Justice and Lung Cancer [to appear in the Journal of Medicine and Philosophy] Aaron Wilson University of Miami, Coral Gables, Florida, USA Lung cancer is the leading cause of cancer deaths, yet research funding is by far the lowest for lung cancer than for any other cancer when compared to respective death rates. While this discrepancy should appear alarming, one could argue that lung cancer deserves less attention because it is more attributable to poor life choices than other common cancers. Accordingly, the general question that I ask in this paper is whether victims of more avoidable diseases, such as lung cancer, deserve to have their needs taken into less consideration than those of less avoidable diseases, on the grounds of either retributive or distributive justice. Such unequal treatment may be the “penalty” one incurs for negligent or reckless behavior. However, I hope to show that such unequal treatment cannot be supported on any coherent accounts of retributive or distributive justice. Key words: Justice, Punishment, Disease, Ethics, Research Funding, Lung Cancer I: Introduction There is a popular tendency to think that justice is served when, following the proverbial expression, people who play with fire get burned. Certainly we could say that poetic justice applies to cases in which people hurt themselves through their own reckless or negligent behavior,; and we tend to feel worse for those who are not victims of their own reckless behavior than for those who are. But does, or must, some form of social justice apply to these cases also? The term “social justice” is often used synonymously with “distributive justice,” but I understand “social justice” to involve a wider concept, encompassing all matters of justice that arise between human beings in a social environment. The sense of “social justice” as I use it here captures both retributive and distributive justice. I intend to pursue this general question in connection with a more specific one: ought victims of lung cancer, because of its connection to smoking, to have their needs and interests taken into less consideration than the needs and interests of victims of equally serious but less avoidable cancers, such as beast cancer? It seems that one can avoid being at high risk of lung cancer by not smoking, but one cannot avoid, or least not to the same extentdegree, being at risk of breast cancer. This fact might incline many to answer positively to the above question: lung cancer victims ought to receive less consideration than one would give victims of other diseases, for the simple fact that a majority of lung cancer victims can be held responsible for their own illness. Of course, whether lung cancer should be understood as a “self-inflicted” disease is still controversial; a significant number of lung cancer victims never smoked. Nevertheless, there is a clear connection between smoking and lung cancer and, —despite its addictiveness, —smoking is usually at first a choice. Lung cancer probably would not be the top cancer killer, killing more per year than breast cancer and prostate cancer combined, were it not for that many chose to pursue a life-long habit of smoking. Stigmas surrounding various afflictions and an often accompanying "blame-the-victim" mentality have been studied for decades. There is evidence that people blame victims for illnesses that are perceived to be largely self-inflicted. See, for instance, Weiner (1995, 53-84). Some afflictions with which this blame-the-victim mentality have been observed are: HIV, alcoholism, obesity and other eating disorders, rape, drug addiction, homelessness, and lung cancer. Some afflictions with which this blame-the-victim mentality are not commonly observed are: Alzheimer's disease, blindness, paraplegia, and breast cancer. Ibid. The key difference between the first list of afflictions and the second is that the first is a list of afflictions that appear controllable and thereby avoidable, where the second is of ones that do not. The controllability of certain afflictions raises perceptions of blameworthiness of their victims, and often accompanyingcorresponding to these perceptions is the view that the victims actually deserve their disease. I will refer to this view as (R): (R): Victims of controllable diseases who are responsible for their affliction deserve their affliction—the disease is retribution for negligent or reckless behavior. Alternatively, there is a ‘less’ retributive view that is not discussed often in the literature, but is a more defensible view to which defenders of (R) would probably retreat if (R) should prove difficult to support. I will refer to this alternative view as (D): (D) While victims of controllable diseases who are responsible for their affliction do not deserve their affliction, neither do they deserve as much help or consideration as victims who are not responsible for their affliction. With (R), the disease is perceived to be a kind of natural punishment. As such, it is not imposed by any social institution, but victims are still thought to deserve it as punishment or, more precisely, retribution for engaging in reckless or negligent behaviors. The concept of retribution assumed here is a broad one: a person is said to deserve some punishment “proportional” to the crime, but the reasons for punishing have nothing to do with any likely positive material consequences of the punishment (deterrence, rehabilitation, etc.). And if one deserves their disease as punishment, then that can be used to defend giving that person less consideration than victims of other equally serious diseases. With (D), the disease itself is not perceived to be a punishment, but a certain conception of social justice requires that we penalize victims whose afflictions are caused by their own reckless or negligent life choices, specifically by giving preferential treatment to victims whose afflictions are not caused by reckless or