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‘Justice in Health or Justice (and Health)?’—How (Not) to Apply a Theory of Justice to Health

‘Justice in Health or Justice (and Health)?’—How (Not) to Apply a Theory of Justice to Health Abstract Some theorists, especially egalitarians, seek to ‘apply’ theories of justice to a specific area or good, such as health, and assess the distribution of that good at the bar of justice. On the one hand, this is understandable, given that egalitarians are often interested in making policy recommendations and these would have to be area-specific. On the other hand, it is surprising in light of the fact that (distributive) theories of justice normally envisage the ‘total package of goods’ or an overall good as the distribuendum. This article aims to show that this approach is problematic at least in the area of health. An increasing number of political theorists and philosophers, especially egalitarians, are interested in making arguments that could have ‘real-life’ impact and could be translated into public policy. To that end, they focus on specific areas and seek to evaluate the distributions in those areas, at the bar of justice. However, we lack a coherent methodological framework for doing this kind of work in normative political theory, and this article seeks to contribute to the effort of finding a suitable framework by showing that one approach commonly used in the area of health ethics, but not only, is misconceived. The approach I envisage, which I will call the ‘partial justice’ approach starts from a ‘general’ theory of justice, in particular distributive justice, and ‘applies’ the theory or one of its principles to a specific area, in this case health. In spite of recognizing this approach to be problematic, some continue to ‘apply’ principles of justice to health. Health practitioners and epidemiologists implicitly adopt this kind of approach and apply an egalitarian principle specifically to health only. Thus, a number of reports and policy documents on the subject explicitly state that ‘health inequalities that are preventable by reasonable means are unfair’ and that ‘reducing health inequalities is a matter of fairness and social justice’ (Marmot, 2010: 16). Indeed, this kind of approach is ‘prominent in medical ethics’ (Albertsen and Knight, 2015: 166). Among its proponents are D. R. Gwatkin (Gwatkin, 2000), who adopts a prioritarian approach, as well as Fabienne Peter (Peter, 2004), Sudhir Anand and Peter (Anand and Peter, 2000) and Robert Veatch (Veatch, 1991), who all adopt a variant of an egalitarian account of justice to inequalities in health (See also Culyer and Wagstaff, 1993; Marchand et al., 1998). We can call the latter ‘specific egalitarianism’. More interestingly, two leading theorists in this area, Norman Daniels and Shlomi Segall, apply Rawlsian or luck egalitarian principles, respectively, to health even though they accept that a theory of justice applies to the overall good (Daniels, 2008; Segall, 2010a). Segall explicitly asks: ‘Why a separate theory of justice in health?’ but does not provide a satisfactory answer (Segall, 2010a: 92–96). So it is puzzling that this approach persists, and there are perhaps some good reasons for it. This is the starting point of this article. This approach in the area of health has been criticized before (Hausman, 2007; Wilson, 2009). This article takes the partial justice approach more seriously and examines the most plausible way in which it can be motived before arguing that it cannot work in the simplistic manner sometimes adopted, which is directly applying a principle of justice to a specific area. This is because theories of distributive justice apply the relevant principle of justice to the currency they identify as relevant and are thus usually concerned with the overall distribution not the distribution in specific domains. If this is the case, it is unclear how they can even begin to evaluate the distribution in a specific area. The discussion in this article, however, will be limited to egalitarian theories of justice, partly because, as I explain below, egalitarianism can motivate a concern with partial or specific inequalities, although this cannot translate into a theory of partial justice. As Hausman points out, a ‘conclusive critique of specific egalitarianism would require an examination of the foundations of egalitarianism’ (Hausman, 2007: 57), and this article aims to begin such an examination. The article is structured as follows: in the next section, I give on overview of different types of application of an egalitarian principle of justice to a specific area. Next, I argue that one type of egalitarian view, telic egalitarianism, can not only support this approach but also entails a concern with specific inequalities, so this view can motivate specific egalitarianism. I then consider, in turn, a direct application of a principle of justice to health and an indirect one. I conclude that the former, isolationist approach is consistent in a very simple but implausible form, while the latter, integrationist one has nothing distinctive to say about specific inequalities. I outline some implications of this argument in the conclusion. Partial Justice Approaches Before looking at specific egalitarianism in more detail, let me make a few clarifications. First, I assume that to deliver a verdict of (distributive) justice for any distribution, one needs a principle of justice, and such a principle must be imported, so to speak, from a theory of justice. So, to have a theory of partial justice, we must start with a general theory of justice, that is, one that applies a principle of (distributive) justice to the overall good. Second, we can distinguish between an isolationist and an integrationist approach to justice in a specific area.1 On the isolationist approach, a certain area is treated in isolation from others and that area is evaluated at the bar of justice by applying the relevant principle of justice directly to it. For instance, if an isolationist approach were adopted, Rawls’s difference principle might be applied to health directly and dictate that the distribution of health should benefit the least advantaged (in terms of health). This is not an application that would be seriously entertained, since Rawls famously insists that his principle applies to the basic structure of a society. But other principles of distributive justice, such as sufficientarian or luck egalitarian principles, are often thought to be directly applicable to a certain good or area and recommend that the distribution in that area matches a sufficientarian or luck egalitarian pattern. So an isolationist sufficientarian approach to education, for example, would recommend that everyone has enough education. On the integrationist approach, the relevant principle of justice is applied only to the overall distribution, and a verdict of justice for a specific area is derived from this application. To take an example again, let us assume that we are dealing with a sufficientarian theory, and we wish to see what implications a sufficientarian principle of justice has for a specific area, for instance education. On this approach, we would not try to distribute education, so that everyone has enough of it, but rather we would seek to establish what kind of distribution of education would be conducive to or required by the idea that everyone should have enough of whatever the currency of justice is, for instance welfare. We might then conclude that different people require different amounts of education depending on their natural talent. The integrationist approach is more complex because it would have to work out what the distribution of a specific good is in a just overall distribution, and this would depend on the distribution of other goods as well and the interplay between them. But, as I already pointed out, there seems to be little reason for a distributive egalitarian to adopt an isolationist approach. In Caney’s words: ‘if we start from a commitment to any of these forms of egalitarianism (equality of welfare or capabilities), they do not on their own give us any reason to adopt an ‘isolationist view’ and to apply equality to one specific good’ (Caney, 2012: 266). I will argue, however, that a certain kind of distributive egalitarianism does give a reason to be concerned with specific inequalities even though such inequalities cannot be deemed unjust. The failure to distinguish between different types of moral concern probably accounts for much of the confusion in the literature. The next question to consider is whether, once an isolationist approach is adopted, the same principle of justice should be applied to different areas. There are, of course, approaches that apply different principles of justice to different areas, such as Michael Walzer’s complex equality account (Walzer, 1984) or James Tobin’s ‘specific egalitarianism’ (Tobin, 1970). I will, however, leave these approaches aside for two reasons. First, it seems to me that such a pluralist approach either depends on a very specific and controversial meta-ethical view, namely, it assumes something like Walzer’s claim that we can (only) identify a principle of distribution by examining the social meaning of goods, or it is somewhat ad hoc and unmotivated as in Tobin’s case.2 Second, as I will argue below, inasmuch as an isolationist approach can be motivated, it requires an egalitarian approach that sees all inequalities as problematic and thus the same (egalitarian) principle(s) must be applied to all inequalities. For these reasons, I also leave aside theories of justice that are not egalitarian about distribution, such as sufficientarian and prioritarian theories, the capabilities approach and views that might fall under the broad umbrella of ‘social egalitarianism’. So the conclusions I reach are limited to egalitarian theories of distributive justice, partly because, as I argue below, some egalitarian theories of distributive justice can support an isolationist approach. Egalitarianism and Partial Justice In this section, I will argue that some forms of egalitarianism entail a concern with the distribution of specific goods. After putting forward what I consider the strongest argument for a concern with partial inequalities, I will argue that this cannot support a partial justice account. In other words, while specific inequalities may be considered bad or problematic, they cannot be unjust. The jump from one category to the other accounts for many misconceived arguments in applied political theory. Derek Parfit made a well-known distinction between telic and deontic egalitarianism. According to him, telic egalitarians subscribe to the principle of equality: ‘it is in itself bad if some people are worse off than others’ (Parfit, 1997: 204). Telic views, in general, assess the badness or goodness of outcomes or states of affairs. So telic egalitarians maintain that inequality makes an outcome worse. By contrast, deontic egalitarians claim that ‘what is (…) bad is not strictly the state of affairs but the way in which it was produced’.3 I want to argue that telic egalitarianism gives us a reason to be concerned with partial inequalities, hence to adopt an isolationist approach, but not to evaluate them at the bar of justice (See also Eyal 2013: 197). Conversely, deontic egalitarianism could deliver verdicts of injustice in specific distributions but gives us no reason to be concerned with partial inequalities to start with. For a deontic egalitarian theory, partial inequalities are unjust inasmuch as they are caused by injustices; here the ‘verdict of injustice spreads forwards’ from causes to the outcome, as Sreenivasan puts it (Sreenivasan, 2014). So, for instance, if the cause of an inequality between racial groups is historical racial injustice, the resulting inequality is unjust because of its cause not because it is an inequality. So deontic egalitarianism does not give us a reason to adopt an isolationist approach. However, telic egalitarianism may offer some support for specific egalitarianism. Now, I want to argue that if (and only if) an egalitarian is concerned with inequality in itself, then any inequality is bad regardless of its metric. As Parfit says, if we are telic egalitarians, ‘(w)e may also think it irrelevant what the respects are in which some people are worse off than others: whether they have less income, or worse health, or are less fortunate in other ways. Any inequality, if undeserved and