The authors of “The Two Front War on Reproductive Rights” make a profoundly important observation—“Because zygotes, embryos and fetuses early in gestation are neither viable nor independent without...

In lieu of an abstract, here is a brief excerpt of the content:Hume Studies Volume XXIV, Number 1, April 1998, pp. 53-70 Hume on Justice to Animals, Indians and Women ARTHUR KUFLIK I. The Circumstances of Humean Justice For Hume, the virtue of justice is its "usefulness" to the support of society.1 To help prove this point, he guides us through a series of imaginative thought-experiments. Suppose that resources were infinitely available or that human beings were generous and (...) kind without limit: in such unusual circumstances, nobody would have even "dreamed of" the various property restrictions associated with justice. If the supposition seems too fanciful, the same point can be illustrated, at least to some extent, by special real-life circumstances as well: e.g., by the way that air or water or land go unregulated in those places where they are super-abundant or the way in which the line between what is "mine" and "thine" blurs in loving families or between intimate friends. Moving to the opposite extreme: suppose that resources were so scarce as to render it impossible for most people (regardless of their cooperative exertions) even to subsist. Or suppose that people were not merely limited in their benevolent concern but "perfectly malicious"! Once again, there would be little or no point to the observance of rules of justice. On Hume's account, such rules define a scheme of social cooperation. But by hypothesis, extreme scarcity makes even well-meaning cooperative effort unproductive. Extreme villainy makes it pointlessly dangerous. Indeed, in a world wholly villainous, just cooperative schemes would be altogether impossible. Arthur Kuflik is at the Department of Philosophy, The University of Vermont, 70 South Williams Street, Burlington, Vermont 05401-3404 USA. email: [email protected] 54 Arthur Kuflik What can we conclude? There is a range of circumstances within which schemes of justice make sense: (1) moderate scarcity (resources are adequate to sustain people, but not so extensive that everyone could have as much as might be desired); and (2) limited benevolence (people are neither saintly nor satanic; though clearly concerned about themselves, they are not incapable of caring about what happens to others). John Rawls has dubbed these conditions "the Humean circumstances of justice."2 Hume wants us to notice that they are the very conditions under which justice is both practically possible and socially necessary. Fortunately, they are also the conditions that most commonly prevail. ("The common situation of society is a medium amidst all these extremes" [EPM 188].) II. A More Puzzling Thought-experiment Suppose we grant that the foundation of justice is its usefulness to society. This raises a certain worry: aren't there groups whose members ought to be treated justly even though "society" could flourish just as well if they weren't? (Another way to put the point is to ask: just who are the members of "society"?) This very issue underlies one more puzzling, and even disturbing, Humean thought-experiment: Were there a species of creatures intermingled with men, which, though rational, were possessed of such inferior strength, both of body and mind, that they were incapable of all resistance, and could never, upon the highest provocation, make us feel the effects of their resentment; the necessary consequence, I think, is that we should be bound by the laws of humanity to give gentle usage to these creatures, but should not, properly speaking, lie under any restraint of justice with regard to them, nor could they possess any right or property, exclusive of such arbitrary lords. Our intercourse with them could not be called society, which supposes a degree of equality; but absolute command on one side, and servile obedience on the other.... And as no inconvenience ever results from the exercise of a power, so firmly established in nature, the restraints of justice and property, being totally useless, would never have place in so unequal a confederacy. (EPM 190-191) What can we learn from this thought-experiment? What insight into justice do we gain by imagining a "species of creatures intermingled" among us who, though endowed with some ability to think and to reason, are: (i) greatly inferior to us both physically and mentally; (ii) "incapable of all resistance" to our provocations; and... (shrink)

