A growing body of empirical research examines the effects of the so-called “social determinants of health” on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the fairness of particular health inequalities; and second, the policy recommendations issued on (...) this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended—such as improving people's living conditions and reducing inequalities in wealth and power—are justified in their own right, the way these recommendations are tied to health is problematic. (shrink)

According to luck egalitarianism, inequalities are justified if and only if they arise from choices for which it is reasonable to hold agents responsible. This position has been criticised for its purported harshness in responding to the plight of individuals who, through their own choices, end up destitute. This paper aims to assess the Harshness Objection. I put forward a version of the objection that has been qualified to take into account some of the more subtle elements of the luck (...) egalitarian approach. Revising the objection in this way suggests that the Harshness Objection has been overstated by its proponents: because luck egalitarians are sensitive to the influence of unequal brute luck on individuals’ choices, it is unlikely that there will be any real world cases in which the luck egalitarian would not have to provide at least partial compensation. However, the Harshness Objection still poses problems for the luck egalitarian. First, it is not clear that partial compensation will be sufficient to avoid catastrophic outcomes. Second, the Harshness Objection raises a theoretical problem in that a consistent luck egalitarian will have to regard it as unjust if any assistance is provided to the victim of pure option luck, even if such assistance could be provided at no cost. I consider three strategies the luck egalitarian could pursue to accommodate these concerns and conclude that none of these strategies can be maintained without either violating basic luck egalitarian principles or infringing upon individual liberty. (shrink)

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons (...) and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being. (shrink)

Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of the empirical (...) literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (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)

In the article by Kristin Voigt in the April 2013 issue of Cambridge Quarterly of Healthcare Ethics, quotation marks around certain phrases were deleted.

The notion of individual responsibility has gained prominence in recent debates about health care. First, responsibility has been proposed as a rationing criterion; second, some policies use rewards and sanctions to encourage individuals to ‘take responsibility’ for their health; finally, acting responsibly within the health care system is portrayed as a requirement of reciprocity. The aim of this paper is two-fold. First, I assess these different kinds of appeal to individual responsibility from the perspective of equality. The literature has identified (...) important concerns about equality and fairness with proposals to use individual responsibility as a rationing criterion; I suggest that there are similar concerns about incentive schemes and reciprocity-based appeals to individual responsibility. The analysis will draw on luck egalitarian accounts of equality, which emphasise the importance of individual responsibility. This allows me to pursue the second objective for paper: to reconsider the luck egalitarian perspective on these different appeals to responsibility. Applying the arguments of recent contributions to the luck egalitarian literature to the health arena suggests that luck egalitarians need not support the use of responsibility as a rationing criterion, and they can also identify problems with incentives and reciprocity-based arguments. However, the language of individual responsibility and its prominence in public debates may have implications for individuals’ health and well-being, which raises challenging issues for luck egalitarians as they attempt to apply their theory to the real world. (shrink)

Expressive theories of state action seek to identify and assess the ‘meaning’ implicit in state action, such as legislation and public policies. In expressive theories developed by relational egalitarians, state action must ‘express’ equal concern and respect for citizens. However, it is unclear how precisely we can determine and assess the meaning of what states do. This paper considers how an expressive theory could be developed, given the commitments of a relational account of equality, and how such a theory would (...) relate to relational egalitarianism more broadly. I suggest that expressive considerations should be tied more closely than they are in the current literature to agents’ attitudes and to their intentions. I discuss a range of real-world policies that are problematic for what they can be taken to express. (shrink)

Incentive schemes, which offer recipients benefits if they meet particular requirements, are being used across the world to encourage healthier behaviours. From the perspective of equality, an important concern about such schemes is that since people often do not have equal opportunity to fulfil the stipulated conditions, incentives create opportunity for further unfair advantage. Are incentive schemes that are available only to disadvantaged groups less susceptible to such egalitarian concerns? While targeted schemes may at first glance seem well placed to (...) help improve outcomes among disadvantaged groups and thus reduce inequalities, I argue in this paper that they are susceptible to significant problems. At the same time, incentive schemes may be less problematic when they operate in ways that differ from the ‘standard’ incentive mechanism; I discuss three such mechanisms. (shrink)

