Comment on Marchman Andersen et al.: Social inequality in health, responsibility and egalitarian justice

Abstract

In their paper ‘Social inequality in health, responsibility and egalitarian justice’, Marchman Andersen et al. argue that on a luck egalitarian account, personal choices which negatively affect individual health cannot morally justify health inequalities. The authors suggest that even in the case of lifestyle-related diseases, the resulting health inequality is neither just nor desirable, and consequently stress the importance of providing free and equal access to health care to everyone. Much of this argument rests on a definition of personal responsibility as being causally regressive. This is to say that no person can ever be fully responsible for her actions, since the causes for a person’s own choices will at least partly be determined by socio-economic or historical circumstances outside of that person’s control. This, the authors suggest, is morally relevant, since only full responsibility for any action creates conditions under which a person can be held accountable for the consequences. Marchman Andersen et al. propose some important challenges to the concept of luck egalitarianism. Here, two observations regarding the argument shall briefly be discussed. First, the conclusion that the authors reach may in fact be narrower than they claim. They do not so much show that appeals to individual responsibility for health cannot justify health inequalities, as that they point out the incompatibility between a broadly conceived notion of luck egalitarianism and a very specific definition of personal responsibility. The authors acknowledge that the condition of causality regression on which their definition of personal responsibility rests is contested and as a result, the strength of their argument largely depends on whether or not the reader shares their views. More importantly, the argument made here is primarily a specific application of a familiar and more general critique of luck egalitarianism, namely that in order to be consistent, luck egalitarians require a detailed account of what can count as personal responsibility. Of course, we need not share the specific understanding of personal responsibility which the authors outline—but neither are we compelled to take a luck egalitarian approach in the first place, and herein lies the second observation. Luck egalitarianism places a singular focus on personal responsibility as a morally relevant category to establish desert for compensation, and views responsibility as dichotomous. Consequently, luck egalitarianism struggles to make sense of multifactorial causes of disease, and cannot account for varying degrees of individual responsibility which would better capture responsibility for health. It therefore stands to question, if luck egalitarianism is in fact an appropriate distributive theory to apply to health care. To summarise, Marchman Andersen et al. provide an argument which rests on a very narrow definition of personal responsibility, and should probably not lead us to dismiss the role of personal responsibility for health outcomes just yet. Their approach does however highlight some important challenges to luck egalitarianism and underlines the importance of revisiting carefully the conditions under which personal responsibility can be seen to be morally relevant for the allocation of health care.