Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should (...) address distributions of health rather than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

In recent literature, there has been much debate about whether and how luck egalitarianism, given its focus on personal responsibility, can justify universal health care. In this paper we argue that, whether or not this is so, and in fact whether or not egalitarianism should be sensitive to responsibility at all, the question of personal responsibilization for health is not settled. This is the case because whether or not individuals are responsible for their own (...) class='Hi'>health condition is not all that is relevant when considering whether we should somehow hold them responsible for their own health condition, e.g. cost-wise. There may also be efficiency-based reasons to hold them responsible, and there may even be egalitarian reasons. Defining universal health care as an insurance system where everyone’s deductible and premium is 0, we will argue that efficiency-based reasons for cost-responsibilization are not convincing, but that there are egalitarian reasons for cost-responsibilization. Luck egalitarianism, therefore, cannot, at least not on its own term, justify universal health care. (shrink)

People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility (...) for their health; responsibility sensitive health policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

The Covid-19 pandemic resulted in school closures around the world, leaving lasting negative impacts on many children. Given that such closures are justified public health measures, this raises the question of compensating children for school closures. In this article I address the question of compensation from the perspective of a popular theory of justice: luck egalitarianism. In doing so, I examine a problem with applying luck egalitarianism to children, called the agency assumption. I then argue (...) this assumption results in a dilemma for luck egalitarianism and suggest how this dilemma can be overcome. I argue that the resulting form of luck egalitarianism reveals something interesting about compensating children for school closures: luck egalitarianism requires us to address all bases of justice-relevant inequality among children—Covid-19-related and beyond. Although much of the current discussion of compensating children for such closures has focused narrowly on the need to make up for lost instruction time or to prevent reductions in educational achievement, I argue that a luck egalitarian conception of justice requires us to go beyond merely compensating children for educational losses and instead aim for radical equality in education. (shrink)

In recent works, Shlomi Segall suggests and defends a luck egalitarian approach to justice in health. Concurring with G. A. Cohen’s mature position he defends the idea that people should be compensated for “brute luck”, i.e. the outcome of actions that it would be unreasonable to expect them to avoid. In his defense of the luck egalitarian approach he seeks to rebut the criticism raised by Norman Daniels that luck egalitarianism is in some way (...) too narrow and in another too wide to uphold justice in health and health care distribution. He points out that a pluralistic outline of luck egalitarianism taking into account the moral requirement of meeting everyone’s basic needs can avoid this line of criticism. In this article I argue against the application of such pluralistic luck egalitarianism in matters of health distribution. First of all, Segall has not shown that luck egalitarianism handles well health distributions above a threshold of basic needs. Secondly, his way of avoiding Elizabeth Anderson’s abandonment objection is theoretically problematic. Finally, I argue that luck egalitarianism in general fails to acknowledge the moral foundation of health and health care as a basic human entitlement. Thus I conclude that luck egalitarianism fails to take health needs seriously and that it cannot therefore uphold justice in health. (shrink)

Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from (...) theory to practise, luck egalitarianism encounters several difficulties. We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. (shrink)

Luck egalitarianism is often taken to task for its alleged harsh implications. For example, it may seem to imply a policy of nonassistance toward uninsured reckless drivers who suffer injuries. Luck egalitarians respond to such objections partly by pointing to a number of factors pertaining to the cases being debated, which suggests that their stance is less inattentive to the plight of the victims than it might seem at first. However, the strategy leaves some cases in which (...) the attribution of individual responsibility is appropriate . One such case is oral health or significant aspects of this. It is appropriate, the paper argues, to hold people responsible for a number of factors that affect their oral health. A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing. (shrink)

Setting out to defend luck egalitarianism in matters of justice in health, Shlomi Segall outlines a pluralistic version of the luck egalitarian framework allowing egalitarian justice to be traded-off against other moral requirements. The suggested pluralism enables luck egalitarian justice to coexist with a concern for meeting everyone’s basic needs thereby avoiding Elizabeth Anderson’s ‘abandonment objection’. In this article, however, we present three objections to Segall’s luck egalitarian justice in health. Firstly, the account (...) is vulnerable to the common objection that luck egalitarianism becomes too expansive, and that Segall’s defence against this is inadequate. Secondly, Segall’s pluralist attempt to balance luck egalitarian justice and other moral requirements ends up compromising its own ideal of justice. Due to the fact that resource scarcity is the reality of health and health care distribution, this problem would often arise in actual health policy. Finally, the account has a way of intensifying blameworthy behaviour which seems contrary to luck egalitarian principles. Based on these three objections, we conclude that Segall’s luck egalitarian account of justice in health must either be rejected or qualified further. (shrink)

