We defend a scalar theory of the relationship between material scarcity and justice. As scarcity increases beyond a specified threshold, we argue that deontological egalitarian constraints should be gradually relaxed and consequentialist considerations should increasingly determine distributions. We construct this theory by taking a bottom-up approach that is guided by principles of medical triage. Armed with this theory, we consider the range of conditions under which justice (of any form) applies. We argue that there are compelling reasons for thinking that justice applies under a far broader range of conditions than is standardly supposed, including those that could sensibly be labelled as conditions of extreme rather than moderate scarcity.
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To clarify, throughout this paper we use this concept of dependence in a logical sense: a condition that is necessary for concepts of justice to be meaningfully applicable. This use can be distinguished from other senses of dependence. For instance, ontological dependence: a condition that is necessary for institutions or practices of justice to develop and survive. (Following Hubin 1979, pp. 8–12.).
“Relaxed” refers to a range of theoretical options. For instance, as we show in Sects. 3 and 4, we may relax egalitarian principles by: reducing the range of goods to which they apply; restricting their application to a particular phase or phases in a distributive scheme; or by qualifying or limiting their application when doing so is necessary to achieve or avoid particular outcomes. “Suspending” refers to temporary but complete restrictions on the application of egalitarian principles.
The fact that consequentialism attempts to reduce the seemingly complex phenomenon of morality to a single, parsimonious principle that applies under all conditions is standardly viewed as one of its theoretical appeals. (See Kagan 1998, pp. 17–22.).
Following Richard Arneson (2013).
This insight is best articulated by Sen (1987).
Estlund (2016a, p. 23).
To clarify, we regard prioritarianism as a type of aggregated consequentialism, as it gives additional weight to the well-being of individuals that are worst off. (See Parfit 1991).
This deontological characterization is necessary for making the contrast between egalitarian constraints and the best aggregated consequences determinate. After all, as Amartya Sen (1992, p. ix) argues, even purely consequentialist theories like act utilitarianism are egalitarian insofar as they give each unit of pleasure equal weight.
This is something that Rawls (2001a, p. 256) recognizes in passing.
See Hume (1751, sec. III, pt. I).
Ibid. See also Hume (1738, bk. III, pt. 2).
For further discussion, see Panichas (1983).
This reference to a “possible distribution” is a slight refinement of Hume’s actual position. As Robert Goodin notes, Hume refers to the holding of actual individuals rather than to possible distributions. This, however, is problematic: “Suppose, for example, that five percent of the population were in a situation of superabundance and the other ninety-five percent were starving [i.e., in a situation of super-scarcity]. That would mean that no one among them, taken individually would be in a condition of ‘moderate scarcity.’ But it would be absurd to say that in such circumstances the ‘circumstances of justice’ do not obtain” (Goodin 2001, p. 203). However, explicating super-scarcity in terms of a possible distribution rather than in terms of individual’s holdings rules out this absurd result. For it shows that super-scarcity obtains if and only if there is no possible distribution of goods that satisfies most people’s basic needs, regardless of people’s actual holdings.
We set aside the difficult interpretive issue of how Hume’s distinction between “strict” and “non-strict” considerations of justice relate to his parallel distinction between “artificial” and “natural” virtues; suffice it to say that, in Hume’s writings, the concept of a non-strict consideration of justice does not seem equivalent to the concept of a natural virtue. For a helpful overview of the debate over natural and artificial virtues in Hume, see O’Day (1994).
Rawls (1999, p. 109).
Ibid., p. 54.
The etymology of the term “triage” is derived from the French word “trier”, originally used with respect to the sorting of agricultural products. The term is now standardly used in a medical context (Iserson and Moskop 2007). Medical triage “requires three elements: at least a modest scarcity of resources, a formal assessment of medical need, and implementation of an algorithm that delineates treatment priority” (Shafran et al. 2014, p. 1650).
Our approach is compatible with a reflective equilibrium methodology, in which one strives to refine one’s considered intuitions about concrete cases and abstract philosophical principles until they are in harmony. For further discussion, see Scanlon (2003, pp. 139–167).
For a helpful overview of different triage systems for distributing organs, and how some actual systems have evolved in the U.S., see Caplan and Coelho (1999, part IV). See also Mulgan (2014, lecture 14) and Arvan (2014a, b) for recent attempts to theorize what justice demands in conditions of extreme scarcity. In contrast to our “bottom-up” approach, Mulgan and Arvan employ a “top-down” methodology, based on a modified version of Rawls’s contractualist framework. Moreover, Mulgan’s and Arvan’s approaches, unlike the one we are defending here, do not aspire to uncover a general account of the relationship between material scarcity and justice.