negligent life choices. A defender of (D) might argue that victims of more controllable diseases do not have as much of a right to certain resources as victims of less controllable diseases. One such resource would be scientific research into new treatments and detection methods for the disease. If lung cancer is a largely self-inflicted disease, then victims of that disease might not deserve as much publically funded research into their disease as victims of less controllable diseases. When one looks at the trend with government funding for lung cancer research and compares it to the trend with government funding for research into other common cancers, one notices quite a discrepancy. In 2009, in the United States, $27,480 was spent on breast cancer research per breast cancer death, with $14,336 on prostate cancer per prostate death, but only $1,249 on lung cancer research per lung cancer death. The Lung Cancer Alliance. Available: HYPERLINK "http://www.lungcanceralliance.org/facing/facts.html"http://www.lungcanceralliance.org/facing/facts.html (accessed Jan. 11th, 2010). The figures are calculated according to data released by the NIH, CDC, and DOD. Available: HYPERLINK "http://report.nih.gov/rcdc/categories/"http://report.nih.gov/rcdc/categories/, HYPERLINK "http://www.cdc.gov/fmo/topic/Budget%20Information/index.html"http://www.cdc.gov/fmo/topic/Budget%20Information/index.html (accessed Jan. 11th, 2010). Moreover, in 2003 the Global Lung Cancer Coalition published the results of a survey of clinicians from around the world which found that 86% of respondents believed that lung cancer receives far less government consideration than other common cancers. See Press Release. "Specialists warn that inadequate funding treats lung cancer as 'the poor relation.'" http://www.lungcancercoalition.org/en/pages/resources/press/07 (accessed August 9th, 2009). Can a prevalent blame-the-victim attitude with respect to lung cancer, because of its connection to smoking, partly account for these differences in cancer research funding? A qualitative study published in the BMJ found that lung cancer patients experience more stigma and blame than victims of other cancers. A. Chapple, S. Ziebland and A McPherson (2004) While certainly there are other reasons that may account formay contribute to these research spending differences, between different diseases, which I will address later, there is a warranted concern about whether there is less effort to find new treatments and detection methods for lung cancer, —because of its connection to smoking,— than there is for other serious cancers. Thus, the main worry of this paper is that it might be in the service of justice to give preferential treatment, say, to breast cancer victims over lung cancer victims, according to views (R) or (D) delineated above. While my case example is lung cancer, the worry can be generalized to cover any affliction which is commonly attributed to negligent or reckless behavior. It might strike some that (R), the view that a largely avoidable disease like lung cancer is a punishment for negligent or reckless behavior, is absurd enough to be set aside as a non-starter. But the phenomenon of perceiving certain diseases as punishments has been prevalent enough across populations to see if it can be rationally supported. See Kopelman (1988) for an examination of the prevalence of this perception of disease. However, (D)—the view that even though victims of controllable diseases like lung cancer do not deserve the disease itself, neither do they deserve as much consideration as victims of less avoidable diseases—should prove to be more defensible. While distributive justice (as opposed to retributive justice) is more at issue with (D), by withholding certain resources from victims of self-inflicted diseases, it seems that one is imposing a kind of punishment that says: if you are responsible for your affliction, you will not be given equal consideration with respect to public resources. I intend to explore the arguments in favor of such a penalty. My ultimate contention is that views (R) and (D) are false, and so practices giving preferential treatment to victims of less avoidable diseases cannot be defended on the grounds of justice. With respect to my case examplelung cancer, I will assume for the sake of argument that lung cancerit is in fact a largely an avoidable disease, even though for many smoking was neither a negligent nor reckless choice because the harms of it were not well known at the time those persons became addicted. But anyone who begins a smoking habit today is taking a risk, and knows she is. But I predict that (R) and (D) will prove incapable of justifying practices that discriminate between victims of more avoidable diseases and those of less avoidable diseases. The current state of government funding of cancer research might involve such a discriminatory practice, and later I will give further reasons to suspect that it does. I. The Retributive View of Lung Cancer The concept of retribution is obscure, having been understood in very different and even conflicting ways. Consequently, since the concept of retribution is essential to (R), a quick review of the literature on the concept is in order. The following are three components of the concept that seem It is generally agreed upon that: retributive punishment is something one is said to deserve, it is distinct from revenge because the reasons for punishing in general issue from rational principles, Or, it might be said, from principles that “would be agreed upon by all rational persons.” and and (iii) these principles are independent of the material consequences of punishing. Retributivism is sometimes defined simply as an account of punishment that stands in contrast to utilitarian accounts of punishment (e.g. Dolinko, 1991). Others, however, have considered retributivism to be compatible with utilitarianism, arguing that retributivism is a logical principle that says one should only punish the guilty. See for instance Hart, H.L.A. (1968, 23). John Cottingham explains this idea: “utilitarian considerations provide the answer to the general question ‘why punish at all?’, while retribution provides the answer to the more specific question ‘whom shall we punish?’ (answer: ‘only the guilty’)” (1979, 241). But, as Cottingham observes, there is nothing distinctively retributivist about the thesis: "one should only punish the guilty." While it may be a fourth necessary componentnecessary condition for of the concept of retributive justiceism, it is not a sufficient one. The second necessary componenetndition requires that retributivism is supplemented with principles that describe the sufficient conditions for punishment in general, answering the question "why punish at all?" I do not think that a reasonable answer could be as simple as "because one may deserve it." As Cottingham points out, if desert itself, without any grounding in further principles, were a sufficient condition for retributive punishment, it “leaves the rationale for that label compressed to the point of unintelligibility” (1979, 239). Etymologically, “retribution” means “repayment,” and this is the pre-philosophical senseunderstanding when it is said that, through punishment, criminals “pay a debt” to their victim or to society. While it is often left unexplained why some amount of suffering serves as payment, or exactly how much suffering is owed on a given occasion, “payment for some wrong” does seem to be at the core of the conceptnotion. But one should be careful not to think of it as payment in the sense of restitution. More often than not, a punishment does not undo the effects of the crime. It is also a mistake to think of it as payment in the sense that it brings satisfaction to those wronged, since the harm done to the offender is often greater than the satisfaction gained by the victim or by society in seeing the offender punished, violating the proportionality requirement. In what other sense does punishing a criminal pay for the crime? One suggestion is that there are simply penalties for breaking laws or not fulfilling duties. But this only pushes the question back, since one can reasonably ask for the justification for such penalties in the first place. A plausible argument for this is that there must be penalties because it would be unfair to those who fulfill their duties if others, who do not fulfill their duties, do not have to face any consequences as a result. This is what Cottingham calls the “fair-play” conception of retributive punishment, and he attributes it to Rawls (1971). With this conception, “[i]t is not that punishing the offender is intrinsically appropriate, but that failure to punish would be unjust to others” (1979, 243). The offender gains an unfair advantage over others who might otherwise benefit from committing the same wrong, but do not out of respect for the moral or social law. However, it seems to me that the unfair advantage that the offender gains with respect to others who obey the law is peripheral to the unfair advantage that the offender gains over his victim. The following quotation from Kant, perhaps the most famous philosophical proponent of retributivism, suggests that it is primarily the wrong done to the victim that requires retribution and determines the extent of the punishment. What kind and what degree of punishment does public legal justice adopt is [sic] its principle and standard? None other than the principle of equality... that is, the principle of not treating one side more favorably than the other. Accordingly, any undeserved evil that you inflict on someone else among the people is one you do to yourself. If you vilify him, you vilify yourself; if you steal from him, you steal from yourself; if you kill him, you kill yourself... (1798/1999, 138) There are a number questions concerning Kant's retributivism with which I do not wish to concern myself. Nevertheless, I take this passage to suggest that retribution primarily concerns preserving equality between the offender and his victim, rather than the offender and the rest of society. But with respect to what does punishment preserve equality? We could say that iIt is equality with respect to transactions and transgressions between persons that might alter the distribution of benefits and burdens between them. When the principle of equality is conceived as under a procedural principlejustice, it would seem that on an occasion where person A is responsible for changing the level of rights, entitlements or other advantages of person B, a change in equal value of the level of rights, entitlements, and other advantages of A is required, all else being equal. Otherwise, it would appear that the transaction or transgression was unfair or imbalanced. Even when the required change lowers the overall level of advantages between the two, the ideal of equality (with respect to procedural justice) trumps such utilitarian concerns. We might refer to this as the ‘reciprocity’ view of retributive justice. The notion that the principle of equality is served when the offender is put at an equal disadvantage with his victim is at the core of this conception. Retribution as ‘reciprocity’ provides a sufficient condition for punishing in general, and suggests conditions for particular punishments. I take this and the ‘fair-play’ conception to be the most plausible general accounts of retributive justice that also offer sufficient conditions for punishment, but I will not defend either accounts any further. Instead, I want to see if these accounts of retributive justice might support the view that diseases can be retribution for reckless behavior. I focus on retributive punishment rather than utilitarian punishment (or utilitarian justifications for punishment) because while I think it is unclear whether retributive punishments need to be