I teach applied ethics and political philosophy at Northwestern University in Evanston. Phone: +1 (847) 491-8918 Address: Department of Philosophy 1880 Campus Drive Northwestern University Evanston, IL 60208
Suppose that a commodity is a good the production, distribution, and consumption of which is prop... more Suppose that a commodity is a good the production, distribution, and consumption of which is properly governed by the norms of the marketplace. Is health care a commodity? One perspective from which health care is clearly not a commodity is the perspective of standard welfare economics. Markets for health care and health care insurance suffer many sources of inefficiency, and this must be at least part of the reason why no developed country on earth leaves the provision of care to the unregulated market. However, philosophers have sought a deeper and perhaps more moralized rationale for the refusal to treat health care as a commodity, grounded in concerns of distributive justice or of the preservation of important social values like community or solidarity. This chapter examines those supposedly deeper arguments and finds them all inconclusive; only the appeal to efficiency can provide a complete and appropriately nuanced account of the imperative to decommodify health care.
It is generally acknowledged that a certain amount of state intervention in health and health car... more It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing (including resource allocation between generations), the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can.
In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficenc... more In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficence and solidarity as mutual advantage. I argue that only the latter is capable of providing a complete foundation for national universal health care programs. On the mutual advantage account, the rationale for universal insurance is parallel to the rationale for a labor union’s “closed shop” policy. In both cases, mandatory participation is necessary in order to stop individuals free-riding on an ongoing system of mutually advantageous cooperation.
This discussion revises and extends Jonny Anomaly's "public goods" account of public health ethic... more This discussion revises and extends Jonny Anomaly's "public goods" account of public health ethics in light of recent criticism from Richard Dees. Public goods are goods that are both non-rival and non-excludable. What is significant about such goods is that they are not always provided efficiently by the market. Indeed, the state can sometimes realize efficiency gains either by supplying such goods directly or by compelling private purchase. But public goods are not the only goods that the market may fail to provide efficiently. This points to a way of broadening the public goods account of public health to accommodate Dees' counterexamples, without abandoning its distinctive appeal. On the market failures approach to public health ethics, the role of public health is to correct public health-related market failures of all kinds, so far as possible. The underlying moral commitment is to economic efficiency in the sense of Pareto: if we can re-allocate resources in the economy so as to raise the welfare of some without lowering the welfare of any other, we ought to do so.
A private, for-profit company has recently opened a pair of plasma donation centres in Canada, at... more A private, for-profit company has recently opened a pair of plasma donation centres in Canada, at which donors can be compensated up to $50 for their plasma. This has sparked a nation-wide debate around the ethics of paying plasma donors. Our aim in this paper is to shift the terms of the current debate away from the question of whether plasma donors should be paid and toward the question of who should be paying them. We consider arguments against paying plasma donors grounded in concerns about exploitation, commodification, and the introduction of a profit motive. We find them all to be normatively inconclusive, but also overbroad in light of Canada’s persistent reliance on plasma from paid donors in the United States. While we believe that there are good reasons to oppose allowing a private company to profit from Canada’s blood supply, these concerns can be addressed if payment is dispensed instead by a public, not-for-profit agency. In short, we reject profiting from plasma while we endorse paying for plasma; we therefore conclude in favour of a new Canadian regime of public sector plasma collection and compensation.
People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kid... more People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kidneys through paired exchanges or chains. We reject anti-commodification accounts of this reaction and offer an egalitarian one. We argue that the morally significant difference between cash markets and kidney chains is that the former allow the wealthy greater access to kidneys, while the latter do not. The only problem with kidney chains is that they do not go far enough in addressing equality concerns, and we show how the introduction of cash payments by the state could remedy this.