We define an “essential need” as something that is necessary for a reasonable person to live at a moderate level of well-being. A “moderate level of well-being” is an unavoidably vague threshold. At one extreme, it clearly rules out purely cosmetic procedures, such as facelifts. At the other extreme, it clearly includes heart-transplant surgeries without which certain people would die. People disagree about how certain medical procedures and treatments such as IVF, Viagra, and even kidney transplants should be categorized. Given our present purposes, however, it suffices to assume that certain solid organ transplants, necessary for survival, qualify as essential. If, for example, kidney transplants do not fit into this category, it does not affect our central argument.
We use “most urgent” here to refer to cases that are in some way temporally exigent. This includes many life-threatening conditions, as well as cases of severe pain or injury.
Following Rhodes et al. (1992, p. 327).
Vlastos (1984, pp. 41–76, 49).
The same idea seems to hold with respect to other social goods, like education. If we assume that all children have a right to a public education, it will not be inegalitarian to spend more, say, transporting some to school than others, simply because they live farther away. Likewise, some students will have special learning needs that can only be met through additional per capita expenditures. In these cases, the right to education does not vary, only the resources needed to effectively ensure it under particular circumstances.
Institute of Medicine of the National Academies (2012).
Shafran, Kodish, and Tzakis (2014, p. 1651).
Rhodes (2007, p. 329).
Unless, of course, their condition significantly deteriorates, in which case they will be reclassified as members of the group in relatively urgent need and treated accordingly.
In the actual world, different solid organs are distributed using slightly different principles. This is because the different organ subcommittees of the United Network of Organ Sharing formulated their respective allocation policies independently of one another. For example, even after the 2014 policy revisions, kidney allocation places great weight on how long patients have been on the waiting list (Ohler 2017, pp. 51–58). In contrast, lung allocations give greater weight to a calculation of pre- and post-transplant survival (Shafran, Kodish, and Tzakis, p. 1652).
See, e.g., Shafran, Kodish, and Tzakis (2014, p. 1650).
This hybrid principle can be situated in a broad research program in bioethics, which argues that the distribution of scarce medical resources should take place according to a combination of egalitarian and consequentialist principles. See, for instance, Becker (1979), Rhodes (2007), Tabery (forthcoming). We add the obvious caveat that this is just one philosophical theory of how principles of medical triage should operate in such material conditions. Nicholas Rescher, for instance, argues that such principles should also take into account considerations of desert such as past societal contribution. See Rescher (1969).
See Rhodes (2007, p. 329).
Alternatively, principle C could be more egalitarian, say, by affording the least likely to survive some chance of receiving an organ, though less chance overall than patients who are more likely to survive. Cf. Arvan (2014a, b), Mulgan (2014, pp. 173–184). We thank an anonymous reviewer for suggesting this possibility.
For this account of what justifies moral principles, see Scanlon (1998, pp. 5, 191–206).
To clarify, we do not mean to imply that the only consideration that is relevant to a transitional nonideal theory is the consequentialist consideration of what will be effective in moving society towards the ideal of perfect justice. Rawls (2001c, p.89) is careful to note that such a transitional path must also be “morally permissible.” We simply emphasize that such consequentialist considerations take on greater weight in the context of a transitional nonideal theory.
This leaves open the possibility that other considerations of justice (e.g., retributive justice) could apply in such conditions. It is even compatible with David Estlund’s thesis that certain considerations of justice would apply in conditions in which people are morally flawless. See Estlund (2016b).
If the reader thinks that distributives shares could also apply to human bodies (at least in sufficiently dire circumstances), then this example can be modified by also including the stipulation that the people in the boat are allergic to each other’s flesh and urine.
See Goodin (2001, p. 201, fn. 2).
See, for instance, Rawls (2001b, pp. 190–224).
Hope (2010, p. 130); emphasis in the original.
Within the Kantian tradition there are some fragmented remarks about distributive norms that apply in conditions of extreme scarcity. Such remarks, however, primarily emphasize that such norms fall outside the scope of the demands of justice and, consequently, fail to illuminate the content of such norms. For example, in The Metaphysics of Morals Kant himself considers the old chestnut of whether someone can shove another person off a plank in order to save their own life after a shipwreck. Kant suggests that while a norm bears on who gets the plank, it falls outside the scope of what he terms “claims of civil right,” which impose demands of justice on people that should be enforced by a penal code (Kant 1791, Mds 6:234–235). For further discussion, see Finkelstein (2001). Still, even if this is correct and such norms are norms of “gustice” rather than “justice,” we have supplied a richer normative account of how the content of such norms depends on material scarcity.
This is implicit in Hume’s account. For instance, he writes: “Water and air, though the most necessary of all objects, are not challenged as the property of individuals; nor can any man commit injustice by the most lavish use and enjoyment of these blessings” (Hume 1751, sec. III, pt. I).
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Adams, M., Mittiga, R. Material scarcity and scalar justice. Philos Stud (2020). https://doi.org/10.1007/s11098-020-01539-3
- Circumstances of justice
- Material resources