products of institutions, as opposed to consequences of natural occurrences (as the onset of a disease usually is), I think that punishments need to be products of institutions when the justification for punishing in general is that it serves some material good. The fact that a mass murderer dies in a car wreck might serve some material good, but the fact that it serves that good also needs to be the explanation for why he died, otherwise it is simply a natural event that just happened to be in the interest of the common good. There must be an intentional act ofto punishment with the utilitarian account in order for an event to qualify as a punishment. But it is less clear that the same goes with the retributive account. It seems that the ideal of equality—on which both fair-play and reciprocity view of retribution are based—can be served intentionally or unintentionally. Equality is met when one is put at an equal level of burdens and benefits with others whether it is at the hands of man or at the hands of nature. So when an offender is put at the same disadvantage at which he put his victim through some natural circumstance, this could be taken to satisfy the retribution requirement. If a murderer dies in a car wreck, it seems natural to say that he ‘got what he deserved.’ Retributive justice is generally an issue in transgressions between at least two numerically different persons: the victim and the offender. However, tThe cases with which weI am concerned, however, are ones in which the victim and the offender arewould have to be the same person—supposing that reckless or negligent behavior results only in one’s own injury. Between the two plausible accounts of retributive justice (‘fair-play’ and ‘reciprocity’), neither of them seem easily applicable to these cases. Reviewing the necessary conditions for retributive justice, we can see why: Retributive punishment is something one must deserve. It is distinct from revenge because the reason for punishing in general issues directly from principles that would be agreed upon by all rational persons. These principles are independent of the material consequences of punishing. Punishment is owed only to the guilty. The principles referred to by ii) and iii) are: On the fair-play account, one is punished to the degree to which one gains an advantage over others by disobeying a law or not fulfilling a duty. On the reciprocity account, one is punished to the degree to which one gains an unfair advantage over his victim in violating his victim’s rights, entitlements, etc... The question is whether (a) or (b) admits of situations where the victim and the offender are identical. With (a), the fair-play view, this does not seem to matter, since the unfair advantage gained by the offender is not relative to the victim, but to others who obey the law. So suppose one engages in reckless behavior but never actually harms himself in doing so. One might have the impression that this would be unfair to those who refrain from reckless behavior. Why? Because it might appear to be a law that those who refrain from such behavior shouldwill, in long run, be better off than those who do not. It would not seem fair if the reckless person is, in the long run, just as well-off as the prudent person. But what sort of law would this be? It is neither an actual law of nature nor a law of man. While later I will discuss whether there is moral ground for enacting such a law, the fair-play account requires that there is a law or duty with respect to which one gains an advantage over others by not obeying or fulfilling it. So far as there is no such law, the fair-game account of retributive justice fails to support (R). Unlike (a), (b), the reciprocity view, does refer to the victim in its calculation of punishment. But retribution-as-reciprocity collapses when the victim and the offender are the same person, and it is clear why. I assume that “persons” are the basic units to which rights are attributed, desert is owed, and goods are distributed. While one might deprive oneself of a right, such as the right to life by committing suicide, only metaphorically can one owe oneself some desert in return, since the point of owing desert in (b) is to preserve the relative level of benefits and burdens in transgressions between distinct persons. But in an intra-personal transgressions, if we can say there areis such a things, no redistribution is necessary since one is always at the same level of rights, entitlements, etc. with oneself. Hence, there is never an inequality. Intuitions that (R) should be treated as a non-starter are on the ball. It does not seem like any plausible account of retributive justice can support the view that lung cancer is retribution for smoking, nor that getting into a car wreck is retribution for driving drunk, and so on. II: Do Lung Cancer Victims Deserve Less Consideration? With (R), retributive justice is the central concept. With (D), the central concept is justice in the distribution of moderately scarce resources. (D) claims that a just distribution will be one in which financial, medical and scientific resources are not distributed evenly between victims of more avoidable diseases and victims of less avoidable diseases, but one in which victims of more avoidable diseases receive less than victims of less avoidable diseases. Hence, it will be argued that while being inflicted with a disease is not itself retribution for reckless behavior, denying those who are victims of their own reckless behavior the same consideration that one would give to victims of other circumstances is the proper penalty for reckless behavior. As suggested earlier, this could be true according to the fair-play account of retributive punishment, since the state might pass a law prohibiting reckless behavior that tends to result in some need from the state (such as medical needs). The penalty for disobeying this law would be that certain of