unchosen, we may think bad’.4 In other words, if inequality is intrinsically bad, then all inequalities are bad. So an outcome that contains an inequality is bad at least in one respect or pro tanto, even if not all-things-considered (ATC) bad.5 Thus, the fact that we are unequally situated in relation to the coffee machine, for instance, and have unequal access to coffee is bad and may trigger a moral concern, even though it may ultimately be found not to matter at all (Segall 2013: 23). But this does not mean that all inequalities are unjust. So far we only have a view about the badness of inequalities, or an axiological view. An axiological view only gives verdicts about value, which may in turn give us a reason for action, but it does not offer a verdict about the right action. How can an egalitarian then move from a claim about value to a claim about (in)justice? One way is by adopting a teleological view, according to which the rightness of actions depends on their consequences. So, if inequality is bad and allowing badness to occur is wrong, allowing inequality is wrong. Principles of justice, let us assume, are a subset of such moral principles. If our theory of justice includes this egalitarian teleological principle, then inequality is also (pro tanto) unjust. At this point, I must clarify some of the other assumptions that the argument that follows rests on. They are neither uncontroversial nor far-fetched. First, I use the term ‘injustice’ here to mean ‘ought to be rectified’. This is not an uncontroversial use, but it is more in line with common usage and the one that is naturally assumed in arguments that envisage policy recommendations. This implies that only inequalities that can be rectified can be deemed unjust. There are philosophers who use this term differently, but they tend not to be the ones who make partial justice arguments; in any case, the argument in this article does not apply to them. Second, I assume here that an egalitarian theory of justice that includes a principle of equality will deem an(y) inequality to be pro tanto unjust, i.e. it ought pro tanto to be rectified. In other words, assuming that all other things are equal, an egalitarian will recommend that partial inequalities be rectified. However, a pro tanto injustice is not an ATC injustice because other considerations may defeat the pro tanto requirement. ‘Pro tanto oughts are normally treated as implying final oughts, at least within a domain, if there are no other relevant pro tanto oughts or other considerations’ (Reisner, 2013). So (only) if our theory is a simple theory, i.e. one that includes only one principle of justice, and that is the principle of equality, any inequality will also be ATC unjust (hereafter unjust). If, however, our theory is a more complex one, and it includes other principles or considerations, not every inequality will be unjust although it remains ‘bad’. A complex principle of justice will emerge and will tell us which (subset of) inequalities are unjust. Finally, I will be assuming a theory that takes well-being as the equalisandum. If this overall good, well-being, has several components, telic egalitarians have a reason to see an inequality in each of these components as unjust other things being equal. This is because, if the egalitarian principle of distributive justice we envisage applies to the overall good, an inequality in one component is pro tanto unjust, since it creates an inequality in the overall good. With these assumptions in mind, the question I want to ask is whether an egalitarian can consistently maintain that partial inequalities are unjust. I will argue that an isolationist account combined with a simple principle of justice is consistent, but it is implausible inasmuch as health is a component of well-being. A complex isolationist approach, on the other hand, is inconsistent. The integrationist approach is less problematic, but it does not provide an account of justice in a specific area, let alone an egalitarian account. It is simply an account of justice that might have implications for the distribution of specific goods. What I have shown so far is that telic egalitarianism allows us to claim that partial inequalities are pro tanto unjust. But this means that all partial—as well as overall—inequalities that affect well-being are pro tanto unjust. If this is the case, only strict or radical egalitarianism, i.e. a theory that requires perfect equality, whatever the equalisandum is, is consistent, but strict egalitarianism is practically impossible for any plausible equalisandum. This is not to say that a theory of justice has nothing to recommend for specific areas, but it cannot be ‘applied’ to a certain area. In other words, there cannot be justice in health, in education, in care etc., only justice overall. Equality in Health I argued that egalitarians who are concerned with inequality in itself ought to be concerned with every inequality, including inequalities in health. The question is then whether egalitarians can consistently claim that inequalities in specific goods, such as health, are unjust, as opposed to merely bad. To answer that question, I will first consider an isolationist approach, where the same egalitarian principle of justice is applied directly both to specific and to overall inequalities. A principle of justice, as I said, can be simple or complex; I will consider these in turn. A simple principle of egalitarian justice would require perfect or strict equality in the relevant distribuendum. An isolationist approach to partial inequalities requires the application of this principle to all inequalities; if this principle is applied to an equalisandum that has several components, a simple principle of egalitarian justice can and must be applied to all its components. So a direct application of this simple principle would require strict equality in all components of the overall good (g) as well as the overall good (G) itself. If this were a plausible principle of justice and if it were possible to achieve a perfectly equal distribution of all components of G, this approach would be entirely adequate. But for any plausible equalisandum, strict equality in all components is impossible to achieve. Let us—plausibly—assume that G is well-being, and well-being has different components, such as for instance, health, income, education, social status. Any plausible account of well-being will include health as a component so, if this approach does not work for health, it cannot work for any plausible equalisandum. So let us consider the case of inequality in health—by which I mean inequality in health outcomes between individuals—and assume that the other components of well-being are distributed equally. If this is the case, the inequality in health is unjust and ought to be rectified. But it is clear that inequalities in individuals’ health outcomes cannot be unjust (in the sense employed here), since equality in health is unachievable, except by levelling-down. So equality in health cannot be a requirement of justice. But let us say that it is possible to ‘up-equalise’ or that equality in health does not mean bringing everyone to the highest level of health but maybe something like a level of health sufficient for normal functioning. If individuals are equally healthy in this sense and all other components of well-being are equally distributed, their well-being is equal as well, so this approach is once again unproblematic. However, as soon as one individual falls below the required health level, there is an unjust inequality, which must be rectified without upsetting the equality in other components of G. As it has been pointed out before, health or its distribution depends on the distribution of socio-economic factors that are also likely to be components of well-being (Marmot, 2010; Sreenivasan, 2014). I will not labour this point here, since it is, I take it, a familiar one. The more general point is that, even though an equalisandum whose components can all be equal is not perhaps inconceivable, it is unlikely that there are no causal relationships between the components, like between health and socio-economic factors. Thus, if one of the components is health, it is no longer plausible to maintain that equality in all components can be maintained, since the distribution of health outcomes depends on the distribution of other components. It might be replied that even a strict egalitarian position does not require strict equality in health outcomes. Perhaps equality in the area of health requires only equal access to healthcare or an equal opportunity to be healthy. But this seems to deny that health is a component of well-being, and such an assumption is necessary for the distributive egalitarian who is concerned both with partial and overall inequalities. In other words, such a view would not be able to assess inequalities in health at the bar of (distributive) justice. Of course, we might want to assess the distribution of specific goods to determine how to restore equality of G. But these partial inequalities would only be of practical not moral interest.6 The isolationist approach then is consistent but unfeasible unless we have an equalisandum whose components, if any, can be equal at all times. Since it is implausible to exclude health (as an outcome) as a component and health outcomes cannot be equal at all times, such an approach is implausible. So far I have assumed a simple egalitarian principle of justice. So let us examine next a direct application of a complex principle of justice to the area of health. Recall that on the isolationist approach we are applying the same principle of justice directly to a specific good as well as to the overall one. If our theory of justice combines an equality principle with other considerations, like responsibility for instance, as in the case of luck egalitarianism, only some inequalities will be deemed unjust. Such an approach would be exemplified by the application of a luck egalitarian principle or a (Rawlsian) principle of fair equality of opportunity (FEO) to the area of health and has in fact been taken by some theorists.7 Segall helpfully summarizes these two applications, respectively: Equality of opportunity for health: it is unfair for an individual to end up less healthy than another if she invested at least as much effort in looking after her health FEO for health: it is unfair for an individual to end up less healthy than another if she invested at least as much effort in looking after her health provided that she has at least as good a genetic disposition as that other person (Segall, 2010a: 99). Let us take the luck egalitarian account first. It does not require strict equality in health, so it is not unfeasible, but it requires that (individual) health outcomes match the individuals’ effort for health. This is inconsistent with the application of the same principle to the overall good because (luck egalitarian) justice in health would require upsetting the just overall distribution. This is because a person's health is determined by three types of factor: natural (genetic), social and personal choice or individual behaviour. Given the requirement that health outcomes not be influenced by anything other than effort, this approach seems to recommend that the effects of social factors on health be neutralized. If social factors have an influence on health outcomes, aside from their influence on individual behaviour, health outcomes do not track one’s effort in looking after their health. The correlation between socio-economic outcomes and health outcomes is now well documented, even though it is still not entirely clear what the causal pathways are. But, if we grant that socio-economic factors have a causal influence on health outcomes that is not mediated through individual behaviour, matching health outcomes to individual effort for health requires neutralizing the influence of these social factors. This makes the application of a complex principle of justice to health inconsistent. If the complex egalitarian principle is applied to G, this will result in a certain distribution of the social determinants of health (SDH), which will therefore be just but probably unequal. If the application of the principle to a specific good like health recommends that the SDH be redistributed, this will upset the overall just distribution. It might be replied that justice in health does not require the redistribution of the SDH, since the effects of SDH on health outcomes can be