Luck egalitarianism is a responsibility-sensitive theory of distributive justice. Its application to health and healthcare is controversial. This article addresses a novel critique of luck egalitarianism, namely, that it wrongfully discriminates against those responsible for their health disadvantage when allocating scarce healthcare resources. The philosophical literature about discrimination offers two primary reasons for what makes discrimination wrong (when it is): harm and disrespect. These two approaches are employed to analyze whether luck egalitarian healthcare (...) prioritization should be considered wrongful discrimination. Regarding harm, it is very plausible to consider the policies harmful but much less reasonable to consider those responsible for their health disadvantages a socially salient group. Drawing on the disrespect literature, where social salience is typically not required for something to be discrimination, the policies are a form of discrimination. They are, however, not disrespectful. The upshot of this first assessment of the discrimination objection to luck egalitarianism in health is, thus, that it fails. (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

In recent work, Norman Daniels extends the application of Rawls's principle of ‘fair equality of opportunity’ from health care to health proper. Crucial to that account is the view that health care, and now also health, is special. Daniels also claims that a rival theory of distributive justice, namely luck egalitarianism (or ‘equal opportunity for welfare’), cannot provide an adequate account of justice in health and health care. He argues that the application (...) of that theory to health policy would result in an account that is, in a sense, too narrow, for it denies treatment to imprudent patients (e.g. lung cancer patients who smoked). In a different sense, Daniels argues, luck egalitarian health policy would be too wide: it arguably tells us to treat individuals for such brute-luck conditions as shyness, stupidity, ugliness, and having the ‘wrong’ skin colour. I seek to advance three claims in response to Daniels's revised theory, and in defence of a luck egalitarian view of health policy. First, I question Daniels's assertion regarding the specialness of health. While he is right to abandon his insistence on the specialness of health care, it is doubtful that health proper can be depicted as special. Second, I try and meet Daniels's objections to luck egalitarianism. Luck egalitarian health policy escapes being too narrow for it does not in fact require denying basic care to imprudent patients. As for it being allegedly too wide, I try to show that it is not, after all, counterintuitive to rid individuals of unfortunate and disadvantageous biological traits (say, a disadvantageous skin colour). And third, I question whether Daniels's own Rawlsian account is in fact wide enough. I argue that fair equality of opportunity fails to justify some standard medical procedures that many health systems do already practice. (shrink)

Much of the philosophical literature on health inequalities seeks to establish the superiority of one or another conception of luck egalitarianism. In recent years, however, an increasing number of self-avowed egalitarian philosophers have proposed replacing luck egalitarianism with alternatives that stress the moral relevance of distinct relationships, rather than the moral relevance of good or bad luck. After briefly explaining why I am not attracted to luck egalitarianism, I seek in this chapter (...) to distinguish and clarify three views that have been characterized in the philosophical literature as forms of relational egalitarianism. I call these three relational views equality of treatment, equality of concern, and social egalitarianism. I will explain why each claims to be a form of egalitarianism and why these three views should not be seen as competitors. I will argue that each brand of relational egalitarianism describes a plausible plank of distributive justice that bears on the evaluation of health inequalities and on the political institutions that create, sustain, or exacerbate them. To illustrate this pluralistic relational egalitarian approach, I will draw on a case study by Horton and Barker (this volume) to discuss how each of the three planks might be brought to bear on the evaluation of oral health disparities among the children of migrant Latino farmworkers in California. (shrink)

In the literature on responsibility and health care, many associate responsibility-sensitive health policies with a form of luck egalitarianism. On this view, if some health inequality is due to the choices, or responsible agency, of one of the patients involved, then it is not unjust, and we have no responsibility to compensate for it. If the inequality’s origins cannot be traced back to the patients’ choices, then it is not their responsibility, and thus it becomes (...) society’s responsibility to compensate for it. This division of responsibilities between the individual and society applies not only to the past, but also to our responsibilities concerning the future. For instance, some luck egalitarians think that inequalities in life expectancy between men and women are unjust (Segall 2010) and should be compensated. Alex Voorhoeve has recently raised a new frontier in this debate concerning ‘prospective’ lives: the lives of those who will be born in the future. Against Voorhoeve, I argue that prospective inequalities are not a concern for egalitarians. This qualifies the claim that all inequalities not traceable to personal responsibility are unjust and suggests that there is no responsibility to structure society or our social institutions to avoid such prospective inequalities. (shrink)

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of (...) personal responsibility would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts. (shrink)

