Abstract
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 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.
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Notes
An exception to this is Gerald Lang who has suggested to replace the notion of responsibility in luck egalitarianism with a notion of moral hazard (Lang 2009).
Note that this is similarly relevant for other principles of distribution that might incorporate an egalitarian element, such as prioritarianism and sufficientarianism.
Here we do not wish to imply anything about genuine responsibility. The point is only that if a persons’ disease is caused (partly) by her behaviour, and she behaved in that way, responsibly or not, because she knew she was covered, then there is room for believing that she would have acted differently if she knew she was not covered.
Of course we cannot exclude the possibility that a complete cure is attainable in the future, such that e.g. just a pill or a very simple surgery could exterminate all cancer cells in some organ leaving the patient with no side effects at all. If so, then it is definitely one reason to revise our considerations about moral hazard.
Note that this reasons may also be non-paternalism, but yet very similar. This is because individuals may consent to being held responsible for their own good, in the same way as Homer’s Ulysses was bound to the mast.
There may still be cases where we would want not to treat the worse off individual in need of health care, especially since as always, resources are scares. Would we prioritize giving the fifth liver transplantation to an otherwise sick alcoholic?
References
Andersen, Martin Marchman. 2012. Reasonable avoidability, responsibility and lifestyle diseases. Ethical Perspectives 19: 295–306.
Anderson, Elisabeth. 1999. What is the point of equality? Ethics 109: 287–337.
Barendregt, Jan, Luc Bonneux, and Paul J. van der Mass. 1997. The health care costs of smoking. The New England Journal of Medicine 337: 1052–1057.
Center for diseases control and prevention. 2011. CDC health disparities and inequalities report—United States. Morbidity and Mortality Weekly Reports 60: 1–113.
Cohen, Gerald A. 1989. On the currency of egalitarian justice. Ethics 99: 906–944.
Daniels, Norman. 1987. Justice and health care. In Health care ethics, ed. D. Van De Veer, and T. Regan. Philadelphia, PA: Temple University Press.
Daniels, Norman. 1988. Am I my parents’ keeper? An essay on justice between the young and the old. New York, NY: Oxford University Press.
de Preux, Laure B. 2011. Anticipatory ex ante moral hazard and the effect of medicare on prevention. Health Economics 20: 1056–1072.
Dworkin, Ronald. 1981. What is equality? Part II: Equality and resources. Philosophy & Public Affairs 10: 283–345.
Fischer, John Martin, and Mark Ravizza. 1998. Responsibility and control: A theory of moral responsibility. New York, NY: Cambridge University Press.
Frankfurt, Harry G. 1971. Freedom of the will and the concept of a person. Journal of Philosophy 68: 5–20.
Gruber, Jonathan. 2005. Public finance and public policy. New York, NY: Worth.
Guindon, G. Emmanuel, Steven Tobin, and Derek Yach. 2002. Trends and affordability of cigarette prices: Ample room for tax increases and related health gains. Tobacco control 11: 35–43.
Kane, Robert. 2005. Free will: New directions for an ancient problem. In Free will: Critical concepts in philosophy, vol. III, ed. J.M. Fischer, 222–248., Libertarianism, alternative possibilities, and moral responsibility New York, NY: Routledge.
Knight, Carl. 2009. Luck egalitarianism: Equality, responsibility, and justice. Edinburgh: Edinburgh University Press.
Lang, Gerald. 2009. Luck egalitarianism, permissible inequalities, and moral hazard. Journal of Moral Philosophy 6: 317–338.
Lynch, John, George Davey Smith, Sam Harper, and Kathleen Baindridge. 2006. Explaining the social gradient in coronary heart disease: Comparing relative and absolute risk approaches. Journal Epidemiology and Community Health 60: 435–441.
Marmot, Michael. 2004. The status syndrome. New York, NY: Times Books.
McKerlie, Dennis. 1989. Equality and time. Ethics 99: 475–491.
Nielsen, Morten E.J., Andersen Martin Marchman. 2013. Should we hold the obese responsible? Some key issues. Cambridge Quarterly of Healthcare Ethics 23: 443–451.
Offer, Avner, Rachel Pechey, and Stanley Ulijaszek. 2010. Obesity under affluence varies by welfare regimes: The effect of fast food, insecurity, and inequality. Economics and Human Biology 8: 297–308.
Oster, Gerry, Graham A. Colditz, and Nancy L. Kelly. 1984. The economic costs of smoking and benefits of quitting for individual smokers. Preventive Medicine 13: 377–389.
Rasmussen, Susanne R., Eva Prescott, Thorkild I.A. Sørensen, and Jes Søgaard. 2005. The total lifetime health cost savings of smoking cessation to society. European Journal of Public Health 15: 601–606.
Ripstein, Arthur. 1994. Equality, luck, and responsibility. Philosophy & Public Affairs 23: 3–23.
Segall, Shlomi. 2010. Health, luck and justice. Princeton, NJ: Princeton University Press.
Sen, Amartya. 1980. Equality of what? The tanner lectures on human values, 197–220. Cambridge: Cambridge University Press.
Stamler, Jeremiah, Rose Stamler, James D. Neaton, Deborah Wentworth, Martha L. Daviglus, Dan Garside, Alan R. Dyer, Kiang Liu, and Philip Greeland. 1999. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: Findings for 5 large cohorts of young adult and middle-aged men and women. The Journal of the American Medical Association 282: 2012–2018.
Strawson, Galen. 1999. The impossibility of moral responsibility. In What do we deserve? A reader on justice and desert, ed. Louis P. Pojman, and Owen McLeod, 114–124. New York, NY: Oxford University Press.
van Baal, Pieter H.M., Johan J. Polder, G. Ardine de Wit, Rudolf T. Hoogenveen, Talitha L. Feenstra, Hendriek C. Boshuizen, Peter M. Engelfriet, and Werner B.F. Brouwer. 2008. Lifetime medical costs of obesity: Prevention no cure for increasing health expenditure. PLoS Medicine 5: e29.
Weyers, Simone, Nico Dragano, Matthias Ritcher, and Hans Bosma. 2010. How does socioeconomic position link to health behaviour? Sociological pathways and perspectives for health promotion. Global Health Promotion 17: 25–33.
Acknowledgments
For comments and discussions related to this paper we would very much like to thank Nils Holtug, Carl Knight, Xavier Landes, Pedro Rosa Dias, Shlomi Segall and Res Publica’s anonymous referee.
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Andersen, M.M., Nielsen, M.E.J. Luck Egalitarianism, Universal Health Care, and Non-Responsibility-Based Reasons for Responsibilization. Res Publica 21, 201–216 (2015). https://doi.org/10.1007/s11158-015-9272-3
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DOI: https://doi.org/10.1007/s11158-015-9272-3