neutralized by providing healthcare. But there are, of course, certain health deficits that may be caused by SDH that cannot be remedied. So the only way to neutralize the impact of SDH on health is by redistributing the SDH. But if the socio-economic inequalities in question are not unjust, redistribution may create an injustice.8 So, the application of a principle in one area conflicts with the application of the same principle in a different one which makes this approach inconsistent. Furthermore, this approach ‘risks imposing burdens on people who experience unchosen disadvantage in every sphere of life except health, thus increasing rather than decreasing the extent to which their lives as a whole reflect unchosen circumstances’ (Albertsen and Knight, 2015: 166). It may again be replied that this approach does not have this implication. Some of those who support this approach (e.g. Segall) concede that, if the SDH are fairly distributed, resulting social inequalities in health are not unjust. But, in that case, the direct application of a luck egalitarian principle to a specific area is simply unwarranted; equal opportunity for health cannot be ensured unless these factors are not allowed to cause certain health outcomes. This is to say that equal opportunity for health cannot be satisfied by either remedying or compensating for health deficits, even when this is possible. If indeed social factors, such as socio-economic factors, education and social rank do indeed cause bad health, certain individuals will not have an equal opportunity for health even if they had an equal opportunity for these factors. The situation is of course similar with the application of a general principle of FEO directly to health. This would allow health outcomes to track luck, but it would not allow socio-economic factors to influence health. But inasmuch as the same principle is applied to the distribution of socio-economic factors, its application to health is inconsistent with its application overall.9 So the direct application of a complex principle of justice to health is inconsistent. This means that, on any of these theories of justice, residual health inequalities, that is, health inequalities that result from a just distribution of the SDH, cannot be deemed unjust, at least not in the sense employed here. One can nevertheless maintain that they are unjust or unfair but do not require rectification in which case this view has no public policy implications. I will next examine the integrationist approach to health inequalities. Egalitarian Justice and Health The integrationist approach applies the principle of justice to the overall good or distribution and the thought here is that we might be able to derive implications for a specific area, such as health, from a general theory of justice. This can be a very complex task and one that should not be undertaken with philosophical means alone. Norman Daniels seems to propose such an approach in that he wants to elaborate or expand on Rawls’s theory in a way that would take account of health.10 Daniels actually takes a two-pronged approach to the issue of health and health inequalities within the framework of a Rawlsian theory. Health disparities are thus evaluated, on the one hand, by looking backward so to speak, to their causes, and, on the other hand, by looking forward, to what they might contribute to. On a backward-looking approach, health inequalities are unjust if their causes, that is the distribution of the socio-economic factors is unjust. It may be worth clarifying here that Daniels does not claim that residual health inequalities are unjust. He admits that once the two principles of justice are implemented and socio-economic inequalities, albeit greatly reduced, are justified, resulting inequalities in health are not unjust. On a forward-looking approach, he considers the role that health plays in fulfilling one of Rawls’s principles of justice, namely FEO. He argues that, because health is instrumental to (effective) opportunity, maintaining equal opportunity requires meeting people’s health needs, so that they attain and maintain the same level of normal functioning. An integrationist luck egalitarian approach to justice and health would work in similar ways, although nobody has proposed such an approach to my knowledge. Assuming that the luck egalitarian subscribes to an overall principle of equality of opportunity for welfare (EOW) or access to advantage, the integrationist luck egalitarian approach to justice in health would require that health outcomes be (re)distributed so as to ensure EOW. Thus, on both the Rawlsian and the luck egalitarian integrationist approach, the justice of a health distribution depends on its contribution to achieving a just distribution overall. On the face of it, this kind of approach seems unproblematic in terms of consistency. But inasmuch as it is consistent, it does not have anything distinctive to say about a particular area; it is merely a general theory of justice. Conversely, inasmuch as it says anything about a particular area, it may rest on some problematic assumptions that undermine the general egalitarian principle envisaged. Let me explain this point first in relation to the application of the Rawlsian account to health. Daniels seeks to extend Rawls's principle of FEO to cover health. He claims that (good) health is instrumental to opportunities and, since one overall principle of the Rawlsian theory of justice is FEO, he argues that FEO requires meeting people’s health needs. Thus, he claims, the FEO principle requires the provision of (universal) healthcare. His argument has two main premises: (i) (good) health is required to secure the fair share of opportunity that individuals are due under the principle of FEO and (ii) (universal) healthcare is required to secure good health. The second premise is vulnerable to various criticisms (Sreenivasan, 2007); but here I will be mainly concerned with the first one. Presumably, a similar premise must be present in the indirect luck egalitarian account. The premise under discussion seems plausible on the face of it. It seems clear that bad health diminishes people's share of opportunities or perhaps, more precisely, their ability to take advantage of them. So health is instrumental to opportunity. But, as Sreenivasan points out, ‘we are not entitled to infer “violation of equal opportunity” merely from “loss of health” (22) since bad health may diminish someone’s share of (effective) opportunities but it need not diminish their fair share at the time when they suffer health shortfalls’. Thus, the first premise requires that the share of opportunity be interpreted in relative terms, so ‘a fair share of opportunity is defined in comparison to the shares held by others in society’.11 But it is not clear that Rawlsian FEO entails equal shares of opportunity throughout people’s lives, at least not in the broad sense of opportunity that Daniels uses. Of course, Rawls’s principle of FEO applies quite narrowly to jobs, and careers and opportunity in this sense must remain equal; the thought is, I take it, that people’s career prospects, which in turn determine to a great extent how their lives go overall, should not be influenced by arbitrary factors such as race, religion, sex or indeed class. But this limited FEO principle would not give us the kind of conclusions that Daniels wants to draw about health. However, Daniels actually modifies, without much argument, Rawls’s principle of FEO, which he admits is problematic. Daniels uses the broader notion of a ‘normal opportunity range’, which is the array of life plans reasonable persons are likely to develop for themselves (Daniels, 2008: 43). This seems closer to the notion of EOW (over a lifetime) that luck egalitarians employ; if this is the principle that is employed, it is difficult to see why the contribution that health makes to opportunity should be taken into account but brute luck should not (Segall, 2010b: 348). But Daniels rejects the luck egalitarian thought that natural talents should also not be allowed to influence individuals’ opportunity for well-being. This forward-looking integrationist approach then is unsuccessful. If FEO is interpreted in the narrow sense intended by Rawls, it does not support the conclusion that justice requires meeting people’s health needs. If FEO is interpreted in a broader sense, it would only support that conclusion if it can be shown that people’s shares of opportunity must remain equal throughout their lives. The more general lesson we should draw from this discussion is that, although this may be a coherent way of ‘applying’ a general theory of justice to a specific area, it will not necessarily deliver the conclusions we may intuitively want to endorse for that area. Stretching the theory to try to accommodate those conclusions means effectively starting with an account of partial justice and expanding that into a theory of justice. But this is no longer an integrationist approach; it is simply a disguised and unsupported isolationist one. It then seems that the only sense in which Rawls’s theory can be ‘applied’ to health is in the backward-looking way, i.e. by pointing out the implications that implementing his principles of justice would have for health, and Daniels argues that it would reduce (social) inequalities in health. Since the Rawlsian principles of justice happen to regulate (most of) the SDH, a Rawlsian distribution would reduce the inequalities in these social determinants and would thus flatten the social gradient. This approach is unproblematic, but it also fails to tell us anything about health specifically and especially about just health inequalities, contrary to what Daniels asserts: ‘If Rawls’s principles constitute a fair distribution of these socially controllable factors affecting health, then we have made some headway in deciding which health inequalities are unjust’ (Daniels, 2008: 23). But all this approach is going to tell us is that health inequalities are unjust when caused by an unjust distribution of the SDH.12 In that sense, it has nothing distinctive to say about health inequalities as such, or ‘residual’ health inequalities, that is inequalities in health whose causes are fair. It cannot evaluate them in isolation from their causes and information about the pathways leading from social factors to health. Daniels accepts that ‘using this approach one might say that inequalities in health that remain after a fair distribution of other goods should count as acceptable or fair inequalities’.13 I would go further and say that under this approach, inequalities in health or any other specific good or area are of no concern to the political theorist, although pointing out that reducing socio-economic inequalities would contribute to reducing health inequalities and/or improving population health might help the politician make the case for a Rawlsian principle of distribution. But it should be clear that it is the socio-economic inequalities that are unjust not the health inequalities they might give rise to. So it is not clear why we would even attempt to establish what justice in health requires on this kind of approach. Daniels agrees that ‘once with recognise the importance of the SDH for levels of population health and its distribution, we cannot talk about a theory of justice for health in isolation from an overall theory of justice’ (Daniels, 2008: 37). But he maintains that pointing out the health implications of various policies is significant, presumably politically rather than morally. It remains unclear though why this is the case if health is not special; on the contrary, it seems counterproductive, since it suggests that an inegalitarian policy is objectionable in virtue of its effects on health rather than in itself. Let me now turn briefly to an integrationist luck egalitarian approach. Luck egalitarianism, I assume, sees opportunity for welfare or access to advantage as the equalisandum, and this entails a certain distribution of income and wealth, i.e. the SDH, which is fair. But we have established that once the SDH are fairly distributed, there is no reason to be concerned with inequalities in health. Departures from equal shares of opportunity for welfare are justified if they are due to people’s own choices. However, the distinctive feature of luck egalitarianism is the additional claim that luck cannot justify such departures, so disadvantages due to luck should be compensated. So, to the extent that