A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing. Luck egalitarianism asserts that distributions are just if, and only if, how well people fare relative to others reflects their exercises of responsibility Lippert-Rasmussen, ; Knight, , Thus, luck egalitarianism embraces personal responsibility and rejects holding people responsible for natural or social circumstances Cohen, ; Voigt, Often, luck egalitarianism is interpreted as encompassing a principle of compensation and a principle of reward.
Three Strikes Out: Objections to Shlomi Segall’s Luck Egalitarian Justice in Health
The former principle states that people who are relatively worse off, in a way that does not reflect their exercises of responsibility, should be compensated; the latter principle states that differences between people that reflect such exercises of responsibility should be left untouched Fleurbaey, ; Roemer, It has famously been argued that luck egalitarianism must refuse to compensate those who make imprudent choices Fleurbaey, , 40; Anderson, Such critics ask whether it is just for society to refuse to treat the reckless motorcyclist who drives without a helmet and is severely injured in a crash.
Since many luck egalitarians wish to resist this conclusion, and since many make imprudent choices, health may be considered a hard case for luck egalitarianism, and for those and other reasons many remain unconvinced of its viability in a health care context Feiring, ; Wikler, ; Venkatapuram, ; Nielsen, ; Nielsen and Axelsen, ; Andersen et al. As explored in Section II, in response to the charge of being too harsh, luck egalitarians have developed a number of reasons why we should not, after all, hold people responsible for their health-affecting choices.
In principle, such reasons can be divided into two categories. The first claims that compensation in such cases does in fact follow from the principle of compensation. The second category consists of different arguments for why we should dispense with the principles of reward and compensation for some choices, even when we acknowledge that people are in fact responsible for being worse off. One such reason is that people should not be held responsible for their choices because the choices reflect their conception of the good life. Doing so, some authors claim, would be unreasonable.
Others allow for compensation when choices leave people with their basic needs unfulfilled.
Redistribution is also recommended by some, who argue that the gambles people undertake by their health-related choices are to be considered quasi-gambles, gambles where people would prefer the expected value to the risk of gambling. Section III discusses whether these reasons are relevant in the context of adult oral health, specifically, in the context of two widespread and well-known sources of bad oral health: periodontal disease and caries. It is concluded that these reasons are less present in this context, so that in most cases people should be held accountable for their choices.
In order to evaluate such inequalities, a luck egalitarian approach inspired by John Roemer is introduced to assess whether people are in fact responsible for their choices by comparing their choices to those of their peers. Having ascertained who is responsible, Section IV evaluates whether such choices are of a kind that allows for compensation, in light of recent arguments by prominent egalitarians. The strongest candidate for some redistribution is the argument that the choices affecting oral health could be classified as quasi-gambles.
In this regard, Section V introduces the idea of a responsibility-weighted queuing system and endorses copayment and general taxation as a scheme for financing it. It would seem that oral health is one area where people can and should in fact be held responsible for their health-affecting choices. In this respect, it is interesting that many European countries have separated oral health care from health care in general and financed it with a larger system of copayment or out-of-pocket payment Holst, Sheiham, and Petersen, , — Some of this institutional arrangement, but not all, is supported by a luck egalitarian theory of justice.
This section surveys important developments in the luck egalitarian literature, especially the tendency to argue that, appearance notwithstanding, the luck egalitarian theory does not have the counterintuitive harsh implications emphasized by critics.
This formulation is unable to evaluate a number of distributions, 5 but a recent interpretation of luck egalitarianism asserts that distributions are just if, and only if, how well people fare relative to others reflects their exercises of responsibility Lippert-Rasmussen, ; Knight, , In his seminal account of the luck egalitarian position, G. According to Cohen, people should be compensated only for what they could not avoid. If, in such instances, they can be cured, we should subsidize their treatment, and if they cannot, they should be compensated to relieve its continued effect on their lives.
Luck egalitarianism is, in its standard interpretation, only concerned with extinguishing the differential effects of brute luck, whereas it leaves the differential effects of option luck untouched Rakowski, The interpretation of the distinction is still a subject for debate, such as how the concepts can be separated in the evaluation of real world distributions. This also holds in a health care context.
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When taken to task for being too harsh on the victims of option luck, luck egalitarians can either claim that the specific disadvantage is not chosen or provide reasons why it should be compensated anyway. Prominent in the first category are those who argue that luck egalitarians are committed to more distribution than its critics assume, because many inequalities are most plausibly understood as caused by brute luck Barry, In a health context it is uncontroversial to state that luck egalitarians wish to compensate those who are relatively worse off for reasons not reflecting their exercises of responsibility.
This, however, seemingly leaves a range of situations where people should be denied compensation because their situations adequately reflect the choices they have made Voigt, One argument of this kind stresses that, regarding some choices, it would be unreasonable for society to hold people responsible for the consequences of their choices. Cohen proposed to revise the luck egalitarian view to cater for such thoughts. According to Cohen, chosen disadvantages may require compensation when they reflect our values. The reason for this is that it would be unreasonable to ask people to avoid making such choices Price, ; Cohen, Under the influence of such thoughts, Segall argues in his influential account of luck egalitarianism in health that we should compensate people for what it would be unreasonable to ask them to avoid Segall, , He further argues that compensation might be justified even for choices that we could reasonably ask people to avoid if people end up with unmet basic needs Segall, The appropriateness of accepting inequalities generated by differential option luck can also be questioned in a different manner.