your needs, such as medical ones, should they arise as a result of your own reckless behavior, will be taken into less consideration by the state than the needs of others. Others will be given preferential consideration. However, such a law would itself need to be justified according to the principles of distributive justice. Hence, the justification for (D) must derive from those principles, to which I now turn. I begin with Rawls’ (1971) account and focus primarily on his “difference principle,” according to which any inequalities resulting from a distribution must be justified according to whether the least well-off are better off in that distribution than they would be in any other distribution. Also, according to Rawls’ difference principle, any inequality must be justified by having some advantage for the least well-off. Incentivizing certain occupations and innovations in general may beis necessary to promote material well-being for all. According to Rawls, the difference principle, along with principle of equality of opportunity and basic liberties, are the two principles of distributive justice. But equality of liberties and opportunities has nothing directly to do with how goods should be distributed; it only guarantees the individual freedom to pursue goods. So my main focus is on the difference principle. In applying Rawls’ difference principle to the case of the distribution of resources to help treat and prevent various illnesses, it should be acknowledged that the state may not have any obligation to redistribute resources for such tasks. However, this does not matter for the present issue. What matters for the present issue is that if the state does redistribute resources to help treat and prevent various illnesses, where the collection of those resources to be redistributed is itself just, the state ought to redistribute them in a certain way. It can either redistribute them evenly or unevenly, according to relative needs. An even distribution would be one which also takes into account relative needs. Following the difference principle, the state is justified in redistributing resources unevenly if that way of redistributing resources benefits the least advantaged more than any other redistribution would. It could be argued (although Rawls himself never argued this) that the distribution which gives preference to those who do not engage in reckless behavior benefits society as a whole, since giving preference to them should help to discourage reckless behavior across the society. Indeed, a society in which reckless behavior is discouraged and minimized is a better society for everyone, and penalizing those who frequently engage in reckless behavior is one way to discourage reckless behavior, in addition to reiterating the harm one might cause oneself. But against this proposal I argue that while common-sense might suggest that treating those who are victims of their own reckless behavior with less concern might curb reckless behavior across a society, the degree to which it would is highly questionable. It seems doubtful that by denying those who are victims of their own reckless behavior the available resources by which to treat their injuries would improve the conditions of the least well-off substantially. It might send a slightly stronger message to those who would engage in reckless behavior, but I doubt that it would be strong enough to deter that reckless behavior to any greater degree. Besides, there are other ways of discouraging reckless behavior that do not involve giving a certain group secondary consideration in medical contexts. Requiring that smokers pay additional taxes and stand far away at public events, or keeping movie theater and airplane seats too small to comfortably fit obese people (if over-eating is reckless health-wise), are perhaps such wayss. Although I do not necessarily endorse them, these ways of discouraging reckless behavior such as smoking or over-eating at least appear more humane. Overall, I think this argument carries some pro tanto weight for (D), but we should be skeptical about whether it carries enough to justify such discriminatory practices. Setting aside the principles of justice that Rawls believes would be chosen in the original position, another principle of justice might be chosen that supports this discriminatory practice. One might contend that a principle of justice that requires the state to redistribute resources evenly between victims of more avoidable diseases and victims of less avoidable diseases is not in reflective equilibrium with our “considered judgments.” I assume that the judgment that victims who are not responsible for their own affliction ought to be given preference over victims who are, is a judgment that resonates with many. Indeed, it is my warrant for my taking up this very topic. If so, we should consider revising our basic principles to reflect this judgment. However, with the method of reflective equilibrium that Rawls adopts, considered judgments have to be sufficiently strong and secure in order to serve as grounds for revising our basic principles. Any major hesitation to accept a certain judgment disqualifies it as a “considered judgment.” Rawls argues: Thus in deciding which of our judgments to take into account, we may reasonably select some and exclude others. For example, we can discard those judgments made with hesitation, or in which we have little confidence. Similarly, those when we are upset or frightened, or when we stand to gain one way or the other can be left aside. (1971, 47-8) Would (D) be a “considered judgment" in Rawls's sense? The question is whether (D) is plausible enough to stand on its own, and force us to revise our basic principles if they do not cohere with it. While it has some intuitive plausibility, I suspect that (D) is not as intuitive as many other considered judgments, such as the judgment that methodical mass murderers deserve to be