abstract According to “legal moralism” it is part of law's proper role to “enforce morality as such”. I explore the idea that legal moralism runs afoul of morality itself: there are good moral reasons not to require by law all that there is nevertheless good moral reason to do. I suggest that many such reasons have broad common‐sense appeal and could be appreciated even in a society in which everyone completely agreed about what morality requires. But I also critique legal (...) moralism from the special perspective of liberal political justice. Liberalism requires that citizens who disagree with one another on a number of morally significant matters nevertheless coexist and cooperate within a political framework of basic rights protections. When it comes to working out the most basic terms of their political association, citizens are expected to address one another within the limits of what Rawls has called “public reason”. Critics of liberalism claim that this is an essentially a‐moral (or expedient) attempt to evade substantive moral issues — such as the moral status of the fetus. I argue, on the contrary, that liberalism's emphasis on public reason is itself grounded in very deep — though (suitably) “non‐comprehensive”— moral considerations. (shrink)

abstract According to “legal moralism” it is part of law's proper role to “enforce morality as such”. I explore the idea that legal moralism runs afoul of morality itself: there are good moral reasons not to require by law all that there is nevertheless good moral reason to do. I suggest that many such reasons have broad common‐sense appeal and could be appreciated even in a society in which everyone completely agreed about what morality requires. But I also critique legal (...) moralism from the special perspective of liberal political justice. Liberalism requires that citizens who disagree with one another on a number of morally significant matters nevertheless coexist and cooperate within a political framework of basic rights protections. When it comes to working out the most basic terms of their political association, citizens are expected to address one another within the limits of what Rawls has called “public reason”. Critics of liberalism claim that this is an essentially a‐moral (or expedient) attempt to evade substantive moral issues — such as the moral status of the fetus. I argue, on the contrary, that liberalism's emphasis on public reason is itself grounded in very deep — though (suitably) “non‐comprehensive”— moral considerations. (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)

To what extent should humans transfer, or abdicate, responsibility to computers? In this paper, I distinguish six different senses of responsible and then consider in which of these senses computers can, and in which they cannot, be said to be responsible for deciding various outcomes. I sort out and explore two different kinds of complaint against putting computers in greater control of our lives: (i) as finite and fallible human beings, there is a limit to how far we can acheive (...) increased reliability through complex devices of our own design; (ii) even when computers are more reliable than humans, certain tasks (e.g., selecting an appropriate gift for a friend, solving the daily crossword puzzle) are inappropriately performed by anyone (or anything) other than oneself. In critically evaluating these claims, I arrive at three main conclusions: (1) While we ought to correct for many of our shortcomings by availing ourselves of the computer''s larger memory, faster processing speed and greater stamina, we are limited by our own finiteness and fallibility (rather than by whatever limitations may be inherent in silicon and metal) in the ability to transcend our own unreliability. Moreover, if we rely on programmed computers to such an extent that we lose touch with the human experience and insight that formed the basis for their programming design, our fallibility is magnified rather than mitigated. (2) Autonomous moral agents can reasonably defer to greater expertise, whether human or cybernetic. But they cannot reasonably relinquish background-oversight responsibility. They must be prepared, at least periodically, to review whether the expertise to which they defer is indeed functioning as he/she/it was authorized to do, and to take steps to revoke that authority, if necessary. (3) Though outcomes matter, it can also matter how they are brought about, and by whom. Thus, reflecting on how much of our lives should be directed and implemented by computer may be another way of testing any thoroughly end-state or consequentialist conception of the good and decent life. To live with meaning and purpose, we need to actively engage our own faculties and empathetically connect up with, and resonate to, others. Thus there is some limit to how much of life can be appropriately lived by anyone (or anything) other than ourselves. (shrink)

We present a game mechanic called pseudo-visibility for games inhabited by non-player characters (NPCs) driven by reinforcement learning (RL). NPCs are incentivized to pretend they cannot see pseudo-visible players: the training environment simulates an NPC to determine how the NPC would act if the pseudo-visible player were invisible, and penalizes the NPC for acting differently. NPCs are thereby trained to selectively ignore pseudo-visible players, except when they judge that the reaction penalty is an acceptable tradeoff (e.g., a guard might accept (...) the penalty in order to protect a treasure because losing the treasure would hurt even more). We describe an RL agent transformation which allows RL agents that would not otherwise do so to perform some limited self-reflection to learn the training environments in question. (shrink)