Rare diseases pose a particular priority setting problem. The UK gives rare diseases special priority in healthcare priority setting. Effectively, the National Health Service is willing to pay much more to gain a quality-adjusted life-year related to a very rare disease than one related to a more common condition. But should rare diseases receive priority in the allocation of scarce healthcare resources? This article develops and evaluates four arguments in favour of such a priority. These pertain to public values, (...) luck egalitarian distributive justice the epistemic difficulties of obtaining knowledge about rare diseases and the incentives created by a higher willingness to pay. The first is at odds with our knowledge regarding popular opinion. The three other arguments may provide a reason to fund rare diseases generously. However, they are either overinclusive because they would also justify funding for many non-rare diseases or underinclusive in the sense of justifying priority for only some rare diseases. The arguments thus fail to provide a justification that tracks rareness as such. There are no data in this work. (shrink)

Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste, Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices in (...) health are disadvantaged in a relevant way and should receive compensation. Employing the ideal that people should be made equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the luck egalitarian position is more compelling than they admit. (shrink)

In the effort to address the persistent organ shortage it is sometimes suggested that we should incentivize people to sign up as organ donors. One way of doing so is to give priority in the allocation of organs to those who are themselves registered as donors. Israel introduced such a scheme recently and the preliminary reports indicate increased donation rates. How should we evaluate such initiatives from an ethical perspective? Luck egalitarianism, a responsibility-sensitive approach to distributive justice, provides (...) one possible justification: Those who decide against being organ donors limit the health care resources available to others. As such, a priority rule can be justified by a luck egalitarian approach to distributive justice. Furthermore, a priority rule inspired by luck egalitarianism is well equipped to avoid prominent criticisms of such a procurement system. Luck egalitarianism provides us with reaons to exempt people who are not responsible for their inability to donate from receiving lower priority, provide sufficient information about donation, and mitigate social and natural circumstances affecting people’s choice to donate. (shrink)

In any normal population, health is unequally distributed across different age groups. Are such age-based health inequalities unjust? A divide has recently developed within egalitarian theories of...

Some people are worse off than others. Does this fact give rise to moral concern? Egalitarianism claims that it does, for a wide array of reasons. It is one of the most important and hotly debated problems in moral and political philosophy, occupying a central place in the work of John Rawls, Thomas Nagel, G. A. Cohen and Derek Parfit. It also plays an important role in practical contexts such as the allocation of health care resources, the design (...) of education and tax systems, and the pursuit of global justice. Egalitarianism is a superb introduction to the problem of contemporary egalitarian theories. It explains how rival theories of egalitarianism evaluate distributions of people’s well-being, and carefully assesses the theoretical structure of each theory. It also examines how egalitarian theories are applied to the distribution of health and health care, thus bringing a deceptively complex philosophical debate into clear focus. Beginning with a brief introduction to basic terminology, Iwao Hirose examines the following topics: Rawlsian egalitarianism luck egalitarianism telic egalitarianism prioritarianism sufficientarianism equality and time equality in health and health care. Including chapter summaries, annotated further reading and a glossary, this is an ideal starting point for anyone studying distributive justice for the first time, and will also be of interest to more advanced students and researchers in philosophy, economics, political theory, public policy, and public health. (shrink)

Luck egalitarianism provides a reason to object to conditionality in health incentive programmes in some cases when conditionality undermines political values such as solidarity or inclusiveness. This is the case with incentive programmes that aim to restrict access to essential healthcare services. Such programmes undermine solidarity. Yet, most people's lives are objectively worse, in one respect, in non-solidary societies, because solidarity contributes both instrumentally and directly to individuals' well-being. Because solidarity is non-excludable, undermining it will deprive both (...) the prudent and the imprudent citizens of its goods. Thereby, undermining solidarity can make prudent citizens worse off than they would have otherwise been, out of no fault or choice of their own, but rather as a result of somebody else's imprudent choice. This goes against the spirit of luck egalitarianism. Therefore (luck egalitarian) justice can require us to save the imprudent and avoid conditionality in access to essential healthcare services. (shrink)