Theorists of the welfare state increasingly recognize that social insurance programs are not well... more Theorists of the welfare state increasingly recognize that social insurance programs are not well-justified by distributive egalitarianism, distributive egalitarianism meaning concern for equality considered as a pattern in the distribution of some good. But recent work by several relational egalitarian theorists suggests that these programs may be justified on relational egalitarian grounds. Relational egalitarians hold that the proper object of egalitarian concern is the way that citizens relate to one another. In this paper, I review the problems facing a distributive egalitarian justification for social insurance before considering and rejecting three relational egalitarian justification. I close by offering a justification for these programs grounded in efficiency, not equality.
Many urge that that distributing health care according to medical need is a requirement of equali... more Many urge that that distributing health care according to medical need is a requirement of equality. But most egalitarians believe that individuals ought to be equal by some overall measure of well-being or life-prospects. It would be a massive coincidence if distributing health care according to medical need turned out to be an effective way of promoting equality overall. I argue instead that distributing health care according to medical need is important as a way of reducing individuals' uncertainty surrounding their future medical needs. Distributing care according to medical need is a natural feature of health care insurance. Medical need is about indemnity, not equality.
While citizens in a liberal democracy are generally expected to see to their basic needs out of t... more While citizens in a liberal democracy are generally expected to see to their basic needs out of their own income shares, health care is treated differently. Most rich liberal democracies provide their citizens with health care or health care insurance in kind. Is this “special” treatment justified? The predominant liberal account of justice in health care holds that the moral importance of health justifies treating health care as special in this way. I reject this approach and offer an alternative account. Health needs are not more important than other basic needs, but they are more unpredictable. I argue that citizens are owed insurance against health risks to provide stability in their future expectations and thus to protect their capacities for self-determination.
Perhaps the deepest divide in contemporary egalitarian theory is the divide between luck egalitar... more Perhaps the deepest divide in contemporary egalitarian theory is the divide between luck egalitarians and relational egalitarians. Luck egalitarians hold that equality requires that no one should end up worse off than another through no fault or choice of their own. Relational egalitarians, by contrast, hold that the luck egalitarian’s focus on redressing undeserved misfortune misses the point of equality, which is to eliminate social hierarchies so that citizens may relate to one another as equals.
When Elizabeth Anderson first articulated many of the concerns that animate relational egalitarians, she took Ronald Dworkin’s “equality of resources” as a foil. I think Anderson unfairly assimilates Dworkin’s view to the later luck egalitarian tradition; properly understood, Dworkin’s egalitarianism is relational at its core. Dworkin’s view is that equality requires that each person should bear the cost of her choices to others. For a person to fail to bear the cost of her own choices, or in other words for a person to shift the costs of her choices to others, is a failure of relational equality in the sense that it subordinates those others to her will. Indeed, the ability to unilaterally impose costs on others is characteristic of paradigmatically inegalitarian social relationships, like relations of dependence or domination. In that vein, I argue that Dworkin’s equality of resources can be understood as the result of applying fundamental relational egalitarian insights to the domain of distributive justice.
This new interpretation of Dworkin is significant, not merely as a correction to the historical record. It also points to a way of incorporating within relational egalitarianism a robust concern for distributive equality (as opposed to mere priority or sufficiency) – an important goal that has so far proved elusive.
Suppose that a commodity is a good the production, distribution, and consumption of which is prop... more Suppose that a commodity is a good the production, distribution, and consumption of which is properly governed by the norms of the marketplace. Is health care a commodity? One perspective from which health care is clearly not a commodity is the perspective of standard welfare economics. Markets for health care and health care insurance suffer many sources of inefficiency, and this must be at least part of the reason why no developed country on earth leaves the provision of care to the unregulated market. However, philosophers have sought a deeper and perhaps more moralized rationale for the refusal to treat health care as a commodity, grounded in concerns of distributive justice or of the preservation of important social values like community or solidarity. This chapter examines those supposedly deeper arguments and finds them all inconclusive; only the appeal to efficiency can provide a complete and appropriately nuanced account of the imperative to decommodify health care.
It is generally acknowledged that a certain amount of state intervention in health and health car... more It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing (including resource allocation between generations), the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can.