punished, or the judgment that everyone ought to share the same basic liberties. While our sympathy is stronger for those who are victims of uncontrollable circumstances than for those who are not, there is still a perceived need to justify for such preferential treatment on more basic principles. It is not easy to argue for (D) on the grounds of the difference principle, nor is it clear that, consequently, the difference principle ought to be revised in light of the intuitive plausibility of (D), since itsthat intuitive plausibility is comparatively weak. However, one might stress the fact that we have less sympathy for and empathize less with those who are victims of their own recklessness, and that fact carries its own requirements for justice. A conception of justice that is based on sympathy and empathy, such as the one developed by Michael Slote (2007), would regard this fact as significant for justice. The just distribution of goods and services should reflect how the constituents of the society tend to care for persons in various circumstances. And, so, if we tend to care less for reckless people, then the way we distribute resources should reflect that fact. But without arguing against this general view, I would insist that it be shown that the fact that we empathize less with those who are victims of their own recklessness is not a consequence of another and less noble fact of human nature: the fact that we do not like to view ourselves as disposed to similar reckless behavior, even when we really are. It is perhaps common wisdom that we tend to perceive ourselves as being safe so long as we feel that we are in control of the forces that can affect us; but we often forget how easy it is to lose control. That sense of control makes us feel safe, and to continue to feel safe we distance ourselves from those who are injured through their own recklessness, for the simple fact that we do not like to identify ourselves with such people. The point is that this comparative lack of empathy for those who are victims of their own recklessness seemsis more the result of a defense mechanism, a resistance to identify ourselves with such reckless people, than it is a reflection of our inherent moral capacities. And we should probably not let such defensive psychological postures have large- scale social consequences. The only ground, as far as I can see, for an uneven distribution with respect to fighting different diseases is to encourage personal responsibility and prudence. To encourage these things is certainly in the best interest of all; but denying victims of certain diseases the same resources to promote research into new treatments for their disease as would be given to others seems to go too far. This, I think, is because the judgment that it is inhumane to give, for instance, lung cancer victims less of a chance at surviving than breast cancer victims is at least as equally intuitive as the judgment that it would be just and fair to do so. While there may be other perspectives that might be considered, Putting aside Rawlsian justice and arguing from a Nozickian emphasis on rights and entitlements is unlikely to help. Nozick’s libertarianism would not seem to support a state in which resources were redistributed for that purpose in the first place. To argue from a Nozickian perspective that victims of less controllable diseases have more of a right to resources for fighting their diseases than victims of more controllable diseases, such a right would have be derived from rights “not to be interfered with,” as those are, basically, the only sort of rights available in the Nozickian framework. See Nozick (1974/1998, 92). it seems terribly unclear that (D), the view that victims of more avoidable diseases ought to receive less consideration than victims of less avoidable diseases, is intuitively strong enough to be self-sustaining, or that any principles of justice could sufficiently support it. Something like Rawls’ difference principle might give some weight to (D), since penalizing reckless behavior in such a manner as (D) might help to deter reckless behavior and improve society as a whole. But I am not convinced that the extent to which society would be improved counter-balances the inhumanity in upholding (D), since (D) would leave too many to suffer more than they must. Other than this, it is unclear why it would be unfair for victims responsible for their own misfortunes to receive the same treatment as victims who are not responsible for their misfortunes, and it is equally unclear why it would not be unfair if they didn’t. Those who still wish to maintain the independent plausibility of (D) will have to respond to a clear psychological explanation for why people are inclined towards (D)—: an explanation that, once considered, should diminish the intuitive appeal of (D). This explanation diminishes its intuitive appeal because it shows that its appeal arises from a fallacious way of thinking common to so many of us. This way of thinking is what has been called the “just world hypothesis.” See, for instance, Lerner (1980). It is connected to the hypothetical law mentioned earlier that those who refrain from reckless behavior should, in long run, be better off than those who do not. It seems a matter of ‘fate’ that someone who regularly plays with fire eventually dies from a fire. Of course, it is simply a matter of probability. It has been widely observed by psychologists that people not only tend to believe that malicious behavior will eventually be punished, but that reckless behavior will be punished as well. See for instance, Kopelman (1988). This phenomenon has been distinguished as part of a cognitive schema under which vigilant and prudent behavior is rewarded, and negligent and reckless behavior is punished. But concepts of reward and punishment are the wrong concepts to apply to general outcomes of rational or irrational behavior. The correct