This chapter discusses whether patients should face penalties for unhealthy lifestyle choices. The idea that people should be held responsible for their bad health decisions is often associated with “luck egalitarianism”. This chapter explains the connection between responsibility-sensitive health care policies and luck egalitarianism and outlines some criticisms that have been made of luck egalitarianism in this context. It then highlights the implications of moral responsibility scepticism for luck egalitarians and other (...) proponents of similarly responsibility-sensitive approaches to health care. Theorists who have discussed the practical implications of moral responsibility scepticism have focused primarily on criminal punishment and, in that context, have often invoked an epistemic argument, maintaining that there are at least serious doubts about whether people are morally responsible (in the sense required for retributive punishment) and that, in view of this uncertainty, retributive punishment is unjust, given the serious harm it inflicts on offenders. This chapter argues that this type of reasoning also implies that we should not take patients’ responsibility for their poor health into account when deciding whether to give these patients treatments and that the health system should not impose significant penalties on individuals for harming their own health. Culpability-based desert seems to stand a better chance of helping luck egalitarians (and others with related views) to justify responsibility-sensitive health care policies compared with some alternative approaches. However, this chapter casts doubt on the idea that responsibility-sensitive health care policies based on this kind of desert are justifiable, focusing on doubts about whether people are morally responsible for harming their own health, whether harming one’s own health is morally wrong, and whether significant penalties for harming one’s health would be proportionate. (shrink)

Luck egalitarianism has been criticized for condoning some cases of oppression and condemning others for the wrong reason—namely, that the victims were not responsible for their oppression. Oppression is unjust, however, the criticism says, regardless of whether victims are responsible for it, simply because it is contrary to the equal moral standing of persons. I argue that four luck egalitarian responses to this critique are inadequate. Two address only the first part of the objection and do so (...) in a way that risks making luck egalitarianism inconsistent. A third severely dilutes the luck egalitarian doctrine. A fourth manages to denounce some instances of oppression for the right reason, but at the same time permits other instances of oppression and condemns yet others for the wrong reason. (shrink)

Relational Egalitarianism focuses on the construction of equal social relationships between persons. It strongly opposes luck egalitarianism, which understands equality as a distributive ideal. In Cohen’s theory of justice, luck egalitarianism and relational egalitarianism simultaneously exist, and Cohen provides arguments corresponding to each. In this paper, we explore the manifestation of tension between these two forms of egalitarianism in his theory. In addition, we also reconstruct some possible solutions provided by Cohen to soften (...) this tension, including the three approaches of market mechanism, egalitarian ethos and value pluralism, and find them to be unsuccessful. This tension is a serious challenge that needs to be addressed in Cohen’s theory of justice. (shrink)

It has been suggested that the era of genetic interventions will sound the death knell for luck egalitarianism, as it will blur the line between chance and choice, on which theories of distributive justice often rest. By examining the threats posed to these theories, a crucial assumption is exposed; it is assumed that a commitment to the neutralisation of the effects of luck implies the endorsement of even the most morally controversial enhancements. In antithesis, I argue that (...) an attractive theory of luck egalitarianism, Dworkinian liberal equality, enables us to deduce plausible implications for genetic engineering. By focusing on the abstract moral commitments at the heart of Dworkin’s theory, a twofold purpose is served. First, they reveal in what ways the criticisms misfire, thereby safeguarding luck egalitarianism. Second, Dworkinian luck egalitarianism is further strengthened, as it produces plausible guidelines for public policy on genetic engineering in liberal societies. (shrink)

According to US law, insurance companies can lawfully differentiate individual health insurance premiums on the basis of non-genetic medical information, but not on the basis of genetic information. The article reviews the case for such genetic exceptionalism. First, I critically assess some standard justifications. Next, I scrutinize an argument appealing to the view that genetically based premium differentiation expresses that persons do not all merit equal concern and respect. In the final section, I argue that even if genetic exceptionalism (...) is unjustified, there is a forceful luck egalitarian argument against basing premiums on genetic risks, to wit, that this tends to make some individuals worse off than others as a result of the bad brute luck involved in having a genetically determined, above-average risk of developing health problems. (shrink)

This paper begins with a simple illustration of the choice between individual and population strategies in population health policy. It describes the traditional approach on which the choice is to be made on the relative merits of the two strategies in each case. It continues by identifying two factors—our knowledge of the consequences of the epidemiological transition and the prevalence of responsibility-sensitive theories of distributive justice—that may distort our moral intuitions when we deliberate about the choice of appropriate risk-management (...) strategies in population health. It argues that the confluence of these two factors may lead us to place too much emphasis on personal responsibility in health policy. (shrink)

I outline and defend two egalitarian theories, which yield distinctive and, I argue, complementary answers to why health-related inequalities matter: a brute luck egalitarian view, according to which inequalities due to unchosen, differential luck are bad because unfair, and a social egalitarian view, according to which inequalities are bad when and because they undermine people’s status as equal citizens. These views identify different objects of egalitarian concern: the brute luck egalitarian view directs attention to health-related (...) well-being, while social egalitarianism focuses on health-related capabilities that are central to a person’s status as a citizen. I argue that both views are correct and should jointly guide priority-setting in health. (shrink)