A fundamental question asked in modal logic is whether a given theory is consistent. But consistent with what? A typical way to address this question identifies a choice of background knowledge axioms (say, S4, D, etc.) and then shows the assumptions codified by the theory in question to be consistent with those background axioms. But determining the specific choice and division of background axioms is, at least sometimes, little more than tradition. This paper introduces generic theories for propositional modal logic (...) to address consistency results in a more robust way. As building blocks for background knowledge, generic theories provide a standard for categorical determinations of consistency. We argue that the results and methods of this paper help to elucidate problems in epistemology and enjoy sufficient scope and power to have purchase on problems bearing on modalities in judgement, inference, and decision making. (shrink)

The aim of this article is to assess the impact of Big Data technologies for insurance ratemaking, with a special focus on motor products.The first part shows how statistics and insurance mechanisms adopted the same aggregate viewpoint. It made visible regularities that were invisible at the individual level, further supporting the classificatory approach of insurance and the assumption that all members of a class are identical risks. The second part focuses on the reversal of perspective currently occurring in data analysis (...) with predictive analytics, and how this conceptually contradicts the collective basis of insurance. The tremendous volume of data and the personalization promise through accurate individual prediction indeed deeply shakes the homogeneity hypothesis behind pooling. The third part attempts to assess the extent of this shift in motor insurance. Onboard devices that collect continuous driving behavioural data could import this new paradigm into these products. An examination of the current state of research on models with telematics data shows however that the epistemological leap, for now, has not happened. (shrink)

Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

Problem-solving software that is not-necessarily infallible is central to AI. Such software whose correctness and incorrectness properties are deducible by agents is an issue at the foundations of AI. The Comprehensibility Theorem, which appeared in a journal for specialists in formal mathematical logic, might provide a limitation concerning this issue and might be applicable to any agents, regardless of whether the agents are artificial or natural. The present article, aimed at researchers interested in the foundations of AI, addresses many questions (...) related to that theorem, including differences between it and results of Gödel and Turing that have sometimes played key roles in Minds and Machines articles. This study also suggests that—if one is willing to assume a thesis due to Donald Knuth—the Comprehensibility Theorem is the first mathematical theorem implying the impossibility of any AI agent or natural agent—including a not-necessarily infallible human agent—satisfying a rigorous and deductive interpretation of the self-comprehensibility challenge. Some have pointed out the difficulty of self-comprehensibility, even according to presumably a less rigorous interpretation. This includes Socrates, who considered it to be among the most important of intellectual tasks. Self-comprehensibility in some form might be essential for a kind of self-reflection useful for self-improvement that might enable some agents to increase their success. We use the methods of applied mathematics, rather than philosophy, although some topics considered could be of interest to philosophers. (shrink)

This article focuses on issues related to improving an argument about minds and machines given by Kurt Gödel in 1951, in a prominent lecture. Roughly, Gödel’s argument supported the conjecture that either the human mind is not algorithmic, or there is a particular arithmetical truth impossible for the human mind to master, or both. A well-known weakness in his argument is crucial reliance on the assumption that, if the deductive capability of the human mind is equivalent to that of a (...) formal system, then that system must be consistent. Such a consistency assumption is a strong infallibility assumption about human reasoning, since a formal system having even the slightest inconsistency allows deduction of all statements expressible within the formal system, including all falsehoods expressible within the system. We investigate how that weakness and some of the other problematic aspects of Gödel’s argument can be eliminated or reduced. (shrink)

Use of normothermic regional perfusion (NRP) for organ recovery in donation after circulatory death (DCD) raises two crucial, and intertwined, ethical questions. The first is whether the use of NRP...

