The unfairness of health inequalities depends on the more fundamental question of the relationship between justice in health and distributive justice more generally. In this article, I discuss some constraints on how health should be incorporated in a theory of justice and their implications for when health inequalities can be considered to be unfair. I argue against adopting separate distributive principles for health, and in favour of conceiving justice in health as interrelated with, and contingent on, justice in the distribution (...) of other important social goods and resources, in particular income. Accordingly, health inequalities are unfair when they are the result of an unfair distribution of resources. (shrink)

Political philosophers have become increasingly interested in questions of justice as applied to health. Much of this literature works from a distributive understanding of justice. In the recent debate, however, ‘relational’ egalitarians have proposed a different way of conceptualising equality, which focuses on the quality of social relations among citizens and/or how social institutions ‘treat’ citizens. This paper explores some implications of a relational approach to health, with particular focus on health care, health inequalities and health policy. While the relational (...) account can add interesting perspectives to current debates on justice and health, we also highlight some tensions and difficulties relational egalitarians might encounter and some discontinuities between the implications of a relational account and current discourse on health equity. (shrink)

There are great health disparities in the world today, both between countries and within them. This problem might be seen as related to the access to various kinds of capabilities. It is not fully clear, however, what the exact relation is between health and capabilities. Neither Amartya Sen nor Martha Nussbaum has explicitly formulated a theory of health to go with their theories of capabilities. This paper attempts to present a clarification of the conceptual relation between health and capabilities. Health, (...) it is argued, should be seen as a holistic multi-dimensional phenomenon, made up of basic abilities and subjective well-being, and of fundamental states and processes. Using this theory, the paper shows how health is related to Nussbaum’s ten capabilities. It is argued that health, in the senses described, is a necessary part of all ten capabilities. Moreover, some of the capabilities on Nussbaum’s list, such as thinking and imagining, and practical reasoning, refer to health. Finally, it is shown that even though health is part of all capabilities, health cannot itself primarily be seen as a capability. An acceptable degree of health is required as a functioning for any theory of human flourishing to be reasonable. (shrink)

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka’s _Metamorphosis_ advance understandings of HIV stigma in medical health education? _Metamorphosis_ amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. _Metamorphosis_ (...) may ultimately promote medical health humanities’ social mission—allowing literature to unfold such revelations towards greater equity in health. (shrink)

Some theorists, especially egalitarians, seek to ‘apply’ theories of justice to a specific area or good, such as health, and assess the distribution of that good at the bar of justice. On the one hand, this is understandable, given that egalitarians are often interested in making policy recommendations and these would have to be area-specific. On the other hand, it is surprising in light of the fact that theories of justice normally envisage the ‘total package of goods’ or an overall (...) good as the distribuendum. This article aims to show that this approach is problematic at least in the area of health. (shrink)

This paper examines two strategies aimed at demonstrating that moral obligations to improve global health exist. The ‘humanitarian model’ stresses that all human beings, regardless of affluence or global location, are fundamentally the same in terms of moral status. This model argues that affluent global citizens’ moral obligations to assist less fortunate ones follow from the desirability of reducing disease and suffering in the world. The ‘political model’ stresses that the lives of the world's rich and poor are inextricably linked (...) because of harmful state-to-state actions and because of the currently existing transnational institutions. These institutions’ design at once secures the high standard of living of the affluent and reinforces the continued foreseeable—and avoidable—deprivation of many of the global poor; and these give rise to compensatory health-related moral obligations beyond borders. This paper argues that political reasoning is unsuitable for the crucial task of determining priority in the receipt of health aid. We conclude that in the context of global health ethics, political reasoning must be supplemented with, if not replaced by, humanitarian reasoning. (shrink)

Many ethical theorists believe that a given distribution of healthcare is morally justified only if (1) it is cost-effective and (2) it does not discriminate against older adults and disabled people. However, if (3) cost-effectiveness involves maximizing the number of quality-adjusted life-years (QALYs) added by a given unit of healthcare resource, or cost, it seems the pursuit of cost-effectiveness will inevitably discriminate against older adults and disabled patients. I show why this trilemma is harder to escape than some theorists think. (...) We cannot avoid it by using age- or disability-weighted QALY scores, for example. I then explain why there is no sense of “discrimination” on which discrimination isbothunjust, and thus something healthcare rationing must avoid,andsomething cost-effective healthcare rationing inevitably involves. I go on to argue that many of the reasons we have for not favoring rationing that maximizes QALYs outside the healthcare context apply in healthcare as well. Thus, claim (1) above is dubious. (shrink)

Christopher Boorse's Bio Statistical Theory (BST) defines health as the absence of disease, and disease as the adverse departure from normal species functioning. This paper presents a two-pronged problem for this account. First I demonstrate that, in order to accurately account for dynamic physiological functions, Boorse's account of normal function needs to be modified to index functions against situations. I then demonstrate that if functions are indexed against situations, the BST can no longer account for diseases that result from specific (...) environmental factors. The BST is impaled on either horn of this dilemma and therefore must be dismissed. (shrink)

Recent years have seen an increase in the turn to rights discourse within the context of access to health and specifically health care. Developments took place at both the national and global levels, with a significant increase in right to health litigation around the world1 and developments at the international level, such as the appointment of a Special Rapporteur on the Right to Health and the adoption of a “General Comment” on the topic by the UN Committee on Economic, Social (...) and Cultural Rights. (shrink)