health deficits are due to bad luck and they detract from one’s fair share of opportunity (for welfare), they should be remedied or compensated for.14 The question is then how should we treat residual social inequalities in health? They are not due to one’s choices about health, but they are arguably due to choices about their social determinants. When health outcomes are direct causal consequences of people’s socio-economic circumstances, that is, they are not mediated through individual behaviour, there seems to be no reason to be concerned with those (unequal) health outcomes. If individuals are responsible for their socio-economic circumstances and these circumstances determine certain health outcomes, it seems that they are responsible for all the outcomes that are direct consequences of those circumstances. Admittedly, this is surprising; the luck egalitarian might be expected to claim the exact opposite, namely, that, inasmuch as socio-economic circumstances determine health outcomes, individuals cannot be held responsible for their health, since they have no control over it as in Segall’s account examined above. However, the thought that one is responsible for all the direct consequences of one’s choices seems implicit in the luck egalitarian’s choice of equalisandum, i.e. opportunity for welfare. As long as opportunities are equalized, the fact that choices result in different levels of welfare does not concern the luck egalitarian, I take it. But if we claim that the effects of these social factors on health should be neutralized, it seems that we deny either that people can be held responsible for the outcomes of their choices. Now, it seems to me that there is some logical space here for an argument that the luck egalitarian can pursue. In particular, one could examine further the causal link between socio-economic factors and health and/or the account of responsibility presupposed there. If it is the case that the appropriate account of responsibility entails that certain (health) effects must be compensated for, if caused by socio-economic factors, we may have an account that has a distinctive contribution to make to this particular area. However, until this space is filled, the luck egalitarian who adopts an integrationist approach to partial inequalities does not seem to have anything distinctive to say about health or indeed other specific goods.15 This is not to say that luck egalitarians should not be interested in the implications that the theory has in the area of health. Indeed, there is a growing literature working out these implications and/or responding to objections that point out the counter-intuitiveness of the potential implications. A convincing response would, however, involve engaging with the core tenets of luck egalitarianism rather than isolating the area of health and seeking a luck egalitarian principle merely for that area as in the isolationist approach. At the same time, the luck egalitarian does not have anything distinctive to say about the distribution of health independently of the distribution overall, i.e. the equalisandum. The conclusion is then that there is no basis for a theory of justice in health. A theory of justice can only be a general one, and what justice requires in specific areas will have to be worked out subsequently for each and every case. This may not be very straightforward and would certainly require engagement with other areas of social sciences. So one lesson to learn from this is that no clear policy implication can be drawn from accounts of partial justice. But egalitarians may have good reasons to examine inequalities that arise in different areas. By this, I mean that they have a reason to be interested in but not be concerned with, at the bar of justice, with partial inequalities. Partial inequalities may be observable indicators of injustices, but they cannot be the location of injustice so to speak. A pragmatic concern with specific inequalities is justified, but there can be no question of justice in health, or any other specific goods; there is only a question of justice. Conclusion I argued here that attempts to formulate principles of (distributive) justice for a specific area such as health are misconceived. An egalitarian theory of justice might give us a reason to be concerned with a specific area, but applying an egalitarian principle of justice to health is only possible inasmuch as other components of well-being can be distributed equally at all times, which is implausible. An integrationist approach to justice and health is not problematic, but it does not have anything distinctive to say about a specific good and its distribution, so in this sense it is not a theory of partial justice. I suggested, however, that a luck egalitarian account might hold some promise, especially for the area of health. Such an account would not entail that inequalities in specific goods are unjust but may show why they are of interest for the egalitarian. Thus, I suggest that egalitarians must start with an account of (overall) justice and work out the implications it has for different areas. This kind of exercise must be fully ‘integrationist’, that is, it must pay attention to the implications the theory has for all relevant areas to avoid issuing conflicting recommendations. The article does not have direct implications for public policy; on the contrary, it suggests that no such implications can be drawn from simply looking at specific inequalities. This may sound like common sense, but unfortunately many arguments proceed as though the mere existence of health inequalities is an injustice that ought to be rectified. Of course, in the real world, inequalities of health, especially inequalities between social groups, are unjust because their causes are unjust. But it is unhelpful to suggest that they are unjust because of their effects on health rather than in themselves. This would encourage the same approach in each specific area, which would result in conflicting policy recommendations. In other words, the ministry of health and the ministry of education would each favour an overall distribution that the other would reject when both should be aiming for a just overall distribution. Footnotes 1. I am borrowing this terminology from Simon Caney (Caney, 2012). 2. Tobin does not seem to have a reason for his ‘specific egalitarianism’ other than the fact that it seems to reflect the society’s sensibilities. See also Caney’s discussion of Tobin in Caney, 2012: 272–276. 3. Ibid, 208. 4. Ibid, 209. 5. To be clear, this only holds for what we might call ‘intrinsic’ egalitarianism, i.e. a view that includes the principle that equality is intrinsically good. Many versions of telic egalitarianism probably subscribe to the broader idea that equality has final, though not intrinsic, value, which probably does not value the same implication. Elaborating on this point may take me too far afield but for the distinction between final and intrinsic value and its implications, see Olson (2004). Arguably, Parfit refers here to intrinsic egalitarianism (cf. Hirose, 2015). See also Preda, 2017. 6. Hausman looks in some details at considerations that count against measuring health inequalities as a proxy for overall inequalities (Hausman, 2007, pp, 60–65). Nevertheless, his view is that incompensable health inequalities do indicate overall inequalities and are thus pro tanto (or prima facie) unjust (Hausman, 2013). I would reject the claim that they are unjust; the injustice is located with the overall inequalities. 7. Anand and Peter, 2000; Segall, 2010a. The second approach also seems to the one taken by many epidemiologists who argue for the redistribution of the SDH on the basis that equity in health requires neutralizing the effect of the SDH. See for example Whitehead, 1990. Daniel Weinstock calls this approach ‘piecemeal’ and also argues against it but on different grounds from me (Weinstock, 2015). 8. I say ‘may’ because some luck egalitarians, and certainly Segall, may want to claim that only inequalities are bad and thus unjust while equality is never bad. So redistributing to equalize the SDH may not be unjust even though the previous distribution was just. I cannot go here into the reasons for rejecting this claim. 9. Of course, Rawls’s principle of fair equality of opportunity applies to jobs and careers specifically, not to the overall distribution. So it is surprising that Segall formulates this Rawlsian approach. 10. Daniels’s view has been discussed and criticized quite a lot in the past, and I do not aim to review those arguments. Some have focused on his claim that health is special (Segall, 2007; Wilson, 2009). It seems that the specialness thesis only concerns healthcare, and the argument made here focuses on inequalities in health outcomes between individuals. 11. Ibid., 22. 12. It is actually not clear to me that unfairness is ‘transferred’ in this way from one inequality to another, but I will leave this question aside here. 13. Idem. 14. When this is the case, it is a rather complex question, which I cannot attempt to answer here. 15. Education may be an exception here, since it is more directly linked with equality of opportunity. Acknowledgements The author would like to thank the participants at the workshop on ‘Egalitarianisms: current debates’, McGill, March 30-31, 2012 and the audiences at the panel on ‘What is Ideal theory?’ at the conference on ‘Ideals and Reality’, Newport, 11–13 April 2012, the panel on political philosophy at the Joint Sessions of the Mind and Aristotelian Society, Stirling, July 2012, the Nuffield College Workshop, November 2015 and the Ethox Centre Seminar, November 2015 as well as Anca Gheauş, Shlomi Segall, Adam Swift, Kristin Voigt and Gry Wester and the referees and especially the associate editors of this journal for very helpful written comments on earlier drafts. The author is also especially grateful to Gopal Sreenivasan and Jo Wolff for listening to and commenting on this article several times. References Albertsen A. , Knight C. ( 2015 ). A Framework for Luck Egalitarianism in Health and Health Care . Journal of Medical Ethics , 41 , 165 – 169 . Google Scholar Crossref Search ADS PubMed Anand S. , Peter F. ( 2000 ). Equal Opportunity. In Cohen J. , Rogers J. (eds), Is Inequality Bad for Our Health ? Boston : Beacon Press . Caney S. ( 2012 ). Just Emissions . Philosophy and Public Affairs , 40 , 255 – 300 . Google Scholar Crossref Search ADS Culyer A. J. , Wagstaff A. ( 1993 ). Equity and Equality in Health and Health Care . Journal of Health Economics , 12 , 431 – 457 . Google Scholar Crossref Search ADS PubMed Daniels N. (ed.) ( 2008 ). Just Health: Meeting Health Needs Fairly . New York, NY : Cambridge University Press . Eyal N. ( 2013 ). Levelling Down Health. In Eyal N. (ed.), Inequality in Health: Concepts, Measures, and Ethics . New York, NY : Oxford University Press . Gwatkin D. R. ( 2000 ). Health Inequalities and the Health of the Poor: What Do We Know? What Can We Do? Bulletin of the World Health Organisation , 78 , 3 – 17 . Hausman D. ( 2007 ). What’s Wrong with Health Inequalities? The Journal of Political Philosophy , 15 , 46 – 66 . Google Scholar Crossref Search ADS Hausman D. ( 2013 ). Egalitarian Critiques of Health Inequalities. In Eyal N. (ed.), Inequality in Health: Concepts, Measures, and Ethics . New York, NY : Oxford University Press , pp. 95 – 112 . Hirose I. (ed.) ( 2015 ). Egalitarianism . Oxon : Routledge . Marchand S. , Wikler D. , Landesman B. ( 1998 ). Class, Health, and Justice . The Milbank Quarterly , 76 , 449 – 467 . Google Scholar Crossref Search ADS PubMed Marmot M. ( 2010 ). Fair Society, Healthy Lives—the Marmot Review. Available at http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf Olson J. ( 2004 ). Intrinsicalism and Conditionalism about Final Value . Ethical Theory and Moral Practice , 7 , 31 – 52 . Google Scholar Crossref Search ADS Parfit D. ( 1997 ). Equality or Priority? Ratio , 10 , 202 – 221 . Google Scholar Crossref Search ADS Peter F. ( 2004 ). Health Equity and Social Justice. In Anand S. , Peter F. , Sen A. (eds), Public Health, Ethics, and Equity . Oxford : Oxford University Press . Preda A. ( 2017 ). Why Inequality Matters: Luck Egalitarianism, Its Meaning and Value, by Shlomi Segall . Ethics , 128 , 276 – 281 . Google Scholar Crossref Search ADS Reisner A. ( 2013 ). Prima facie oughts and pro tanto oughts. In Hugh L. N. (ed.), International Encyclopedia of Ethics Blackwell Publishing Ltd., pp. 4082 – 4086 . Segall S. ( 2007 ). Is Health Care (Still) Special? Journal of Political Philosophy , 15 , 342 – 361 . Google Scholar Crossref Search ADS Segall S. ( 2010a ). Health, Luck, and Justice . Princeton : Princeton University Press . Segall S. ( 2010b ). Is Health (Really) Special? Health Policy between Rawlsian and Luck Egalitarian Justice . Journal of Applied Philosophy , 27 , 344 – 348 . Google Scholar Crossref Search ADS Segall S. ( 2013 ). Equality and Opportunity . Oxford : Oxford University Press . Sreenivasan G. ( 2007 ). Health Care and Equality of Opportunity . Hastings Center Report , 37 , 21 – 31 . Google Scholar Crossref Search ADS PubMed Sreenivasan G. ( 2014 ). Justice, Inequality, and Health. In Edward N. Zalta (ed.), The Stanford Encyclopedia of Philosophy , available at: https://plato.stanford.edu/archives/fall2014/entries/justice-inequality-health/ Tobin J. ( 1970 ). On Limiting the Domain of Inequality . Journal of Law and Economics , 13 , 263 – 277 . Google Scholar Crossref Search ADS Veatch R. M. ( 1991 ). Justice and the Right to Health Care: An Egalitarian Account. In Bole T. J. , Bondeson W. B. (eds), Rights to Health Care. Philosophy and Medicine . Dordrecht : Springer , pp. 83 – 102 . Walzer M. (ed.) ( 1984 ). Spheres of Justice . New York: Basic Books . Weinstock D. ( 2015 ). Health Justice after the Social Determinants of Health Revolution . Social Theory and Health , 13 , 437 – 453 . Google Scholar Crossref Search ADS Whitehead M. (ed.) ( 1990 ). The Concepts and Principles of Equity and Health . Copenhagen : World Health Organisation . Wilson J. ( 2009 ). Not so Special after All? Daniels and the Social Determinants of Health . Journal of Medical Ethics , 35 , 3 – 6 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