Eli Feiring has developed a concept of forward-looking responsibility in healthcare. On this account, what matters morally in the allocation of scarce healthcare resources is not people's past behaviours but rather their commitment to take on lifestyles that will increase the benefit acquired from received treatment. According to Feiring, this is to be preferred over the backward-looking concept of responsibility often associated with luck egalitarianism. The article critically scrutinises Feiring's position. It begins by spelling out the wider implications (...) of Feiring's view. Against this background, it shows that (i) Feiring's distinction between backward-looking and forward-looking responsibility is incompatible with the Scanlonian notion of responsibility she apparently endorses; (ii) her favoured forward-looking notion of responsibility is subject to the objections levelled against the luck egalitarian view (whatever the strength of such objections). (shrink)

A considerable literature has emerged around the idea of using ‘personal responsibility’ as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as ‘responsibilisation’. This discussion focuses most prominently, but not exclusively, on ‘luck egalitarianism’, the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns (...) the two–way relationship between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem. (shrink)

Luck egalitarianism — the theory that makes individual responsibility central to distributive justice, so that bad luck underwrites a more compelling case for redistribution than do the bad choices of the disadvantaged — has recently come under a sustained attack from critics who are deeply committed to the broader struggle for equality. These egalitarian critics object, first, that luck egalitarianism’s policy recommendations are often unappealing. Second, they add that luck egalitarianism neglects the deep (...) political connection between equality and non-subordination, in favor of a shallowly distributive regime. This Article argues that both objections to luck egalitarianism have been exaggerated. Insofar as the criticisms are accurate, they apply only to a particular, maximalist strand of luck egalitarianism, whose distributive principle does not merely adjust allocations in light of responsibility but instead proposes that allocations should precisely track responsibility. However, this responsibility-tracking view does not represent the best or truest development of the basic luck egalitarian ideal. Moreover, the pathologies of the responsibility-tracking view help to cast the appeal of more judicious luck egalitarianism into sharp relief. The redistributive policies that more moderate developments of luck egalitarianism recommend are less objectionable than critics have supposed. And, more importantly, such modest luck egalitarianism is not a purely distributive ideal but instead contains, at its core, a vision of political solidarity among free and equal citizens. (shrink)

Many public debates over policies aimed at curbing alcohol consumption start from an assumption that policies should not affect ‘responsible’ drinkers. In this article, I examine this normative claim, which I call prudentialism. In the first part of the article, I argue that prudentialism is both a demanding and distinctive doctrine, which philosophers should consider seriously. In the middle sections, I examine the relationship between prudentialism and two familiar topics in public health ethics: the prevention paradox and the relationship (...) between responsibility and solidarity. I argue that standard positions in these debates do not necessarily undermine prudentialism. In the final part of the article, I outline an alternative, more successful, argument against prudentialism: that the categories of ‘responsible’ and ‘irresponsible’ drinking behaviour are not ‘apt’ for use in policy. I show how this objection relates to Elizabeth Anderson's arguments against the more familiar doctrine of ‘luck egalitarianism’. (shrink)

In his classic paper “Equality of What? Part 1: Equality of Welfare”, Ronald Dworkin argued that we should reject the notion that welfare is the currency of egalitarian justice. One reason is that this notion implies we should compensate individuals for expensive tastes they have deliberately cultivated. However, several egalitarians have objected that Dworkin conflates the resource/welfare and the luck/choice distinction. In particular, welfare luck egalitarianism implies that expensive tastes that are deliberately cultivated may not be compensable. (...) In response to this criticism, Dworkin has more recently argued that welfare luck egalitarianism in fact collapses into ordinary welfare egalitarianism, or relies on an account of luck that is either incoherent or at least cannot provide a basis for egalitarian redistribution. Therefore, according to Dworkin, welfare luck egalitarianism does not solve the problem of expensive tastes. In the current article, I critically assess these recent arguments of Dworkin’s about the inadequacy of welfare luck egalitarianism. I argue that Dworkin has not shown that this notion collapses into ordinary welfare egalitarianism, or that it harbours a problematic account of luck. (shrink)

How should we decide which inequalities between people are justified, and which are unjustified? One answer is that such inequalities are only justified where there is a corresponding variation in responsible action or choice on the part of the persons concerned. This view, which has become known as 'luck egalitarianism', has come to occupy a central place in recent debates about distributive justice. This book is the first full length treatment of this significant development in contemporary political philosophy. (...) Each of its three parts addresses a key question concerning the theory. Which version of luck egalitarian comes closest to realizing luck egalitarian objectives? Does luck egalitarianism succeed as a view of egalitarian justice? And is it sound as an account of distributive justice in general? The book provides a distinctive answer to each of these questions, along the way engaging with the leading theorists identified in the literature as luck egalitarians, such as Richard Arneson, G. A. Cohen, and Ronald Dworkin, as well as the most influential critics, including Elizabeth Anderson, Marc Fleurbaey, Susan Hurley, Samuel Scheffler, and Jonathan Wolff. (shrink)