In this paper we aim to demonstrate the enormous ethical complexity that is prevalent in child obesity cases. This complexity, we argue, favors a cautious approach. Against those perhaps inclined to blame neglectful parents, we argue that laying the blame for child obesity at the feet of parents is simplistic once the broader context is taken into account. We also show that parents not only enjoy important relational prerogatives worth defending, but that children, too, are beneficiaries of that relationship in (...) ways difficult to match elsewhere. Finally, against the backdrop of growing public concern and pressure to intervene earlier in the life cycle, we examine the perhaps unintended stigmatizing effects that labeling and intervention can have and consider a number of risks and potential harms occasioned by state interventions in these cases. (shrink)

Childhood obesity has become a central concern in many countries and a range of policies have been implemented or proposed to address it. This co-authored book is the first to focus on the ethical and policy questions raised by childhood obesity and its prevention. -/- Throughout the book, the authors emphasize that childhood obesity is a multi-faceted phenomenon, and just one of many issues that parents, schools and societies face. They argue that it is important to acknowledge the resulting complexities (...) and not to think in terms "single-issue" policies. -/- After first reviewing some of the factual uncertainties about childhood obesity, the authors explore central ethical questions. What priority should be given to preventing obesity? To what extent are parents responsible? How should we think about questions of stigma and inequality? In the second part of the book, the authors consider key policy issues, including the concept of the 'obesogenic environment,' debates about taxation and marketing, and the role that schools can play in obesity prevention. -/- The authors argue that political debate is needed to decide the importance given to childhood obesity and how to divide responsibilities for action. These debates have no simple answers. Nonetheless, the authors argue that there are reasons for hope. There are a wide range of opportunities for action. Many of these options also promise wider social benefits. (shrink)

Paternalistic interventions restrict individuals’ liberty or autonomy so as to guide their decisions towards options that are more beneficial for them than the ones they would choose in the absence of such interventions. Although some philosophers have emphasised that there is a case for justifiable paternalism in certain circumstances, much of contemporary moral and political philosophy works from a strong presumption against paternalistic interventions. However, Richard Arneson has argued that there are egalitarian reasons that support the case for paternalism: paternalistic (...) interventions can protect poor decision-makers from making ‘bad’ choices, thus preventing inequalities between them and those with better decision-making skills. This paper seeks to clarify and advance our understanding of the egalitarian argument for paternalism. Arneson’s argument adds an important and often neglected dimension to the debate about paternalism but also raises a number of questions about equality, paternalism and the relationship between the two. (shrink)

Does the unequal participation of non-traditional students in higher education indicate social injustice, even if it can be traced back to individuals' choices? Drawing on luck egalitarian approaches,this article suggests that an answer to this question must take into account the effects of unequal brute luck on educational choices.I use a framework based on expected utility theory to analyse qualitative studies on educational choice.This reveals a variety of mechanisms through which differences in background conditions make non-traditional students less likely to (...) apply to university and/or particular institutions; the unequal participation of nontraditional students in higher education remains a problem of social justice. (shrink)

The Global Burden of Disease project quantifies the impact of different health conditions by combining information about morbidity and premature mortality within a single metric, the Disability Adjusted Life Year. One important goal for the GBD project has been to inform decisions about global health priorities. A number of recent studies have used GBD data to argue that global health funding fails to align with the GBD. We argue that these studies’ shared assumption that global health resources should ‘align’ with (...) the burden of disease is unfounded and has troubling implications. First, since the allocation of resources involves difficult trade-offs between different, potentially competing goals, any ‘misalignment’ of allocation and disease burdens need not necessarily indicate that the allocation of funds fails to meet recipient countries’ needs or interests. Second, using alignment as a baseline implicitly makes controversial assumptions about how harms of different magnitudes affecting different numbers of individuals should be aggregated. We discuss two alternative ways in which GBD data could help inform decisions about resource allocation, neither of which gives more than a limited role to GBD data. (shrink)