In recent years we have noticed an increase in the turn to rights analysis in litigation relating to access to health care. Examining litigation, we can notice a contradiction between on the one hand the ability of the right to health to reinforce privatization and commodification of health care, by rearticulating claims to private health care in terms of human rights, and on the other hand, its ability to reinforce and reinstate public values, especially that of equality, against the background (...) of privatization and commodification. While many hope that rights discourse will do the latter, and secure that access to health care should occur on the basis of need as opposed to ability to pay, it has actually been used to attempt to advance arguments that will allow access to private or semiprivate health insurance in ways that may exacerbate inequality. These types of arguments won ground in the Canadian Supreme Court, but were rejected by the Israeli Supreme Court. In order to avoid this co-optation of right to health, a notion of rights that incorporates the principles of substantive equality is required. Otherwise, one of the unintended consequences of inserting rights analysis into public health care may be that it will reinforce rather than challenge privatization in a way that may increase inequalities. (shrink)

In the context of clinical and non-clinical biomedical practices, negligence is usually understood as a lapse of a specific professional duty by a healthcare worker or by a medical facility. This paper tries to delineate systemic negligence as another kind of negligence in the context of health systems, particularly in developing countries, that needs to be recognized and addressed. Systemic negligence is not just a mere collection of stray incidences of medical errors and system failures in a health system, but (...) is proposed in this paper as a more pervasive kind of neglect. Several non-medical factors, such as lack of social and political will, also contribute to it and hence is more difficult to address in a health system. This paper argues that recognizing systemic negligence and including it research agenda have special moral importance for researchers in developing world bioethics, public health ethics and for health activists in the developing world. For, it can be a potent health system barrier, and can seriously impair efforts to ensure patient safety, particularly in the weaker health systems. As it erodes accountability in a health system, addressing it is also important for the twin goals of ensuring patient safety and improving health system performance. Above all, it needs to be addressed because the tolerance of its persistence in a health system seems to undervalue health as a social good. (shrink)

We review methods for economic evaluation recently developed in health economics by focusing on the epistemic and non-epistemic values they embody. The emphasis is on insights into valuing health,...

Die epidemiologische Morbiditätsverschiebung der vergangenen Jahrzehnte hat verhaltensassoziierte Erkrankungen in das Zentrum der Public Health-Arbeit rücken lassen. Sowohl die Prävention Lebensstil-bedingter Erkrankungen als auch die Behandlung ihrer Folgen gehören angesichts steigender Morbiditäts- und Mortalitätszahlen zu den größten Herausforderungen für moderne Gesundheitssysteme. Eine Beeinflussung von Gesundheitsverhalten sowie dessen Berücksichtigung in der Mittelverteilung – prominent verhandelt in der medizinethischen Debatte um gesundheitliche Eigenverantwortung – sind jedoch kontrovers. Bisher konnte dafür noch kein allgemein akzeptiertes theoretisches Modell entwickelt werden. Im vorliegenden Beitrag wird der (...) in letzter Zeit im angloamerikanischen Raum intensiv im Public Health-Kontext verhandelte libertäre Paternalismus als ein solches Modell untersucht und einer kritischen Untersuchung zugeführt. Es wird geschlussfolgert, dass dieses Modell zwar argumentativ in wesentlicher Hinsicht unterbestimmt ist, jedoch viele willkommene und sinnvolle Impulse für die moderne Public Health-Politik liefern kann. (shrink)

Departing from theories of distributive justice and their relation with the distribution of health care within society, especially egalitarianism and libertarianism, this paper aims at demonstrating that the approach taken by the European Court of Justice regarding the application of the Internal Market principles (or the market freedoms) to the field of health care services has introduced new values which are more concerned with a libertarian view of health care. Moreover, the paper also addresses the question of how these new (...) values introduced by the Court may affect common principles of European health systems, such as equity and accessibility. (shrink)

:The distinction between brute luck and option luck is fundamental for luck egalitarianism. Many luck egalitarians write as if it could be used to specify which outcomes people should be held responsible for. In this paper, I argue that the distinction can’t be used this way. In fact, luck egalitarians tend to rely instead on rough intuitive judgements about individual responsibility. This makes their view vulnerable to what’s known as the neutrality objection. I show that attempts to avoid this objection (...) are unsuccessful. I conclude that until it provides a better account of attributing responsibility, luck egalitarianism remains incomplete. (shrink)

An absolute decline in US life expectancy in low education whites has alarmed policy makers and attracted media attention. Depending on which studies are correct, low education white women have lost between 3 and 5 years of lifespan; men, between 6 months and 3 years. Although absolute declines in life expectancy are relatively rare, some commentators see the public alarm as reflecting a racist concern for white lives over black ones. How ought we ethically to evaluate this lifespan contraction in (...) low education whites? Should we care, or is it racist to care? Does it constitute an injustice or reflect justice being done? I argue that the lifespan contraction in low education whites violates key normative criteria used to make determinations of health justice, and that these judgments do not vitiate concerns about racism. I conclude with reflections on US population health policy and building an inclusive health equity movement. (shrink)