The paper presents an analysis and interpretation of axiology and ethics as seen by the writer and philosopher Ayn Rand. The author follows the assumption that, in a situation where indifference is observed with regard to values (cf. Simmel, Sloterdijk), a return of philosophical reasoning to the idea of objectivity of values could be worthwhile. Therefore, he examines a specific type of axiological objectivism that can be found in Rand’s work. In the present paper, the suggested comparison with Baden neo-Kantism (...) as well as phenomenological axiology serves to capture the specifics of Rand’s axiological approach. These lie in placing emphasis on such a relationship between facts and values in which values result from the facts of reality, as well as in the very understanding of the objectivity of values that Rand identifies with long-term life goals and identifies them as an objective necessity for an individual’s life. Following the analysis of Rand’s axiology, the author focuses on her understanding of ethics, which he places in contrast to Kant’s deontology, as well as morality, which he views through the prism of a business relationship based on the exchange of values. The aim of the paper is to, by means of an analysis and interpretation of Rand’s ideas, show that objective values can be understood as a necessary prerequisite for consequential ethics and an individual living a happy life without being anchored in transcendence or social consensus. (shrink)

We study whether it is possible to generalise Seidenfeld et al.’s representation result for coherent choice functions in terms of sets of probability/utility pairs when we let go of Archimedeanity. We show that the convexity property is necessary but not sufficient for a choice function to be an infimum of a class of lexicographic ones. For the special case of two-dimensional option spaces, we determine the necessary and sufficient conditions by weakening the Archimedean axiom.

Many Faculties of Education in the UK and elsewhere have ‘social justice’ written into their mission statements. But are they concerned by questions of social justice in education, or has the term become somewhat vacuous and devoid of substantive meaning? The present article subjects recent discourses about social justice in education to scrutiny and finds them wanting in various respects, in particular when juxtaposed with historical accounts of justice by philosophers such as Aristotle or Aquinas. Among the complaints made here (...) is that most educational accounts (a) make do with a ‘negative’ conception of social justice as focused on specific cases of injustices without any positive conception of what social justice means in its entirety, (b) foreground institutional justice at the expense of justice as a moral or civic virtue, (c) fail to connect the identification of justice or injustice to an account of phronesis or practical wisdom for integrating values, (d) shy away from associating social justice with the ‘common good’ and (e) fail to get to grips with some thorny normative questions about the role of justice in the ordering of goods in a hierarchy towards the highest good. Along the way, various remedies are suggested. (shrink)

Se sabe relativamente poco acerca de las ideas de los maestros en formación sobre la naturaleza y el propósito de la enseñanza de la historia. Este artículo revisa la investigación sobre este tema y presenta un análisis de cómo el currículum nacional inglés ha conceptualizado los objetivos de la enseñanza de la historia desde el año 1991. Los datos derivados de una discusión en línea permiten explorar el pensamiento de 40 docentes de historia en prácticas y analizarlos cualitativamente para conocer (...) la variedad de ideas presentes en esta muestra. Los estudiantes tuvieron una amplia gama de puntos de vista sobre los objetivos y propósitos de la enseñanza de la historia y se identificaron las divergencias y convergencias entre el pensamiento de los estudiantes y el pensamiento de los políticos ingleses y de los líderes de opinión. Se concluye que quienes desarrollan los currículos deben prestar mucha más atención que en el pasado al pensamiento de los actuales y futuros profesores de historia, que son en último término los responsables del diseño de las propuestas curriculares. (shrink)

The computational complexity of finding a shortest path in a two-dimensional domain is studied in the Turing machine-based computational model and in the discrete complexity theory. This problem is studied with respect to two formulations of polynomial-time computable two-dimensional domains: domains with polynomialtime computable boundaries, and polynomial-time recognizable domains with polynomial-time computable distance functions. It is proved that the shortest path problem has the polynomial-space upper bound for domains of both type and type ; and it has a polynomial-space lower (...) bound for the domains of type, and has a #P lower bound for the domains of type. (shrink)