‘Justice in Health or Justice (and Health)?’—How (Not) to Apply a Theory of Justice to Health

Adina, Preda,
Public Health Ethics , Volume 11 (3) – Nov 1, 2018
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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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Abstract

Abstract Some theorists, especially egalitarians, seek to ‘apply’ theories of justice to a specific area or good, such as health, and assess the distribution of that good at the bar of justice. On the one hand, this is understandable, given that egalitarians are often interested in making policy recommendations and these would have to be area-specific. On the other hand, it is surprising in light of the fact that (distributive) theories of justice normally envisage the ‘total package of goods’ or an overall good as the distribuendum. This article aims to show that this approach is problematic at least in the area of health. An increasing number of political theorists and philosophers, especially egalitarians, are interested in making arguments that could have ‘real-life’ impact and could be translated into public policy. To that end, they focus on specific areas and seek to evaluate the distributions in those areas, at the bar of justice. However, we lack a coherent methodological framework for doing this kind of work in normative political theory, and this article seeks to contribute to the effort of finding a suitable framework by showing that one approach commonly used in the area of health ethics, but not only, is misconceived. The approach I envisage, which I will call the ‘partial justice’ approach starts from a ‘general’ theory of justice, in particular distributive justice, and ‘applies’ the theory or one of its principles to a specific area, in this case health. In spite of recognizing this approach to be problematic, some continue to ‘apply’ principles of justice to health. Health practitioners and epidemiologists implicitly adopt this kind of approach and apply an egalitarian principle specifically to health only. Thus, a number of reports and policy documents on the subject explicitly state that ‘health inequalities that are preventable by reasonable means are unfair’ and that ‘reducing health inequalities is a matter of fairness and social justice’ (Marmot, 2010: 16). Indeed, this kind of approach is ‘prominent in medical ethics’ (Albertsen and Knight, 2015: 166). Among its proponents are D. R. Gwatkin (Gwatkin, 2000), who adopts a prioritarian approach, as well as Fabienne Peter (Peter, 2004), Sudhir Anand and Peter (Anand and Peter, 2000) and Robert Veatch (Veatch, 1991), who all adopt a variant of an egalitarian account of justice to inequalities in health (See also Culyer and Wagstaff, 1993; Marchand et al., 1998). We can call the latter ‘specific egalitarianism’. More interestingly, two leading theorists in this area, Norman Daniels and Shlomi Segall, apply Rawlsian or luck egalitarian principles, respectively, to health even though they accept that a theory of justice applies to the overall good (Daniels, 2008; Segall, 2010a). Segall explicitly asks: ‘Why a separate theory of justice in health?’ but does not provide a satisfactory answer (Segall, 2010a: 92–96). So it is puzzling that this approach persists, and there are perhaps some good reasons for it. This is the starting point of this article. This approach in the area of health has been criticized before (Hausman, 2007; Wilson, 2009). This article takes the partial justice approach more seriously and examines the most plausible way in which it can be motived before arguing that it cannot work in the simplistic manner sometimes adopted, which is directly applying a principle of justice to a specific area. This is because theories of distributive justice apply the relevant principle of justice to the currency they identify as relevant and are thus usually concerned with the overall distribution not the distribution in specific domains. If this is the case, it is unclear how they can even begin to evaluate the distribution in a specific area. The discussion in this article, however, will be limited to egalitarian theories of justice, partly because, as I explain below, egalitarianism can motivate a concern with partial or specific inequalities, although this cannot translate into a theory of partial justice. As Hausman points out, a ‘conclusive critique of specific egalitarianism would require an examination of the foundations of egalitarianism’ (Hausman, 2007: 57), and this article aims to begin such an examination. The article is structured as follows: in the next section, I give on overview of different types of application of an egalitarian principle of justice to a specific area. Next, I argue that one type of egalitarian view, telic egalitarianism, can not only support this approach but also entails a concern with specific inequalities, so this view can motivate specific egalitarianism. I then consider, in turn, a direct application of a principle of justice to health and an indirect one. I conclude that the former, isolationist approach is consistent in a very simple but implausible form, while the latter, integrationist one has nothing distinctive to say about specific inequalities. I outline some implications of this argument in the conclusion. Partial Justice Approaches Before looking at specific egalitarianism in more detail, let me make a few clarifications. First, I assume that to deliver a verdict of (distributive) justice for any distribution, one needs a principle of justice, and such a principle must be imported, so to speak, from a theory of justice. So, to have a theory of partial justice, we must start with a general theory of justice, that is, one that applies a principle of (distributive) justice to the overall good. Second, we can distinguish between an isolationist and an integrationist approach to justice in a specific area.1 On the isolationist approach, a certain area is treated in isolation from others and that area is evaluated at the bar of justice by applying the relevant principle of justice directly to it. For instance, if an isolationist approach were adopted, Rawls’s difference principle might be applied to health directly and dictate that the distribution of health should benefit the least advantaged (in terms of health). This is not an application that would be seriously entertained, since Rawls famously insists that his principle applies to the basic structure of a society. But other principles of distributive justice, such as sufficientarian or luck egalitarian principles, are often thought to be directly applicable to a certain good or area and recommend that the distribution in that area matches a sufficientarian or luck egalitarian pattern. So an isolationist sufficientarian approach to education, for example, would recommend that everyone has enough education. On the integrationist approach, the relevant principle of justice is applied only to the overall distribution, and a verdict of justice for a specific area is derived from this application. To take an example again, let us assume that we are dealing with a sufficientarian theory, and we wish to see what implications a sufficientarian principle of justice has for a specific area, for instance education. On this approach, we would not try to distribute education, so that everyone has enough of it, but rather we would seek to establish what kind of distribution of education would be conducive to or required by the idea that everyone should have enough of whatever the currency of justice is, for instance welfare. We might then conclude that different people require different amounts of education depending on their natural talent. The integrationist approach is more complex because it would have to work out what the distribution of a specific good is in a just overall distribution, and this would depend on the distribution of other goods as well and the interplay between them. But, as I already pointed out, there seems to be little reason for a distributive egalitarian to adopt an isolationist approach. In Caney’s words: ‘if we start from a commitment to any of these forms of egalitarianism (equality of welfare or capabilities), they do not on their own give us any reason to adopt an ‘isolationist view’ and to apply equality to one specific good’ (Caney, 2012: 266). I will argue, however, that a certain kind of distributive egalitarianism does give a reason to be concerned with specific inequalities even though such inequalities cannot be deemed unjust. The failure to distinguish between different types of moral concern probably accounts for much of the confusion in the literature. The next question to consider is whether, once an isolationist approach is adopted, the same principle of justice should be applied to different areas. There are, of course, approaches that apply different principles of justice to different areas, such as Michael Walzer’s complex equality account (Walzer, 1984) or James Tobin’s ‘specific egalitarianism’ (Tobin, 1970). I will, however, leave these approaches aside for two reasons. First, it seems to me that such a pluralist approach either depends on a very specific and controversial meta-ethical view, namely, it assumes something like Walzer’s claim that we can (only) identify a principle of distribution by examining the social meaning of goods, or it is somewhat ad hoc and unmotivated as in Tobin’s case.2 Second, as I will argue below, inasmuch as an isolationist approach can be motivated, it requires an egalitarian approach that sees all inequalities as problematic and thus the same (egalitarian) principle(s) must be applied to all inequalities. For these reasons, I also leave aside theories of justice that are not egalitarian about distribution, such as sufficientarian and prioritarian theories, the capabilities approach and views that might fall under the broad umbrella of ‘social egalitarianism’. So the conclusions I reach are limited to egalitarian theories of distributive justice, partly because, as I argue below, some egalitarian theories of distributive justice can support an isolationist approach. Egalitarianism and Partial Justice In this section, I will argue that some forms of egalitarianism entail a concern with the distribution of specific goods. After putting forward what I consider the strongest argument for a concern with partial inequalities, I will argue that this cannot support a partial justice account. In other words, while specific inequalities may be considered bad or problematic, they cannot be unjust. The jump from one category to the other accounts for many misconceived arguments in applied political theory. Derek Parfit made a well-known distinction between telic and deontic egalitarianism. According to