In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficenc... more In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficence and solidarity as mutual advantage. I argue that only the latter is capable of providing a complete foundation for national universal health care programs. On the mutual advantage account, the rationale for universal insurance is parallel to the rationale for a labor union’s “closed shop” policy. In both cases, mandatory participation is necessary in order to stop individuals free-riding on an ongoing system of mutually advantageous cooperation.
This discussion revises and extends Jonny Anomaly's "public goods" account of public health ethic... more This discussion revises and extends Jonny Anomaly's "public goods" account of public health ethics in light of recent criticism from Richard Dees. Public goods are goods that are both non-rival and non-excludable. What is significant about such goods is that they are not always provided efficiently by the market. Indeed, the state can sometimes realize efficiency gains either by supplying such goods directly or by compelling private purchase. But public goods are not the only goods that the market may fail to provide efficiently. This points to a way of broadening the public goods account of public health to accommodate Dees' counterexamples, without abandoning its distinctive appeal. On the market failures approach to public health ethics, the role of public health is to correct public health-related market failures of all kinds, so far as possible. The underlying moral commitment is to economic efficiency in the sense of Pareto: if we can re-allocate resources in the economy so as to raise the welfare of some without lowering the welfare of any other, we ought to do so.
A private, for-profit company has recently opened a pair of plasma donation centres in Canada, at... more A private, for-profit company has recently opened a pair of plasma donation centres in Canada, at which donors can be compensated up to $50 for their plasma. This has sparked a nation-wide debate around the ethics of paying plasma donors. Our aim in this paper is to shift the terms of the current debate away from the question of whether plasma donors should be paid and toward the question of who should be paying them. We consider arguments against paying plasma donors grounded in concerns about exploitation, commodification, and the introduction of a profit motive. We find them all to be normatively inconclusive, but also overbroad in light of Canada’s persistent reliance on plasma from paid donors in the United States. While we believe that there are good reasons to oppose allowing a private company to profit from Canada’s blood supply, these concerns can be addressed if payment is dispensed instead by a public, not-for-profit agency. In short, we reject profiting from plasma while we endorse paying for plasma; we therefore conclude in favour of a new Canadian regime of public sector plasma collection and compensation.
People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kid... more People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kidneys through paired exchanges or chains. We reject anti-commodification accounts of this reaction and offer an egalitarian one. We argue that the morally significant difference between cash markets and kidney chains is that the former allow the wealthy greater access to kidneys, while the latter do not. The only problem with kidney chains is that they do not go far enough in addressing equality concerns, and we show how the introduction of cash payments by the state could remedy this.
Theorists of the welfare state increasingly recognize that social insurance programs are not well... more Theorists of the welfare state increasingly recognize that social insurance programs are not well-justified by distributive egalitarianism, distributive egalitarianism meaning concern for equality considered as a pattern in the distribution of some good. But recent work by several relational egalitarian theorists suggests that these programs may be justified on relational egalitarian grounds. Relational egalitarians hold that the proper object of egalitarian concern is the way that citizens relate to one another. In this paper, I review the problems facing a distributive egalitarian justification for social insurance before considering and rejecting three relational egalitarian justification. I close by offering a justification for these programs grounded in efficiency, not equality.
Many urge that that distributing health care according to medical need is a requirement of equali... more Many urge that that distributing health care according to medical need is a requirement of equality. But most egalitarians believe that individuals ought to be equal by some overall measure of well-being or life-prospects. It would be a massive coincidence if distributing health care according to medical need turned out to be an effective way of promoting equality overall. I argue instead that distributing health care according to medical need is important as a way of reducing individuals' uncertainty surrounding their future medical needs. Distributing care according to medical need is a natural feature of health care insurance. Medical need is about indemnity, not equality.