The need for rationing of clinical services and medical resources is a crucial issue facing healthcare systems. On most accounts, the demand for medical services vastly exceeds what can be provided on limited budgets, requiring difficult decisions about which services should and should not be provided to patients, whether patients might have to bear some of the cost of the services they use, and on what basis rationing decisions should be made. At the same time, we know that healthcare systems (...) are far from perfectly efficient; some of the expenditures of healthcare systems are wasteful and bring no benefits at all to patients. In light of the evidence of such inefficiencies within healthcare systems, it may seem problematic to insist on the importance of rationing: can it really be appropriate to deny patients beneficial services while inefficiencies remain within the system?1This is the question Strech and Danis take on in their paper, ‘How can bedside rationing be justified despite coexisting inefficiency? The need for “benchmarks of efficiency”’. As they highlight, the evidence about inefficiencies within the healthcare system is sometimes taken to undermine the legitimacy of rationing. Their response focuses on the implications of particular clinicians’ involvement in both inefficient decisions and bedside rationing: if clinicians cause or contribute to inefficiencies in the system—for example by prescribing more expensive ‘brand name’ medication instead of equally effective but cheaper generic drugs—is it legitimate for them also to make, or be involved in, rationing decisions? Strech and Danis argue that even though no healthcare system can be fully efficient, clinicians must make ‘sufficient’ efforts to reduce inefficiencies within their own realm of decision-making if their engagement in rationing decisions is to be legitimate. They offer a set of ‘benchmarks’ against which we can judge whether or not such efforts should …. (shrink)

A growing body of research emphasises the role of ‘social determinants of health’ in generating inequalities in health outcomes. How, if at all, should primary care providers respond? In this paper, I want to shed light on this issue by focusing on the role that ‘big data’ might play in allowing primary care providers to respond to the social determinants that affect individual patients’ health. The general idea has been proposed and endorsed by the Institute of Medicine, and the idea (...) has been developed in more detail by Bazemore et al.. In Bazemore et al.’s proposal, patients’ addresses are used to generate information about the patients’ neighbourhood; this information is then included in patients’ health care records and made available to providers. This allows primary care providers to take this information into account when interacting with, and providing care to, patients. I explore three issues arising from this proposal. First, while questions of privacy have been central to discussions about big data, Bazemore et al.’s proposal also allows us to see that there might be costs to not making certain information available. Second, I consider some of the questions arising for primary care from the influence of social factors on health outcomes: given that we know these factors to be significant contributors to social inequalities in health, what precisely should be done about this in the primary care context? Finally, I address problems arising from the use of population level data when dealing with individuals. (shrink)

Starting from Miranda Fricker’s recent work on the concept of testimonial injustice, this paper considers what duties testimonial justice creates for speakers. I discuss this question in relation to disclosures of so-called personal conflicts of interest, which authors are sometimes required or encouraged to declare when submitting their work to journals. Personal characteristics that have been disclosed by authors include smoking status, class background and ethnicity. The purpose of this paper is two-fold. First, I argue that disclosures of personal characteristics (...) raise problems of testimonial injustice in two ways: they can unfairly undermine researchers’ credibility and prejudice readers against the results or arguments proposed; and such disclosures can contribute to epistemic injustice more broadly by strengthening the view that individuals who share the features disclosed should, at least in some contexts, be given less credibility than others. The second goal of the paper is to argue that, while Fricker’s account focuses on the epistemic virtues of hearers in responding in the right way to testimonial injustice, there are also important duties of testimonial injustice incumbent on speakers. I propose three such duties. (shrink)