Lippert-Rasmussen argues that it may be proper to compensate some unfortunate gamblers Lippert-Rasmussen, ; Temkin, However, Kasper Lippert-Rasmussen has introduced a distinction between gambles proper and quasi-gambles that renders redistribution more plausible. In the quasi-gambles, the persons involved would have preferred the expected value of the gamble as opposed to risking the gamble.
Proper gambles are well-known, that is, gambles at casinos and race-tracks, where the risk is part of the purpose of the gamble Lippert-Rasmussen, , The argument against redistribution between winners and losers of gambles seems implausible when applied to quasi-gambles. It seems that luck egalitarians, who wish to argue for compensation to those whose health-related choices make them worse off than others in regard to their oral health, have several options available. Besides claiming the behavior to be not sufficiently chosen i.
In what follows, these highlighted developments in the luck egalitarian literature will be evaluated in order to determine whether these different reasons for not holding people responsible are present in oral health. Although the different strands of luck egalitarianism are distinct in important ways, they are all considered in order to evaluate the widest possible range of luck egalitarian reasons to not hold people responsible for their own oral health.
In this and the next section, it will be argued that many of the reasons luck egalitarians give for not holding people responsible for their health are not present in the area of oral health. The discussion considers this in the context of two widespread and well-known sources of bad oral health: periodontal disease and caries. First, in any debate over responsibility and health there are discussions about whether people are responsible for the choices that affect their health Kaufman, ; Barry, If it could be shown that people are not responsible for their oral health, luck egalitarianism would consider it unjust to hold them responsible for it.
In oral health, we have good reasons to examine this discussion thoroughly. Regarding consumption choices, it is relevant whether people had a healthy alternative at a reasonable price and whether their preference for certain sugary foods can be related to habits instilled in childhood Mennella et al. The argument to be considered is whether people are, in the relevant sense, responsible for suffering from bad oral health through periodontal disease and caries. Following Cohen, the question is whether the disadvantages from which people suffer could initially have been avoided.
Periodontal disease is a gum disease caused by a build-up of plaque on the teeth. Plaque can be bad for the gum health, leading to soreness and inflammation, and it has a possibility of evolving into more severe gum diseases such as periodontitis, which, among other things, can lead to damage of the tissue that connects the tooth to the socket, receding gums, loose teeth, and loss of teeth National Health Service, To understand whether a person could have avoided periodontal disease, it is necessary to find out what causes it.
Periodontal disease can be avoided through oral hygiene, since it is caused by bacteria on the teeth Hioe and van der Weijden, ; Sambunjak et al. Further, it should be mentioned that there is little evidence for an association between diet and periodontal disease Moynihan and Petersen, , If we first consider the social factors, periodontal disease shows a social gradient Zini, Sgan-Cohen, and Marcenes, This means that the burden of disease is unequally spread in society and indicates that social factors contribute to this unequal distribution.
Furthermore, alcohol Lages et al. It is well documented that the ability to avoid periodontal disease is worsened by the presence of some specific diseases. Periodontal disease is also known to be widespread among people with intellectual and developmental disabilities Fisher, ; Moreira et al. Consider next, in a similar fashion, the factors influencing the development of dental caries. This is an infection that causes demineralization of the hard tissues and destruction of the organic matter of the tooth. It is usually brought about through the production of acid by bacteria accumulated on the tooth surface Selwitz, Ismail, and Pitts, Developed caries can lead to both pain and tooth loss and is, as such, a cause for bad oral health.
In several ways, the development of caries is contingent on human behavior and thus, to some extent, avoidable.
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Caries is related to sugary diet and negligent tooth brushing Reisine and Psoter, ; Chankanka et al. However, the relationship is yet again altered and affected by social factors such as the diet of the mother Tanaka et al. Apart from social circumstances, caries is also affected by natural circumstances. Reduced production of saliva in the mouth is among the prominent causes for caries.
Justice, Luck & Responsibility in Health Care Catalogue en ligne
Thus, a number of diseases make the particular individual more vulnerable to caries and its adverse effects by reducing the natural production of saliva. Other diseases are known risk factors for caries, including types of cancer treated with chemo and radiography Michelet, Some of these factors are most plausibly understood as beyond the control of the individual, whereas others are highly manageable, though they require knowledge and the correct application of materials e.
The following section presents an approach inspired by the work of John Roemer Roemer, , , Roemer, , It is also possible to compare the exercise of responsibility in different types of people. Two people from different types varying equally from the median 9 of their respective type are deemed to have exercised a comparative degree of responsibility Roemer, , ; see also: Roemer, , —2; , The key point in both forms of comparisons is that whether one is responsible for such choices, in the relevant sense, depends on how these choices vary from the choices of people in comparable circumstances.
Roemer illustrates his position in relation to smoking and lung cancer Roemer, , He asks us to consider a black male steelworker and a female college professor, both 60 years of age and both now suffering from lung cancer. The former has been smoking for 25 years, whereas the latter only smoked for 8 years. For simplicity, we can assume they belong to types of black male steel workers and female college professors, respectively.
Any political philosopher or bioethicist will come away from the book knowing much more about both luck egalitarianism and philosophical approaches to health and healthcare. It is bound to provoke much more extensive discussion. Hausman, Economics and Philosophy.
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But it is also important in showing the limits of theories of justice when we think about the value of health in our overall scheme of good lives and human flourishing. Graduate students and academics interested in political philosophy and health ethics will find this book interesting and a rich resource. It is clearly written, rigorously argued, and thoroughly engaged with relevant literature.
Like many other arguments in this significant contribution to the egalitarian literature, it is certain to spark considerable debate. Olson, Perspectives on Politics. Paulus Kaufmann.
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