In this book, an international group of philosophers, economists and theologians focus on the relationship between justice, luck and responsibility in health care. Together, they offer a thorough reflection on questions such as: How should we understand justice in health care? Why are health care interests so important that they deserve special protection? How should we value health? What are its functions and do these make it different from other goods? Furthermore, how much equality should (...) there be? Which inequalities in health and health care are unfair and which are simply unfortunate? Which matters of health care belong to the domain of justice, and which to the domain of charity? And to what extent should we allow personal responsibility to play a role in allocating health care services and resources, or in distributing the costs? With this book, the editors meet a double objective. First, they provide a comprehensive philosophical framework for understanding the concepts of justice, luck and responsibility in contemporary health care; and secondly, they explore whether these concepts have practical force to guide normative discussions in specific contexts of health care such as prevention of infectious diseases or in matters of reproductive technology. Particular and extensive attention is paid to issues regarding end-of-life care. (shrink)

Kasper Lippert-Rasmussen tackles all the major questions concerning luck egalitarianism, providing deep, penetrating and original discussion of recent academic discourses on distributive justice as well as responses to some of the main objections in the literature. It offers a new answer to the “Why equality?” and “Equality of what?” questions, and provides a robust luck egalitarian response to the recent criticisms of luck egalitarianism by social relations egalitarians. This systematic, theoretical introduction illustrates the broader picture (...) of distributive justice and enables the reader to understand the core intuitions underlying, or conflicting with, luck egalitarianism. (shrink)

Luck egalitarianism is a family of egalitarian theories of distributive justice that give a special place to luck, choice, and responsibility. These theories can be understood as responding to perceived weaknesses in influential earlier theories of both the left – in particular Rawls’ liberal egalitarianism (1971) – and the right – Nozick’s libertarianism (1974) stands out here. Rawls put great emphasis on the continuity of his theory with the great social contract theories of modern political thought, (...) particularly emphasising its Kantian character, while Nozick overtly develops his theory as an elaboration of John Locke’s account of property. By contrast, how luck egalitarianism is related to the history of political thought or philosophy more generally has been left unexplored by its proponents. Perhaps this is because they see luck egalitarianism, with its focus on individual choice and association with such contemporary concerns as equality of opportunity, as without significant predecessors in the canon. My purpose in this chapter is to make the tentative first steps towards identifying some historical antecedents of luck egalitarianism among the main works of Western political thought, in particular Aristotle, Machiavelli, and Locke. (shrink)

The article has two aims. First, to show that a version of luck egalitarianism that includes relational goods amongst its distribuenda can, as a matter of internal logic, account for one of the core beliefs of relational egalitarianism. Therefore, there will be important extensional overlap, at the level of domestic justice, between luck egalitarianism and relational egalitarianism. This is an important consideration in assessing the merits of and relationship between the two rival views. Second, (...) to provide some support for including relational goods, including those advocated by relational egalitarianism, on the distribuenda of justice and therefore to put in a good word for the overall plausibility of this conception of justice. I show why relational egalitarians, too, have reason to sympathise with this proposal. (shrink)

The paper critically examines a series of objections to luck egalitarianism raised by Elizabeth Anderson in her essay “What is the Point of Equality?” According to Anderson, current egalitarian writing has come to be dominated by the distinction between choice and brute luck and that strict adherence to this distinction will mean treating some people in ways we have other egalitarian reasons not to want to treat them.A case is made for moving the debate on by adopting (...) a pluralistic view of the fundamental egalitarian impulse that combines concerns about the influence on people’s lives of brute luck with more traditional egalitarian concerns. It is perfectly consistent with pluralistic egalitarianism to say that someone who faces social oppression or lacks effective access to valued functionings should receive public assistance even if not qua the victim of brute luck. (shrink)

Luck egalitarianism is a family of egalitarian theories of distributive justice that aim to counteract the distributive effects of luck. This article explains luck egalitarianism's main ideas, and the debates that have accompanied its rise to prominence. There are two main parts to the discussion. The first part sets out three key moves in the influential early statements of Dworkin, Arneson, and Cohen: the brute luck/option luck distinction, the specification of brute luck (...) in everyday or theoretical terms and the specification of advantage as resources, welfare, or some combination of these. The second part covers three later developments: the democratic egalitarian critique of luck egalitarianism, the luck egalitarian acceptance of pluralism, and luck egalitarian doubts about the significance of the brute luck/option luck distinction. (shrink)

