regulation of comparable genetic inequalities. I defend this stance against recent arguments from the authors of From Chance to Choice and from Colin Farrelly’s alternative of the genetic difference principle. Thanks and appreciation to Dr. Pete Morris, Noreen McGuire and Ann Feeney for their support and encouragement. My thanks also to the participants of the Ninth Manchester Graduate (Brave New World 2005) Conference in Political Theory, where a shorter version of this paper was read.     

INEQUALITY,INCENTIVES AND THE INTERPERSONAL TEST

This article defends three claims: (1) even if Rawls' difference principle permits incentives to induce talented people to be more productive, it does not follow that it permits inequalities; (2) the difference principle, when adequately specified, may in some circumstances permit incentives and allow that the worst off are not made as well off as they could be; and (3) an argument for incentives might pass Cohen's interpersonal test even if it is unsound and might not pass it even if it is sound. 1     

Against Global Egalitarianism

This article attacks the view that global justice should be understood in terms of a global principle of equality. The principle mainly discussed is global equality of opportunity – the idea that people of similar talent and motivation should have equivalent opportunity sets no matter to which society they belong. I argue first that in a culturally plural world we have no neutral way of measuring opportunity sets. I then suggest that the most commonly offered defences of global egalitarianism – the cosmopolitan claim that human lives have equal value, the argument that a persons nationality is a morally arbitrary characteristic, and the more empirical claim that relationships among fellow-nationals are no longer special in a way that matters for justice – are all defective. If we fall back on the idea of equality as a default principle, then we have to recognize that pursuing global equality of opportunity systematically would leave no space for national self-determination. Finally, I ask whether global inequality might be objectionable for reasons independent of justice, and argue that the main reason for concern is the inequalities of power that are likely to emerge in a radically unequal world.I am very grateful to Gillian Brock and Kok-Chor Tan for their helpful comments on an earlier draft of this article.     

The Irrationality of Choosing Egoism—A Reply to Eshelman

Despite the vast literature on Rawls's work, few have discussed his arguments for the value of democracy. When his arguments have been discussed, they have received staunch criticism. Some critics have charged that Rawls's arguments are not deeply democratic. Others have gone further, claiming that Rawls's arguments denigrate democracy. These criticisms are unsurprising, since Rawls's arguments, as arguments that the principle of equal basic liberty needs to include democratic liberties, are incomplete. In contrast to his trenchant remarks about core civil liberties, Rawls does not say much about the inclusion of political liberties of a democratic sort – such as the right to vote – among the basic liberties.

In this paper, I complete some of Rawls's arguments and show that he has grounds for including political liberties, particularly those of a democratic nature, in the principle of equal basic liberty. In doing so, I make some beginning steps toward illustrating the genuinely democratic nature of Rawls's arguments. Rawls believes that a few different arguments can be given for democratic institutions and that these arguments work together to support the value of democracy. In this paper, I focus on Rawls's arguments relating to self-respect. I focus on this set of arguments because they are among the strongest of Rawls's arguments for equal political liberty and its fair value.     

Disability,Respect and Justice

Recent political philosophers have argued that criteria of social justice that defend distributing resources to individuals on the basis of the disadvantages of their natural endowments are disrespectful and disparaging. Clearly influenced by the social model of disability, Elizabeth Anderson and Thomas Pogge have recently defended criteria of social justice that distribute resources to people with disabilities on the basis of eliminating discrimination, not making up for so‐called natural disadvantage. I argue that it is implausible to suggest that just entitlements for people with disability can be secured solely by eliminating discrimination. Resources for people with disabilities must sometimes be justified on the grounds that some natural endowments pose disadvantages even in societies that do not discriminate. I argue further that there need be nothing at all disrespectful about this way of explaining disadvantage; nor have proponents of the social model of disability or political philosophers provided any compelling reasons for supposing that it is disrespectful. There is thus no motivation for Anderson's and Pogge's attempts to secure justice for people with disabilities by appealing solely to the imperative to eliminate discrimination.     

