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Opportunity and Responsibility for Health

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Abstract

Wealth and income are highly predictive of health and longevity. Egalitarians who maintain that this “socioeconomic-status gradient” in health is unjust are challenged by the fact that a significant component of it is owed to the higher prevalence of certain kinds of voluntary risk-taking among members of lower socioeconomic groups. Some egalitarians have argued that these apparently free personal choices are not genuinely free, and that those who make them should not be held morally responsible for the resulting harms to their health. I argue to the contrary that such choices usually are fully free, and that those who make them are responsible for their consequences. This does not imply, however, that society cannot also be responsible for those consequences. It is responsible for them if they are statistically foreseeable and avoidable outcomes of unjust public institutions and policies. I show that many of the harms to health that contribute to the voluntary behavioral component of the SES health gradient satisfy that description. Society can therefore be morally responsible for those harms, even though the individuals who suffer them are also fully responsible for them.

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Notes

  1. Primary-enforcement seat-belt laws are those under which drivers can be ticketed for not wearing seat belts, even when there is no other infraction. In the 30 US States that have such laws, the average rate of seat belt use is 91%, while the corresponding rate for states that lack such laws is 71% (National Highway Traffic Safety Administration 2016).

  2. One QALY is defined as a year of life in perfect health; half a year in perfect health is .5 QALYs. A year of life in poor health represents some fraction of a QALY. For example, a year of life in a bedridden but mentally alert condition with moderate pain/discomfort and normal mood might be measured at .5 QALYs. The scale is calibrated by aggregating survey results.

  3. For an opposing view, see Segal (2013) and Lippert-Rasmussen (2013).

  4. Of course, we cannot presume that inequalities across any of these groups are wholly socially caused. Genetic dispositions to illness can vary by sex, race, and even by SES status (since genetic dispositions to illnesses can both lower individual income and be passed on to the next generation).

  5. One reason this condition is important is because some component of society's contribution to the SES gradient stems from the fact that its more affluent and educated members are more likely to modify their behavior in response to public health-awareness programs. SES differences in the success of, for example, public anti-tobacco campaigns have contributed to the SES gradient without harming lower-SES individuals (Susser et al. 1985).

  6. Such balancing problems are endemic to egalitarian theories of distributive justice. The present problem is comparable, for example, to that of weighting the components of an index of primary goods, or of a conception of individual welfare.

  7. EOH contrasts with an alternative principle of equality of opportunity for health proposed by Segal (2013). It holds that "It is unfair for individuals to suffer worse health than others owing to factors that they do not control." It is not entirely clear what metric of health, or of health opportunity, Segal intends. If, however, we assume that health is to be measured in terms of something like QALYS (thus factoring in longevity), and that opportunity is to be measured as a statistically based expectation of health at birth, then Segal's proposal governs inequalities across what I above termed a “fully individualized health-opportunity assessment." The principle he defends would thus condemn as unjust health-opportunity inequalities stemming from all social or natural factors, including genetic ones.

  8. Some "luck egalitarians" advocate policies that would require those who bring illness on themselves through their voluntary choices to bear the monetary costs of their healthcare. Not to do so would be to permit those individuals to shift the costs of their voluntary risk taking to others (Arneson 1990; Rakowski 1991; Roemer 1993, 1998; Cappelen and Norheim 2005). I have argued against such policies elsewhere (2011). EOH itself, however, does not directly disallow them. It does so only insofar as they contribute to SES inequalities in opportunity for health (as, for reasons discussed in the last paragraph of this section, is likely to be the case in actual societies). The reason for disallowing these policies is not that society has a duty to compensate individuals for the costs of voluntary risks to health. Rather, the reason is that society has a duty to mitigate the brute-luck social disadvantages that foreseeably cause unequal patterns of voluntary risk-taking in the first place.

  9. Needless to say, there are other moral reasons besides EOH that could be adduced in support of a social duty to ensure that the children of lower-SES households are able to develop to their full cognitive potential.

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Acknowledgments

I am grateful to the Harvard Program in Ethics and Health for research support during an early stage of this project. For advice or comments on previous drafts I thank Hannah Byrnes-Enoch, Richard Volkman, and two anonymous reviewers for Journal of Ethics.

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Cavallero, E. Opportunity and Responsibility for Health. J Ethics 23, 369–386 (2019). https://doi.org/10.1007/s10892-019-09300-7

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