In her recent, provocative essay “What Is the Point of Equality?”, Elizabeth Anderson argues against a common ideal of egalitarian justice that she calls “ luck egalitarianism” and in favor of an approach she calls “democratic equality.”1 According to the luck egalitarian, the aim of justice as equality is to eliminate so far as is possible the impact on people’s lives of bad luck that falls on them through no fault or choice of their own. In (...) the ideal luck egalitarian society, there are no inequalities in people’s life prospects except those that arise through processes of voluntary choice or faulty conduct, for which the agents involved can reasonably be held responsible. Anderson asserts that the adherents of luck egalitarianism, which can be elaborated in many different ways, include John Roemer, Erik Rakowski, Thomas Nagel, Ronald Dworkin, Gerald Cohen, Richard Arneson, and Philippe Van Parijs.2 In contrast, according to the democratic equality conception, justice as equality requires an end to oppressive social relationships. In the ideal society of democratic equality, the social conditions of everyone’s freedom are secured, each stands to every other in a relationship of fundamental equality, including equal respect, and all have real freedom to participate in democratic self-government. (shrink)

In this paper I discuss a frequent reply to what is usually called ‘the harshness objection,’ or “the abandonment objection” to luck egalitarianism. This objection has been used by Elizabeth Anderson to argue that luck egalitarianism is not, in any of its versions, an adequate interpretation of the ideal of social justice. According to the luck egalitarian reply discussed in this paper, luck egalitarianism can be saved from the harshness objection by value pluralism. (...) After a few short considerations on luck egalitarianism, on the harshness objection invoked by Anderson, and on pluralism as a strategy of dealing with this objection, I will try to show that, in fact, luck egalitarianism cannot be saved from the harshness objection by value pluralism. (shrink)

Luck egalitarianism has come under a lot of criticism for its apparent harshness towards negligent victims of voluntary actions (the harshness objection) and its inability to respond to morally-acceptable voluntary acts that lead to disadvantage (the discrimination objection). This paper surveys a series of responses in the luck egalitarian literature, showing that for the most part each one is unable to respond, on its own, to the crux of the objections. These responses often face a dilemma: Either (...) they must bite the bullet on the objections to retain their luck egalitarian commitments, or they must propose a reply to the objection that diverges from their core luck egalitarian principles. In this paper, I advance a preliminary framework for grounding luck egalitarian theories of justice based upon a two-level model and what I shall call the Fact of Inherent Normativity. Two-level luck egalitarianism makes fundamental rights and basic needs de facto insensitive to responsibility at the first level, while retaining the scope for responsibility for the distribution of second-level goods. The account remains distinctly luck egalitarian, while leaving scope for the consideration of rights, respect, and a host of other morally relevant considerations within the luck egalitarian framework. Luck egalitarianism, properly understood as a two-level theory, can successfully respond to objections against its harshness and propensity to discriminate. (shrink)

According to luck egalitarianism it is bad or unjust if someone is worse off than another through no fault or choice of her own. This article argues that there is a tension in standard luck egalitarian theory between justifying absolute and comparative welfare levels. If a person responsibly acts in a way that brings her welfare level below that of others, this is justified according to the theory. However, even if we can say that the person's new (...) welfare level is justified in absolute terms, it is less clear that her now being worse off than others, is justified. The reason is that while she has in one sense chosen her welfare level, she has not chosen to be worse off than others. Her relative standing, something with which egalitarians ought to be concerned, is determined by her choices in conjunction with the choices of all others. But no individual controls the choices of all others. Hence, for any one individual it is the case that her relative standing is beyond her control. Some responses to this problem are available. It is doubtful, however, that these are entirely successful. (shrink)

It is generally acknowledged that most accounts of distributive justice face a trilemma pertaining to agents who are badly off, or risk becoming so, due to their own imprudent behavior: If we a) leave such agents to their own devices, some might perish, which is harsh (Harshness). If we b) force such agents to buy insurance, for their own good (or ban certain risky activities), we act paternalistically (Paternalism). If we c) secure sufficiency for such agents by taxing everyone, we (...) exploit the prudent (Exploitation). This paper discusses how luck egalitarianism should handle this trilemma. The view defended is that luck egalitarianism should avoid Harshness and Paternalism, and accept Exploitation, by incorporating a sufficientarian constraint. The paper further shows how this can be done without violating core luck egalitarian commitments. Lastly, the paper asks whether securing sufficiency for the imprudent really amounts to exploitation as such, and whether it is, in any case, unfair. (shrink)