him, telic egalitarians subscribe to the principle of equality: ‘it is in itself bad if some people are worse off than others’ (Parfit, 1997: 204). Telic views, in general, assess the badness or goodness of outcomes or states of affairs. So telic egalitarians maintain that inequality makes an outcome worse. By contrast, deontic egalitarians claim that ‘what is (…) bad is not strictly the state of affairs but the way in which it was produced’.3 I want to argue that telic egalitarianism gives us a reason to be concerned with partial inequalities, hence to adopt an isolationist approach, but not to evaluate them at the bar of justice (See also Eyal 2013: 197). Conversely, deontic egalitarianism could deliver verdicts of injustice in specific distributions but gives us no reason to be concerned with partial inequalities to start with. For a deontic egalitarian theory, partial inequalities are unjust inasmuch as they are caused by injustices; here the ‘verdict of injustice spreads forwards’ from causes to the outcome, as Sreenivasan puts it (Sreenivasan, 2014). So, for instance, if the cause of an inequality between racial groups is historical racial injustice, the resulting inequality is unjust because of its cause not because it is an inequality. So deontic egalitarianism does not give us a reason to adopt an isolationist approach. However, telic egalitarianism may offer some support for specific egalitarianism. Now, I want to argue that if (and only if) an egalitarian is concerned with inequality in itself, then any inequality is bad regardless of its metric. As Parfit says, if we are telic egalitarians, ‘(w)e may also think it irrelevant what the respects are in which some people are worse off than others: whether they have less income, or worse health, or are less fortunate in other ways. Any inequality, if undeserved and unchosen, we may think bad’.4 In other words, if inequality is intrinsically bad, then all inequalities are bad. So an outcome that contains an inequality is bad at least in one respect or pro tanto, even if not all-things-considered (ATC) bad.5 Thus, the fact that we are unequally situated in relation to the coffee machine, for instance, and have unequal access to coffee is bad and may trigger a moral concern, even though it may ultimately be found not to matter at all (Segall 2013: 23). But this does not mean that all inequalities are unjust. So far we only have a view about the badness of inequalities, or an axiological view. An axiological view only gives verdicts about value, which may in turn give us a reason for action, but it does not offer a verdict about the right action. How can an egalitarian then move from a claim about value to a claim about (in)justice? One way is by adopting a teleological view, according to which the rightness of actions depends on their consequences. So, if inequality is bad and allowing badness to occur is wrong, allowing inequality is wrong. Principles of justice, let us assume, are a subset of such moral principles. If our theory of justice includes this egalitarian teleological principle, then inequality is also (pro tanto) unjust. At this point, I must clarify some of the other assumptions that the argument that follows rests on. They are neither uncontroversial nor far-fetched. First, I use the term ‘injustice’ here to mean ‘ought to be rectified’. This is not an uncontroversial use, but it is more in line with common usage and the one that is naturally assumed in arguments that envisage policy recommendations. This implies that only inequalities that can be rectified can be deemed unjust. There are philosophers who use this term differently, but they tend not to be the ones who make partial justice arguments; in any case, the argument in this article does not apply to them. Second, I assume here that an egalitarian theory of justice that includes a principle of equality will deem an(y) inequality to be pro tanto unjust, i.e. it ought pro tanto to be rectified. In other words, assuming that all other things are equal, an egalitarian will recommend that partial inequalities be rectified. However, a pro tanto injustice is not an ATC injustice because other considerations may defeat the pro tanto requirement. ‘Pro tanto oughts are normally treated as implying final oughts, at least within a domain, if there are no other relevant pro tanto oughts or other considerations’ (Reisner, 2013). So (only) if our theory is a simple theory, i.e. one that includes only one principle of justice, and that is the principle of equality, any inequality will also be ATC unjust (hereafter unjust). If, however, our theory is a more complex one, and it includes other principles or considerations, not every inequality will be unjust although it remains ‘bad’. A complex principle of justice will emerge and will tell us which (subset of) inequalities are unjust. Finally, I will be assuming a theory that takes well-being as the equalisandum. If this overall good, well-being, has several components, telic egalitarians have a reason to see an inequality in each of these components as unjust other things being equal. This is because, if the egalitarian principle of distributive justice we envisage applies to the overall good, an inequality in one component is pro tanto unjust, since it creates an inequality in the overall good. With these assumptions in mind, the question I want to ask is whether an egalitarian can consistently maintain that partial inequalities are unjust. I will argue that an isolationist account combined with a simple principle of justice is consistent, but it is implausible inasmuch as health is a component of well-being. A complex isolationist approach, on the other hand, is inconsistent. The integrationist approach is less problematic, but it does not provide an account of justice in a specific area, let alone an egalitarian account. It is simply an account of justice that might have implications for the distribution of specific goods. What I have shown so far is that telic egalitarianism allows us to claim that partial inequalities are pro tanto unjust. But this means that all partial—as well as overall—inequalities that affect well-being are pro tanto unjust. If this is the case, only strict or radical egalitarianism, i.e. a theory that requires perfect equality, whatever the equalisandum is, is consistent, but strict egalitarianism is practically impossible for any plausible equalisandum. This is not to say that a theory of justice has nothing to recommend for specific areas, but it cannot be ‘applied’ to a certain area. In other words, there cannot be justice in health, in education, in care etc., only justice overall. Equality in Health I argued that egalitarians who are concerned with inequality in itself ought to be concerned with every inequality, including inequalities in health. The question is then whether egalitarians can consistently claim that inequalities in specific goods, such as health, are unjust, as opposed to merely bad. To answer that question, I will first consider an isolationist approach, where the same egalitarian principle of justice is applied directly both to specific and to overall inequalities. A principle of justice, as I said, can be simple or complex; I will consider these in turn. A simple principle of egalitarian justice would require perfect or strict equality in the relevant distribuendum. An isolationist approach to partial inequalities requires the application of this principle to all inequalities; if this principle is applied to an equalisandum that has several components, a simple principle of egalitarian justice can and must be applied to all its components. So a direct application of this simple principle would require strict equality in all components of the overall good (g) as well as the overall good (G) itself. If this were a plausible principle of justice and if it were possible to achieve a perfectly equal distribution of all components of G, this approach would be entirely adequate. But for any plausible equalisandum, strict equality in all components is impossible to achieve. Let us—plausibly—assume that G is well-being, and well-being has different components, such as for instance, health, income, education, social status. Any plausible account of well-being will include health as a component so, if this approach does not work for health, it cannot work for any plausible equalisandum. So let us consider the case of inequality in health—by which I mean inequality in health outcomes between individuals—and assume that the other components of well-being are distributed equally. If this is the case, the inequality in health is unjust and ought to be rectified. But it is clear that inequalities in individuals’ health outcomes cannot be unjust (in the sense employed here), since equality in health is unachievable, except by levelling-down. So equality in health cannot be a requirement of justice. But let us say that it is possible to ‘up-equalise’ or that equality in health does not mean bringing everyone to the highest level of health but maybe something like a level of health sufficient for normal functioning. If individuals are equally healthy in this sense and all other components of well-being are equally distributed, their well-being is equal as well, so this approach is once again unproblematic. However, as soon as one individual falls below the required health level, there is an unjust inequality, which must be rectified without upsetting the equality in other components of G. As it has been pointed out before, health or its distribution depends on the distribution of socio-economic factors that are also likely to be components of well-being (Marmot, 2010; Sreenivasan, 2014). I will not labour this point here, since it is, I take it, a familiar one. The more general point is that, even though an equalisandum whose components can all be equal is not perhaps inconceivable, it is unlikely that there are no causal relationships between the components, like between health and socio-economic factors. Thus, if one of the components is health, it is no longer plausible to maintain that equality in all components can be maintained, since the distribution of health outcomes depends on the distribution of other components. It might be replied that even a strict egalitarian position does not require strict equality in health outcomes. Perhaps equality in the area of health requires only equal access to healthcare or an equal opportunity to be healthy. But this seems to deny that health is a component of well-being, and such an assumption is necessary for the distributive egalitarian who is concerned both with partial and overall inequalities. In other words, such a view would not be able to assess inequalities in health at the bar of (distributive) justice. Of course, we might want to assess the distribution of specific goods to determine how to restore equality of G. But these partial inequalities would only be of practical not moral interest.6 The isolationist approach then is consistent but unfeasible unless we have an equalisandum whose components, if any, can be equal at all times. Since it is implausible to exclude health (as an outcome) as a component and health outcomes cannot be equal at all times, such an approach is implausible. So far I have assumed a simple egalitarian principle of justice. So let us examine next a direct application of a complex principle of justice to the area of health. Recall that on the isolationist approach we are applying the same principle of justice directly to a specific good as well as to the overall one. If our theory of justice combines an equality principle with other considerations, like responsibility for instance, as in the case of luck egalitarianism, only some inequalities will be deemed unjust. Such an approach would be exemplified by the application of a luck egalitarian principle or a (Rawlsian) principle of fair equality of opportunity (FEO) to the area of health and has in fact been taken by some theorists.7 Segall helpfully summarizes these two applications, respectively: Equality of opportunity for health: it is unfair for an individual to end up less healthy than another if she invested at least as much effort in looking after her health FEO for health: it is unfair for an individual to end up less healthy than another if she invested at least as much effort in looking after her health provided that she has at least as good a genetic disposition as that other person (Segall, 2010a: 99). Let us take the luck egalitarian account first. It