While citizens in a liberal democracy are generally expected to see to their basic needs out of t... more While citizens in a liberal democracy are generally expected to see to their basic needs out of their own income shares, health care is treated differently. Most rich liberal democracies provide their citizens with health care or health care insurance in kind. Is this “special” treatment justified? The predominant liberal account of justice in health care holds that the moral importance of health justifies treating health care as special in this way. I reject this approach and offer an alternative account. Health needs are not more important than other basic needs, but they are more unpredictable. I argue that citizens are owed insurance against health risks to provide stability in their future expectations and thus to protect their capacities for self-determination.
Perhaps the deepest divide in contemporary egalitarian theory is the divide between luck egalitar... more Perhaps the deepest divide in contemporary egalitarian theory is the divide between luck egalitarians and relational egalitarians. Luck egalitarians hold that equality requires that no one should end up worse off than another through no fault or choice of their own. Relational egalitarians, by contrast, hold that the luck egalitarian’s focus on redressing undeserved misfortune misses the point of equality, which is to eliminate social hierarchies so that citizens may relate to one another as equals.
When Elizabeth Anderson first articulated many of the concerns that animate relational egalitarians, she took Ronald Dworkin’s “equality of resources” as a foil. I think Anderson unfairly assimilates Dworkin’s view to the later luck egalitarian tradition; properly understood, Dworkin’s egalitarianism is relational at its core. Dworkin’s view is that equality requires that each person should bear the cost of her choices to others. For a person to fail to bear the cost of her own choices, or in other words for a person to shift the costs of her choices to others, is a failure of relational equality in the sense that it subordinates those others to her will. Indeed, the ability to unilaterally impose costs on others is characteristic of paradigmatically inegalitarian social relationships, like relations of dependence or domination. In that vein, I argue that Dworkin’s equality of resources can be understood as the result of applying fundamental relational egalitarian insights to the domain of distributive justice.
This new interpretation of Dworkin is significant, not merely as a correction to the historical record. It also points to a way of incorporating within relational egalitarianism a robust concern for distributive equality (as opposed to mere priority or sufficiency) – an important goal that has so far proved elusive.
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When Elizabeth Anderson first articulated many of the concerns that animate relational egalitarians, she took Ronald Dworkin’s “equality of resources” as a foil. I think Anderson unfairly assimilates Dworkin’s view to the later luck egalitarian tradition; properly understood, Dworkin’s egalitarianism is relational at its core.
Dworkin’s view is that equality requires that each person should bear the cost of her choices to others. For a person to fail to bear the cost of her own choices, or in other words for a person to shift the costs of her choices to others, is a failure of relational equality in the sense that it subordinates those others to her will. Indeed, the ability to unilaterally impose costs on others is characteristic of paradigmatically inegalitarian social relationships, like relations of dependence or domination. In that vein, I argue that Dworkin’s equality of resources can be understood as the result of applying fundamental relational egalitarian insights to the domain of distributive justice.
This new interpretation of Dworkin is significant, not merely as a correction to the historical record. It also points to a way of incorporating within relational egalitarianism a robust concern for distributive equality (as opposed to mere priority or sufficiency) – an important goal that has so far proved elusive.
When Elizabeth Anderson first articulated many of the concerns that animate relational egalitarians, she took Ronald Dworkin’s “equality of resources” as a foil. I think Anderson unfairly assimilates Dworkin’s view to the later luck egalitarian tradition; properly understood, Dworkin’s egalitarianism is relational at its core.
Dworkin’s view is that equality requires that each person should bear the cost of her choices to others. For a person to fail to bear the cost of her own choices, or in other words for a person to shift the costs of her choices to others, is a failure of relational equality in the sense that it subordinates those others to her will. Indeed, the ability to unilaterally impose costs on others is characteristic of paradigmatically inegalitarian social relationships, like relations of dependence or domination. In that vein, I argue that Dworkin’s equality of resources can be understood as the result of applying fundamental relational egalitarian insights to the domain of distributive justice.
This new interpretation of Dworkin is significant, not merely as a correction to the historical record. It also points to a way of incorporating within relational egalitarianism a robust concern for distributive equality (as opposed to mere priority or sufficiency) – an important goal that has so far proved elusive.