Christian Munthe, David Fumagalli and Erik Malmqvist argue that well-known healthcare resource allocation principles, such as need, prognosis, equal treatment and cost-effectiveness, should be supplemented with a principle of sustainability.1 Employing such a principle would entail that the allocation of healthcare resources should take into account whether a specific allocation causes negative dynamics, which would limit the amount of resources available in the future. As examples of allocation decisions, which may have such negative dynamics, they mention those who cause a (...) lack of vaccines, anti-bioethics resistance and drug shortages. Thus, the overall thought is that we can spend and allocate healthcare resources in a certain way at t1, which means that we will have fewer resources available at a later point, t2. The authors argue that we should include a principle of sustainability to justify allocations, which avoids or diminishes the negative dynamics. The authors argue that existing principles cannot sufficiently include proper regard for how our current decisions affect future allocation decisions and, therefore, the people who need healthcare resources in the future. I am sympathetic to the developed argument and believe that the authors are correct that negative dynamics provide reasons to take our ability to meet future health needs …. (shrink)

abstract This article defends luck egalitarianism as an interpretation of the egalitarian ideal against two major criticisms levelled against it by Elizabeth Anderson — that it is trapped in the distributive paradigm, and that it treats the victims of bad option luck too harshly to be considered an egalitarian theory. Against the first criticism, I argue that luck egalitarianism will condemn non‐material inequalities and injustices if an appropriate conception of well‐being is adopted. I demonstrate this (...) by showing how the approach is sensitive to the five faces of oppression developed by Iris Young. Although the second criticism is more troubling, it does not defeat luck egalitarianism, either. I will show that few of the inequalities that arise in the real world result from option luck. Further, if cases do occur, rather than abandoning the theory, the best response is to combine luck egalitarianism with another egalitarian principle that will ensure that the basic needs of all citizens are satisfied. The paper concludes by defending the appeal of the distinction between option luck and brute luck, in light of the preceding discussion. (shrink)

The late G.A. Cohen is routinely considered a founding father of luck egalitarianism, a prominent responsibility-sensitive theory of distributive justice. David Miller argues that Cohen’s considered beliefs on distributive justice are not best understood as luck egalitarian. While the relationship between distributive justice and personal responsibility plays an important part in Cohen’s work, Miller maintains that it should be considered an isolated theme confined to Cohen’s exchange with Dworkin. We should not understand the view Cohen defends in (...) this exchange as Cohen’s considered view. Accepting this thesis would change both our understanding of Cohen’s political philosophy and many recent luck egalitarian contributions. Miller’s argument offers an opportunity to reassess Cohen’s writings as a whole. Ultimately, however, the textual evidence against Miller’s argument is overwhelming. Cohen clearly considers the exchange with Dworkin to be about egalitarianism as such rather than about the best responsibility-sensitive version of egalitarianism. Furthermore, Cohen often offers luck egalitarian formulations of his own view outside of the exchange with Dworkin and uses luck egalitarianism as an independent yardstick for evaluating principles and distributions. (shrink)

This paper discusses what implications global luck egalitarianism (GLE) has for border control. Some authors suggest that an open‐borders policy follows from GLE. The idea is that various unchosen inequalities inevitably follow from differences in birthplace, such that GLE will always have principled reason to condemn closed borders. Others are skeptical of the assumption that GLE will have liberal implications for border control, because open borders may have other, adverse effects that outweigh the reductions in unjust inequality. Against (...) such skeptics, we argue that GLE will (typically) have quite liberal implications for border control. However, this connection is not a principled one: Whether (and to what extent) GLE favors opening or closing borders will depend upon empirical circumstances. (shrink)

Luck egalitarians think that considerations of responsibility can excuse departures from strict equality. However critics argue that allowing responsibility to play this role has objectionably harsh consequences. Luck egalitarians usually respond either by explaining why that harshness is not excessive, or by identifying allegedly legitimate exclusions from the default responsibility-tracking rule to tone down that harshness. And in response, critics respectively deny that this harshness is not excessive, or they argue that those exclusions would be ineffective or lacking (...) in justification. Rather than taking sides, after criticizing both positions I also argue that this way of carrying on the debate – i.e. as a debate about whether the harsh demands of responsibility outweigh other considerations, and about whether exclusions to responsibility-tracking would be effective and/or justified – is deeply problematic. On my account, the demands of responsibility do not – in fact, they can not – conflict with the demands of other normative considerations, because responsibility only provides a formal structure within which those other considerations determine how people may be treated, but it does not generate its own practical demands. (shrink)