concepts are those of ‘success’ and ‘lack of success,’ since ‘reward’ and ‘punishment’ are connected to ‘praise’ and ‘blame’ that relate to psychological states. From the standpoint of the universe, rational behavior is not praised, but only successful relative to subjective preferences. Nevertheless, we feel that people who are prudent should not have to encounter as many ills in life as people who are reckless. This is only because we think that prudent behavior is rewarded. But it is not rewarded; it is merely successful, more often than not. Suffice it to say, these “just world” views are generally agreed to be unsupportable. The more important point is that these views are common, and explain why people may find (D) intuitively appealing. But once we eliminate the notion that those who lead prudent lives ought to enjoy longer and fuller lives, from the standpoint of the universe, the intuitive appeal of giving preferential treatment to victims of less controllable diseases over victims of more controllable ones should beis reduced. It is not that prudent individuals ought to enjoy better lives; it is simply that they are more likely to enjoy better lives. On these considerations, I do not see how funding research into new detection methods and treatments for lung cancer less than for breast cancer, simply because lung cancer often results from poor life choices while breast cancer does not, serves either retributive or distributive justice. However, in using this as my case example, I have been assuming that funding lung cancer research at least as close to the amount that breast cancer research is funded would do as much good to prevent lung cancer deaths as it haswould to prevent breast cancer deaths. But it might be that there is simply less meritorious research into lung cancer to fund than there is with breast cancer. If this is true, a clear justification for funding lung cancer research less than breast cancer research is presentgiven. But while there may be such justifications for particular practices as cancer research funding, what I have argued against is that there are ethical justifications for the general practice of giving preferential treatment to victims of less avoidable afflictions over victims of more avoidable afflictions. Nevertheless, I will conclude by turning to the possible justifications for that particular practice, the government funding of cancer research, in the next section. III: The Ethics of Research Funding As I have shown that the possibilities for ethically justifying the general practice of giving preference to victims of less avoidable diseases (over those of more avoidable diseases) are scarce, the question is whether current government funding of research into various cancers are, therefore, ethically problematic. The figures provided earlier display that lung cancer research receives far less government funds than what breast cancer research or prostate cancer research receives, and there is evidence of a consensus among practitioners that lung cancer does receive less funding. But many of the actual reasons may be tied to politics. The breast cancer lobby has been more successful than the lung cancer lobby at getting congress to approve funding for research into their disease. Spokespersons for breast cancer include President Clinton and Oprah Winfrey; but lung cancer lacks such powerful spokespersons. Moreover, since the survival rate for lung cancer is much lower, there are fewer survivors to help raise awareness. National Institute of Health. Available: HYPERLINK "http://rex.nci.nih.gov/NCI_Pub_Interface/raterisk/rates28.html"http://rex.nci.nih.gov/NCI_Pub_Interface/raterisk/rates28.html (accessed Jan., 11th 2010). The National Cancer Institute, among other agencies that fund cancer research, allocates funds primarily based on peer review of funding applications. The peer review process does not, or rather should not, show favoritism between research projects into different cancers, unless of course the funding opportunity or initiative is intended for one particular type of disease. National Institute of Health. Available: HYPERLINK "http://grants.nih.gov/Grants/peer_review_process.htm"http://grants.nih.gov/Grants/peer_review_process.htm (accessed Jan. 11th, 2010). The Department of Defense, for instance, has a specific research program geared fortowards breast cancer called the Breast Cancer Research Program (BCRP). This research program was, much at the behest of breast cancer lobbyists, designed and approved by congress in 1992. However, the Department of Defense has no such programs for lung cancer. Department of Defense. Available: HYPERLINK "http://cdmrp.army.mil/bcrp/"http://cdmrp.army.mil/bcrp/ (accessed Feb. 9th 2010). There are currently more such government funding opportunities for breast cancer research than there are for lung cancer research, or any other type of cancer research. But not only may politics account for the current research funding discrepancies, a difference in research quality and interest between diseases might also account for them. If individual researchers do not have much interest in investigating a disease, then pouring more money into research opportunities will not do much good. The scientific interest must be present. Moreover, even if there are researchers willing to accept the funds, there is no guarantee that their research will do any good. Some, if not many, applications for research funds are based on work which lack a sufficient degree of scientific merit. Simply throwing money at researchers will not guarantee any product. If this is the case with lung cancer research, then the funding discrepancies might not constitute any ethical problem; the problem might simply be that there isn’t enough good research to fund. However, given that advancements in detection and treatment methods for breast cancer haves advanced, and the five-year survival rate of breast cancer