does not require strict equality in health, so it is not unfeasible, but it requires that (individual) health outcomes match the individuals’ effort for health. This is inconsistent with the application of the same principle to the overall good because (luck egalitarian) justice in health would require upsetting the just overall distribution. This is because a person's health is determined by three types of factor: natural (genetic), social and personal choice or individual behaviour. Given the requirement that health outcomes not be influenced by anything other than effort, this approach seems to recommend that the effects of social factors on health be neutralized. If social factors have an influence on health outcomes, aside from their influence on individual behaviour, health outcomes do not track one’s effort in looking after their health. The correlation between socio-economic outcomes and health outcomes is now well documented, even though it is still not entirely clear what the causal pathways are. But, if we grant that socio-economic factors have a causal influence on health outcomes that is not mediated through individual behaviour, matching health outcomes to individual effort for health requires neutralizing the influence of these social factors. This makes the application of a complex principle of justice to health inconsistent. If the complex egalitarian principle is applied to G, this will result in a certain distribution of the social determinants of health (SDH), which will therefore be just but probably unequal. If the application of the principle to a specific good like health recommends that the SDH be redistributed, this will upset the overall just distribution. It might be replied that justice in health does not require the redistribution of the SDH, since the effects of SDH on health outcomes can be neutralized by providing healthcare. But there are, of course, certain health deficits that may be caused by SDH that cannot be remedied. So the only way to neutralize the impact of SDH on health is by redistributing the SDH. But if the socio-economic inequalities in question are not unjust, redistribution may create an injustice.8 So, the application of a principle in one area conflicts with the application of the same principle in a different one which makes this approach inconsistent. Furthermore, this approach ‘risks imposing burdens on people who experience unchosen disadvantage in every sphere of life except health, thus increasing rather than decreasing the extent to which their lives as a whole reflect unchosen circumstances’ (Albertsen and Knight, 2015: 166). It may again be replied that this approach does not have this implication. Some of those who support this approach (e.g. Segall) concede that, if the SDH are fairly distributed, resulting social inequalities in health are not unjust. But, in that case, the direct application of a luck egalitarian principle to a specific area is simply unwarranted; equal opportunity for health cannot be ensured unless these factors are not allowed to cause certain health outcomes. This is to say that equal opportunity for health cannot be satisfied by either remedying or compensating for health deficits, even when this is possible. If indeed social factors, such as socio-economic factors, education and social rank do indeed cause bad health, certain individuals will not have an equal opportunity for health even if they had an equal opportunity for these factors. The situation is of course similar with the application of a general principle of FEO directly to health. This would allow health outcomes to track luck, but it would not allow socio-economic factors to influence health. But inasmuch as the same principle is applied to the distribution of socio-economic factors, its application to health is inconsistent with its application overall.9 So the direct application of a complex principle of justice to health is inconsistent. This means that, on any of these theories of justice, residual health inequalities, that is, health inequalities that result from a just distribution of the SDH, cannot be deemed unjust, at least not in the sense employed here. One can nevertheless maintain that they are unjust or unfair but do not require rectification in which case this view has no public policy implications. I will next examine the integrationist approach to health inequalities. Egalitarian Justice and Health The integrationist approach applies the principle of justice to the overall good or distribution and the thought here is that we might be able to derive implications for a specific area, such as health, from a general theory of justice. This can be a very complex task and one that should not be undertaken with philosophical means alone. Norman Daniels seems to propose such an approach in that he wants to elaborate or expand on Rawls’s theory in a way that would take account of health.10 Daniels actually takes a two-pronged approach to the issue of health and health inequalities within the framework of a Rawlsian theory. Health disparities are thus evaluated, on the one hand, by looking backward so to speak, to their causes, and, on the other hand, by looking forward, to what they might contribute to. On a backward-looking approach, health inequalities are unjust if their causes, that is the distribution of the socio-economic factors is unjust. It may be worth clarifying here that Daniels does not claim that residual health inequalities are unjust. He admits that once the two principles of justice are implemented and socio-economic inequalities, albeit greatly reduced, are justified, resulting inequalities in health are not unjust. On a forward-looking approach, he considers the role that health plays in fulfilling one of Rawls’s principles of justice, namely FEO. He argues that, because health is instrumental to (effective) opportunity, maintaining equal opportunity requires meeting people’s health needs, so that they attain and maintain the same level of normal functioning. An integrationist luck egalitarian approach to justice and health would work in similar ways, although nobody has proposed such an approach to my knowledge. Assuming that the luck egalitarian subscribes to an overall principle of equality of opportunity for welfare (EOW) or access to advantage, the integrationist luck egalitarian approach to justice in health would require that health outcomes be (re)distributed so as to ensure EOW. Thus, on both the Rawlsian and the luck egalitarian integrationist approach, the justice of a health distribution depends on its contribution to achieving a just distribution overall. On the face of it, this kind of approach seems unproblematic in terms of consistency. But inasmuch as it is consistent, it does not have anything distinctive to say about a particular area; it is merely a general theory of justice. Conversely, inasmuch as it says anything about a particular area, it may rest on some problematic assumptions that undermine the general egalitarian principle envisaged. Let me explain this point first in relation to the application of the Rawlsian account to health. Daniels seeks to extend Rawls's principle of FEO to cover health. He claims that (good) health is instrumental to opportunities and, since one overall principle of the Rawlsian theory of justice is FEO, he argues that FEO requires meeting people’s health needs. Thus, he claims, the FEO principle requires the provision of (universal) healthcare. His argument has two main premises: (i) (good) health is required to secure the fair share of opportunity that individuals are due under the principle of FEO and (ii) (universal) healthcare is required to secure good health. The second premise is vulnerable to various criticisms (Sreenivasan, 2007); but here I will be mainly concerned with the first one. Presumably, a similar premise must be present in the indirect luck egalitarian account. The premise under discussion seems plausible on the face of it. It seems clear that bad health diminishes people's share of opportunities or perhaps, more precisely, their ability to take advantage of them. So health is instrumental to opportunity. But, as Sreenivasan points out, ‘we are not entitled to infer “violation of equal opportunity” merely from “loss of health” (22) since bad health may diminish someone’s share of (effective) opportunities but it need not diminish their fair share at the time when they suffer health shortfalls’. Thus, the first premise requires that the share of opportunity be interpreted in relative terms, so ‘a fair share of opportunity is defined in comparison to the shares held by others in society’.11 But it is not clear that Rawlsian FEO entails equal shares of opportunity throughout people’s lives, at least not in the broad sense of opportunity that Daniels uses. Of course, Rawls’s principle of FEO applies quite narrowly to jobs, and careers and opportunity in this sense must remain equal; the thought is, I take it, that people’s career prospects, which in turn determine to a great extent how their lives go overall, should not be influenced by arbitrary factors such as race, religion, sex or indeed class. But this limited FEO principle would not give us the kind of conclusions that Daniels wants to draw about health. However, Daniels actually modifies, without much argument, Rawls’s principle of FEO, which he admits is problematic. Daniels uses the broader notion of a ‘normal opportunity range’, which is the array of life plans reasonable persons are likely to develop for themselves (Daniels, 2008: 43). This seems closer to the notion of EOW (over a lifetime) that luck egalitarians employ; if this is the principle that is employed, it is difficult to see why the contribution that health makes to opportunity should be taken into account but brute luck should not (Segall, 2010b: 348). But Daniels rejects the luck egalitarian thought that natural talents should also not be allowed to influence individuals’ opportunity for well-being. This forward-looking integrationist approach then is unsuccessful. If FEO is interpreted in the narrow sense intended by Rawls, it does not support the conclusion that justice requires meeting people’s health needs. If FEO is interpreted in a broader sense, it would only support that conclusion if it can be shown that people’s shares of opportunity must remain equal throughout their lives. The more general lesson we should draw from this discussion is that, although this may be a coherent way of ‘applying’ a general theory of justice to a specific area, it will not necessarily deliver the conclusions we may intuitively want to endorse for that area. Stretching the theory to try to accommodate those conclusions means effectively starting with an account of partial justice and expanding that into a theory of justice. But this is no longer an integrationist approach; it is simply a disguised and unsupported isolationist one. It then seems that the only sense in which Rawls’s theory can be ‘applied’ to health is in the backward-looking way, i.e. by pointing out the implications that implementing his principles of justice would have for health, and Daniels argues that it would reduce (social) inequalities in health. Since the Rawlsian principles of justice happen to regulate (most of) the SDH, a Rawlsian distribution would reduce the inequalities in these social determinants and would thus flatten the social gradient. This approach is unproblematic, but it also fails to tell us anything about health specifically and especially about just health inequalities, contrary to what Daniels asserts: ‘If Rawls’s principles constitute a fair distribution of these socially controllable factors affecting health, then we have made some headway in deciding which health inequalities are unjust’ (Daniels, 2008: 23). But all this approach is going to tell us is that health inequalities are unjust when caused by an unjust distribution of the SDH.12 In that sense, it has nothing distinctive to say about health inequalities as such, or ‘residual’ health inequalities, that is inequalities in health whose causes are fair. It cannot evaluate them in isolation from their causes and information about the pathways leading from social factors to health. Daniels accepts that ‘using this approach one might say that inequalities in health that remain after a fair distribution of other goods should count as acceptable or fair inequalities’.13 I would go further and say that under this approach, inequalities in health or any other specific good or area