The Rawls–Harsanyi Dispute: A Moral Point of View

Central to the Rawls–Harsanyi dispute is the question of whether the core modeling device of Rawls' theory of justice, the original position, justifies Rawls' principles of justice, as Rawls suggests, or whether it justifies the average utility principle, as Harsanyi suggests. Many commentators agree with Harsanyi and consider this dispute to be primarily about the correct application of normative decision theory to Rawls' original position. I argue that, if adequately conceived, the Rawls–Harsanyi dispute is not primarily a dispute about the correct application of normative decision theory to Rawls' original position. Instead, Rawls and Harsanyi aim to model different moral ideals, and this difference in their moral assumptions leads them to significantly different conclusions about justice. There is no winner in the Rawls–Harsanyi dispute. Instead, the dispute merely clarifies the moral ideals and their formal representations that need to be assumed in order to justify either Rawls' contractualist principles of justice or the average utility principle. Thus understood, the Rawls–Harsanyi dispute offers a promising starting point for future research that can deepen and enrich our understanding of the demands of justice.     

Do Rawls's theories of justice fit together? A reply to Pogge

In my reply to Pogge's critique of Rawls's international relations theory, I will try to show two things: (1) that Pogge's account of the public criterion of domestic social justice endorsed by Rawls is a partial one and (2) that this leads him to wrongly postulate a significant asymmetry between Rawls's domestic and international theories of justice. In the end, I hope to show that the domestic and international accounts are characterized by a significant degree of symmetry – that both accounts are motivated by Rawls's fundamental concern with self-respect. In other words, a more expansive, complete account of the domestic public criterion of social justice necessarily leads us (contra Pogge) to affirm a significant degree of continuity between the domestic and international accounts.     

The limits of fair equality of opportunity

The principle of fair equality of opportunity is regularly used to justify social policies, both in the philosophical literature and in public discourse. However, too often commentators fail to make explicit just what they take the principle to say. A principle of fair equality of opportunity does not say anything at all until certain variables are filled in. I want to draw attention to two variables, timing and currency. I argue that once we identify the few plausible ways we have at our disposal for filling in those variables, it will become apparent that a reasonable version of the principle will be quite narrow. Its usefulness as a justificatory basis for social policies will be limited to those policies that target the distribution of competitive opportunities among people entering majority.     

Justice,Health, and Healthcare

Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health and healthcare with an account of fair process for setting limits or rationing care. This account is provided by three conditions that comprise "accountability for reasonableness."     

Left–right ideological differences in system justification following exposure to complementary versus noncomplementary stereotype exemplars

The capacity for victim‐derogating stereotypes and attributions to justify social inequality and maintain the status quo is well known among social scientists and other observers. Research conducted from the perspective of system justification theory suggests that an alternative to derogation is to justify inequality through the use of complementary stereotypes that ascribe compensating benefits and burdens to disadvantaged and advantaged groups, respectively. In two experimental studies conducted in Poland we investigated the hypothesis that preferences for these two routes to system justification would depend upon one's political orientation. That is, we predicted that the system‐justifying potential of complementary versus noncomplementary stereotype exemplars would be moderated by individual differences in left–right ideology, such that left‐wingers would exhibit stronger support for the societal status quo following exposure to complementary (e.g., “poor but happy,” “rich but miserable”) representations, whereas right‐wingers would exhibit stronger support for the status quo following exposure to noncomplementary (e.g., “poor and dishonest,” “rich and honest”) representations. Results were supportive of these predictions. Implications for theory and practice concerning stereotyping, ideology, and system justification are discussed. Copyright © 2008 John Wiley & Sons, Ltd.     

From the Editors

This article examines the relationship between global poverty and terrorism. The approach is built around a concept of ‘social bandit’ developed by Eric Hobsbawm. By social bandits, Hobsbawm refers to those outlaws in pre-capitalist societies who robbed the rich, and gave (at least some of their loot) to the poor. What was common to social bandits is a myth that surrounded their activity, and a strong popular sympathy and support. This article uses Hobsbawm's notion of social bandit to deal with the fact that in today's international setting, particularly in the context of huge international inequality and widespread poverty in the non-western world, violence against western states, particularly the United States, enjoys significant sympathy elsewhere. This is not only an outcome of inequality and has to do with other factors, particularly certain political or military actions of the USA and other western states, but what is important to note here is that violence perpetrated by terrorists is directed at those who are seen as beneficiaries of the existing order, of international inequalities and injustices. In short, the operation of the international order, its asymmetries and inequalities, riches and wealth in developed countries and poverty and misery elsewhere, seems to play a role in the creation of such social bandits, and in providing them with support and legitimacy which they otherwise would not have had.