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Social Inequality in Health, Responsibility and Egalitarian Justice

DOI: 10.1093/pubmed/fdt012

Marchman Andersen, M et al. “Social Inequality in Health, Responsibility and Egalitarian Justice.” Journal of Public Health 35.1 (2013): 4–8. Print.

p.4: Are social inequalities in health unjust when brought about by differences in lifestyle? A widespread idea, luck egalitarianism, is that inequality stemming from individuals’ free choices is not to be considered unjust, since individuals, presumably, are themselves responsible for such choices. Thus, to the extent that lifestyles are in fact results of free choices, social inequality in health brought about by these choices is not in tension with egalitarian justice. If this is so, then it may put in question the justification of free and equal access to health care and existing medical research priorities. However, personal responsibility is a highly contested issue and in this article we first consider the case for, and second the case against, personal responsibility for health in light of recent developments in philosophical accounts of responsibility and equality. We suggest—but do not fully establish—that at the most fundamental level people are never responsible in such a way that appeals to individuals’ own responsibility can justify inequalities in health. -- Highlighted may 7, 2014

p.4: An answer to this question is of relevance to issues of how to prioritize within institutions of health and health care, including access and coverage of universal health care and the allocation of medical research funds. -- Highlighted may 7, 2014

p.5: First, we will assume that insofar as we are concerned with inequality, we should be concerned with inequality in health. (Luck) egalitarians have come up with different suggestions as to what it is that people should have equal shares of—including welfare, resources and capabilities — but each of these suggestions seems to imply that we should be concerned about the distribution of health. Secondly, (luck) egalitarians are most often value pluralists as there are difficult issues of balancing concerns of equality with efficiency. It is beyond the scope of this article to come up with suggestions as for how to balance these concerns. What we are concerned with is whether there are individual responsibility-based reasons not to care about some inequalities in health. Thirdly, though it is common in social epidemiology we will not use the term inequity. This term is usually associated with a distinction between socially caused inequalities and biological variations, such that the latter are not to be considered inequities. In line with the luck egalitarian literature, where this distinction is generally considered to be morally arbitrary (because we are responsible neither for the social environment or the genes we are born with), we will address whether inequalities are unjust, and this they may be for both social and biological reasons. -- Highlighted may 7, 2014

p.5: In a recent book Shlomi Segall has defended a luck egalitarian approach to justice in health and health care. He concludes that in order not to abandon the imprudent, luck egalitarianism needs to be combined with a model of meeting basic needs. But insofar as it is possible, he maintains, costs associated with imprudent behavior, such as smoking, eating fatty food and dangerous sporting-activities, can fairly be passed on to the imprudent themselves. For a broad range of reasons, however, the costs should be charged ex ante and not ex post. This means, for example, that when a smoker ends up in a hospital, with say lung cancer, then she and her fellow smokers have already paid for the treatment through taxes imposed on each single pack of tobacco. It therefore seems possible never to abandon the imprudent, and yet pass on the costs of imprudent behavior in accordance with the luck egalitarian intuition. -- Highlighted may 7, 2014

p.5: However, personal responsibility for health does not only affect the question of access to health care. It determines whether and when inequalities are unjust. So if we accept that individuals are responsible for (some) lifestyle choices, such as smoking, then it follows that the inequality in health between those who smoke and those who do not is not unjust. To accept this may have quite serious implications, e.g. on publicly funded research: why give a high priority to say research on lung cancer, if, as suggested, 95.1% of lung cancer patients are smokers or former smokers, and hence, ex hypothesi, responsible for their own situation. -- Highlighted may 7, 2014

p.6: Of course, we might be willing to accept selective taxation of unhealthy lifestyles for paternalistic reasons. For example, it has been shown that tobacco consumption goes down when the tobacco prices go up. By taxing tobacco we can potentially reduce the number of smokers for the smokers’ own good. But accepting such a policy is possible quite independently of considerations of personal responsibility, and it is likely that we will recommend different levels of taxation depending on whether our aim is to prevent smoking or to hold smokers responsible for the costs of their smoking. Therefore, in order to consider how personal responsibility affects the question of when social inequalities in health are unjust it is important to keep these matters apart. -- Highlighted may 7, 2014

p.7: Many people tend to find the conclusion that responsibility is ultimately impossible somewhat unattractive. It is contestable what it fundamentally takes for an individual to be responsible, and in this article we can therefore by no mean fully establish this conclusion. But given it’s strong plausibility, it is important to clarify what it actually implies. T.M. Scanlon has made a very useful distinction between what he calls attributive and substantive responsibility. Responsibility in the former sense simply implies that it is appropriate to make a person subject for moral appraisal. In the latter sense responsibility regards substantive claims about what people are required to do for each other. This distinction is very useful since if real responsibility is impossible, then it does not follow that we should not be subject to moral criticism. Rather it is a good thing to criticize each other, insofar there are reasons to believe we thereby change our behavior in desirable ways. Similarly, the impossibility of responsibility does not imply that we cannot have a system of punishment, but only that the criminal is not ultimately responsible. Naturally, we would still want to punish the criminal, since we would still want to prevent crime. -- Highlighted may 7, 2014

p.7: If we accept the conclusion that responsibility is fundamentally impossible it follows from luck egalitarianism that all otherwise relevant inequalities are unjust—ceteris paribus. The latter reservation, however, is quite important, since we may have other reasons not to correct for inequality, such as reasons of efficiency, incentive regulation and, especially important in a health context, how to balance our aim for equality with respect for personal freedom. -- Highlighted may 7, 2014

p.8: But even though there might then be nothing we can legitimately do about the health inequality between, e.g. smokers and non-smokers it should not be thought that the inequality is just—ceteris paribus. First, given medical progress there might later be something we can do about it. Secondly, when this inequality is unjust, it explains why we should give free and equal health care access to individuals affected by diseases for which lifestyle choices are a risk factor. Or, at least, we do not find responsibility-based reasons not to do so. -- Highlighted may 7, 2014