are of no concern to the political theorist, although pointing out that reducing socio-economic inequalities would contribute to reducing health inequalities and/or improving population health might help the politician make the case for a Rawlsian principle of distribution. But it should be clear that it is the socio-economic inequalities that are unjust not the health inequalities they might give rise to. So it is not clear why we would even attempt to establish what justice in health requires on this kind of approach. Daniels agrees that ‘once with recognise the importance of the SDH for levels of population health and its distribution, we cannot talk about a theory of justice for health in isolation from an overall theory of justice’ (Daniels, 2008: 37). But he maintains that pointing out the health implications of various policies is significant, presumably politically rather than morally. It remains unclear though why this is the case if health is not special; on the contrary, it seems counterproductive, since it suggests that an inegalitarian policy is objectionable in virtue of its effects on health rather than in itself. Let me now turn briefly to an integrationist luck egalitarian approach. Luck egalitarianism, I assume, sees opportunity for welfare or access to advantage as the equalisandum, and this entails a certain distribution of income and wealth, i.e. the SDH, which is fair. But we have established that once the SDH are fairly distributed, there is no reason to be concerned with inequalities in health. Departures from equal shares of opportunity for welfare are justified if they are due to people’s own choices. However, the distinctive feature of luck egalitarianism is the additional claim that luck cannot justify such departures, so disadvantages due to luck should be compensated. So, to the extent that health deficits are due to bad luck and they detract from one’s fair share of opportunity (for welfare), they should be remedied or compensated for.14 The question is then how should we treat residual social inequalities in health? They are not due to one’s choices about health, but they are arguably due to choices about their social determinants. When health outcomes are direct causal consequences of people’s socio-economic circumstances, that is, they are not mediated through individual behaviour, there seems to be no reason to be concerned with those (unequal) health outcomes. If individuals are responsible for their socio-economic circumstances and these circumstances determine certain health outcomes, it seems that they are responsible for all the outcomes that are direct consequences of those circumstances. Admittedly, this is surprising; the luck egalitarian might be expected to claim the exact opposite, namely, that, inasmuch as socio-economic circumstances determine health outcomes, individuals cannot be held responsible for their health, since they have no control over it as in Segall’s account examined above. However, the thought that one is responsible for all the direct consequences of one’s choices seems implicit in the luck egalitarian’s choice of equalisandum, i.e. opportunity for welfare. As long as opportunities are equalized, the fact that choices result in different levels of welfare does not concern the luck egalitarian, I take it. But if we claim that the effects of these social factors on health should be neutralized, it seems that we deny either that people can be held responsible for the outcomes of their choices. Now, it seems to me that there is some logical space here for an argument that the luck egalitarian can pursue. In particular, one could examine further the causal link between socio-economic factors and health and/or the account of responsibility presupposed there. If it is the case that the appropriate account of responsibility entails that certain (health) effects must be compensated for, if caused by socio-economic factors, we may have an account that has a distinctive contribution to make to this particular area. However, until this space is filled, the luck egalitarian who adopts an integrationist approach to partial inequalities does not seem to have anything distinctive to say about health or indeed other specific goods.15 This is not to say that luck egalitarians should not be interested in the implications that the theory has in the area of health. Indeed, there is a growing literature working out these implications and/or responding to objections that point out the counter-intuitiveness of the potential implications. A convincing response would, however, involve engaging with the core tenets of luck egalitarianism rather than isolating the area of health and seeking a luck egalitarian principle merely for that area as in the isolationist approach. At the same time, the luck egalitarian does not have anything distinctive to say about the distribution of health independently of the distribution overall, i.e. the equalisandum. The conclusion is then that there is no basis for a theory of justice in health. A theory of justice can only be a general one, and what justice requires in specific areas will have to be worked out subsequently for each and every case. This may not be very straightforward and would certainly require engagement with other areas of social sciences. So one lesson to learn from this is that no clear policy implication can be drawn from accounts of partial justice. But egalitarians may have good reasons to examine inequalities that arise in different areas. By this, I mean that they have a reason to be interested in but not be concerned with, at the bar of justice, with partial inequalities. Partial inequalities may be observable indicators of injustices, but they cannot be the location of injustice so to speak. A pragmatic concern with specific inequalities is justified, but there can be no question of justice in health, or any other specific goods; there is only a question of justice. Conclusion I argued here that attempts to formulate principles of (distributive) justice for a specific area such as health are misconceived. An egalitarian theory of justice might give us a reason to be concerned with a specific area, but applying an egalitarian principle of justice to health is only possible inasmuch as other components of well-being can be distributed equally at all times, which is implausible. An integrationist approach to justice and health is not problematic, but it does not have anything distinctive to say about a specific good and its distribution, so in this sense it is not a theory of partial justice. I suggested, however, that a luck egalitarian account might hold some promise, especially for the area of health. Such an account would not entail that inequalities in specific goods are unjust but may show why they are of interest for the egalitarian. Thus, I suggest that egalitarians must start with an account of (overall) justice and work out the implications it has for different areas. This kind of exercise must be fully ‘integrationist’, that is, it must pay attention to the implications the theory has for all relevant areas to avoid issuing conflicting recommendations. The article does not have direct implications for public policy; on the contrary, it suggests that no such implications can be drawn from simply looking at specific inequalities. This may sound like common sense, but unfortunately many arguments proceed as though the mere existence of health inequalities is an injustice that ought to be rectified. Of course, in the real world, inequalities of health, especially inequalities between social groups, are unjust because their causes are unjust. But it is unhelpful to suggest that they are unjust because of their effects on health rather than in themselves. This would encourage the same approach in each specific area, which would result in conflicting policy recommendations. In other words, the ministry of health and the ministry of education would each favour an overall distribution that the other would reject when both should be aiming for a just overall distribution. Footnotes 1. I am borrowing this terminology from Simon Caney (Caney, 2012). 2. Tobin does not seem to have a reason for his ‘specific egalitarianism’ other than the fact that it seems to reflect the society’s sensibilities. See also Caney’s discussion of Tobin in Caney, 2012: 272–276. 3. Ibid, 208. 4. Ibid, 209. 5. To be clear, this only holds for what we might call ‘intrinsic’ egalitarianism, i.e. a view that includes the principle that equality is intrinsically good. Many versions of telic egalitarianism probably subscribe to the broader idea that equality has final, though not intrinsic, value, which probably does not value the same implication. Elaborating on this point may take me too far afield but for the distinction between final and intrinsic value and its implications, see Olson (2004). Arguably, Parfit refers here to intrinsic egalitarianism (cf. Hirose, 2015). See also Preda, 2017. 6. Hausman looks in some details at considerations that count against measuring health inequalities as a proxy for overall inequalities (Hausman, 2007, pp, 60–65). Nevertheless, his view is that incompensable health inequalities do indicate overall inequalities and are thus pro tanto (or prima facie) unjust (Hausman, 2013). I would reject the claim that they are unjust; the injustice is located with the overall inequalities. 7. Anand and Peter, 2000; Segall, 2010a. The second approach also seems to the one taken by many epidemiologists who argue for the redistribution of the SDH on the basis that equity in health requires neutralizing the effect of the SDH. See for example Whitehead, 1990. Daniel Weinstock calls this approach ‘piecemeal’ and also argues against it but on different grounds from me (Weinstock, 2015). 8. I say ‘may’ because some luck egalitarians, and certainly Segall, may want to claim that only inequalities are bad and thus unjust while equality is never bad. So redistributing to equalize the SDH may not be unjust even though the previous distribution was just. I cannot go here into the reasons for rejecting this claim. 9. Of course, Rawls’s principle of fair equality of opportunity applies to jobs and careers specifically, not to the overall distribution. So it is surprising that Segall formulates this Rawlsian approach. 10. Daniels’s view has been discussed and criticized quite a lot in the past, and I do not aim to review those arguments. Some have focused on his claim that health is special (Segall, 2007; Wilson, 2009). It seems that the specialness thesis only concerns healthcare, and the argument made here focuses on inequalities in health outcomes between individuals. 11. Ibid., 22. 12. It is actually not clear to me that unfairness is ‘transferred’ in this way from one inequality to another, but I will leave this question aside here. 13. Idem. 14. When this is the case, it is a rather complex question, which I cannot attempt to answer here. 15. Education may be an exception here, since it is more directly linked with equality of opportunity. Acknowledgements The author would like to thank the participants at the workshop on ‘Egalitarianisms: current debates’, McGill, March 30-31, 2012 and the audiences at the panel on ‘What is Ideal theory?’ at the conference on ‘Ideals and Reality’, Newport, 11–13 April 2012, the panel on political philosophy at the Joint Sessions of the Mind and Aristotelian Society, Stirling, July 2012, the Nuffield College Workshop, November 2015 and the Ethox Centre Seminar, November 2015 as well as Anca Gheauş, Shlomi Segall, Adam Swift, Kristin Voigt and Gry Wester and the referees and especially the associate editors of this journal for very helpful written comments on earlier drafts. The author is also especially grateful to Gopal Sreenivasan and Jo Wolff for listening to and commenting on this article several times. References Albertsen A. , Knight C. ( 2015 ). A Framework for Luck Egalitarianism in Health and Health Care . Journal of Medical Ethics , 41 , 165 – 169 . 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Google Scholar Crossref Search ADS Whitehead M. (ed.) ( 1990 ). The Concepts and Principles of Equity and Health . Copenhagen : World Health Organisation . Wilson J. ( 2009 ). Not so Special after All? Daniels and the Social Determinants of Health . Journal of Medical Ethics , 35 , 3 – 6 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Public Health Ethics – Oxford University Press

Published: Nov 1, 2018

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