victims has dramatically increased, since breast cancer research funding dramatically increased in the early 1990’s, there is reason to believe that more funding opportunities for lung cancer research will, overtime, lead to more research results. Or, rather, we should hear the arguments that more research funding opportunities will not lead to advancements in lung cancer diagnostics and treatments over time. If anything, more funding opportunities may stimulate quality research into the disease at the personal level. Again, while scientists ought to be and often are motivated by scientific interest, money remains the bottom line. There are good reasons to believe that a lack of funding opportunities contributes to the lack actual funded research. A lack of scientific interest and quality of applications for funding may also be to blame, since non-disease- specific cancer research funding programs, such as the NCI’s, may not be receiving as many quality applications for lung cancer specific research as for research into other diseases. It could be that the current state of lung cancer science provides fewer clear and reputable research paths than the current state of breast cancer science. Yet, with respect to the matter of scientific interest, it is difficult not to question whether the same sort of retributive attitudes and blame-the-victim mentality about lung cancer might not carry over into the scientific arena—after all, scientists are people too. It is difficult to measure researchers’ actual motivations and biases, yet there is evidence that lung cancer patients experience biases from their own clinicians, some of whom presumably have also conducted research. The qualitative study published in the BMJ, mentioned earlier, reported that a number of lung cancer patients experienced stigma from their own doctors, who are quick to assume that a patient diagnosed with lung cancer is or was a smoker, despite the patient claiming otherwise. Hence, there is reason to believe that these negative attitudes and beliefs are hindering advancements in lung cancer detection and treatment in two ways: first through those who fund research (the public, primarily through their governments) and those who would conduct the research. In summary, with respect to government distribution of disease research funds, funding research into one disease more than another seems ethically problematic unless at least one of the following conditions is met: one disease is more serious than the other, or the need is greater; the scientific interest and merit of research proposals is greater with one disease than it is with another; the promise of new treatments and detection methods, provided research, is greater with one disease than it is with another; or one disease is simply more deserving of those funds, because the victims of that disease are more deserving of help due to the less controllable nature of their disease. My primary efforts in this paper have been to show that (IV) is false and therefore cannot be used to defend current funding practices. No victims of a disease deserve to have their needs and interests taken into less consideration than the needs and interests of victims of another disease, given that the diseases are equally serious. Neither can (I) justify current distributions, since lung cancer is one of the most serious diseases given that it has one of the lowest survival rates. Perhaps only childhood cancers, like leukemia, are more deserving of research funds than lung cancer on the grounds of (I), given that the average amount of productive life lost is so much greater. The justification of current government cancer research funding practices thus turns on (II) and (III). I am unable to comment on (III), given that I am primarily an ethicist. But with respect to (II), it should be observed that any potential bias among the scientific community is equally problematic, if such a bias is partly responsible for less interest in researching a particular disease—and I am not claiming that it is. Additionally, more funding opportunities would likelyshould stimulate more research interest. For these reasons, one should conclude that current government funding practices, with respect to research into different diseases, likely pose an ethical problem. Acknowledgments This paper was written with the support of the University of Miami Ethics Program's "Arsht Ethics Initiative" with the generous financial support of philanthropist Adrienne Arsht. Thanks are due to Michael Slote (University of Miami) and Kenneth Goodman (University of Miami) for helpful advice and feedback on drafts of this paper. References A. Chapple, S. Ziebland and A McPherson. 2004. Stigma, Shame, and Blame Experienced by Patients with Lung Cancer: A Qualitative Study. British Journal of Medicine 328 (2004): 1470-1472. Cottingham, John. Varieties of Retribution. The Philosophical Quarterly 29.116 (1979): 238-246. Dolinko, David. Retributivism, Consequentialism, and the Intrinsic Goodness of Punishment. Law and Philosophy 16 (1997): 507-528. Hart, H.L.A. 1968. Punishment and Responsibility. Oxford: Oxford University Press. Kant, Immanuel. 1798/1999. The Metaphysical Elements of Justice. 7th ed. John Ladd (trans.). Indianapolis, IN: Hackett. Kopelman, Loretta. 1988. The Punishment Concept of Disease. In: Aids: Ethics and Public Policy (pp. 49-55), C. Pierce and D. Van DeVeer (eds). Belmont, CA: Wadsworth Publishing Company Lerner, Melvin J. 1980. The Belief in a Just World: A Fundamental Delusion. New York, NY: Plenum Press. Nozick, Robert. 1974/1998. Anarchy, State, and Utopia. New York, NY: Basic Books. Rawls, John. 1971/2002. A Theory of Justice. Cambridge, MA: Harvard University Press/ Slote, Michael. 2007. The Ethics of Care and Empathy. New York, NY: Routledge Presss. Weiner, Bernard. 1995. Judgments of Responsibility: A Foudation for a Theory of Social Conduct. New York, NY: The Guilford Press. PAGE 1