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Published online by Cambridge University Press:  01 June 2015

Kristin Voigt
Philosophy, and Health and Social Policy, McGill University
Gry Wester
Global Public Health and Primary Care, University of Bergen


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Research Article
Copyright © Social Philosophy and Policy Foundation 2015 

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Previous versions of this essay were presented to the Research Group on Constitutional Studies (RGCS) and to the Montreal Health Equity Research Consortium (MHERC), at McGill University; at the Equality and Public Policy Conference, Ohio University; and at the Center for Interdisciplinary Studies at the University of Bielefeld. We are grateful to the audiences for their helpful comments and suggestions. For detailed written comments, we would like to thank J. Paul Kelleher and Govind Persad. This work was supported by the Canadian Institutes of Health Research (grant no. ROH-115214) and the Fonds de recherche du Québec – Société et culture (grant no. 172569).


1 Most prominently, Daniels, Norman, Just Health Care (Cambridge: Cambridge University Press, 1985).CrossRefGoogle ScholarPubMed

2 See, for example, Daniels, , Just Health: Meeting Health Needs Fairly (Cambridge: Cambridge University Press, 2008)Google Scholar and Segall, Shlomi, Health, Luck, and Justice (Princeton, NJ: Princeton University Press, 2009).CrossRefGoogle Scholar

3 On education, see Anderson, Elizabeth, “Fair Opportunity in Education: A Democratic Equality Perspective,” Ethics 117, no. 4 (2007)CrossRefGoogle Scholar; on command structures in workplaces, see Anderson, , “Expanding the Egalitarian Toolbox: Equality and Bureaucracy,” Aristotelian Society Supplementary Volume 82, no. 1 (2008)CrossRefGoogle Scholar; on income distribution, see Schemmel, Christian, “Why Relational Egalitarians Should Care About Distributions,” Social Theory and Practice 37, no. 3 (2011).CrossRefGoogle Scholar

4 Much of the relational critique is leveled against so-called luck egalitarian interpretations of distributive justice. According to luck egalitarianism, distributive inequalities are unfair unless they can be traced to choices for which individuals should be held responsible. While various aspects of luck egalitarianism have been criticized in the literature, the relational objection we are considering here applies not only to luck egalitarianism but to any theory that seeks to assess directly the fairness of distributions. The focus of the relational critique has been on the accounts offered in Dworkin, Ronald, “What Is Equality? Part 2: Equality of Resources,” Philosophy and Public Affairs 10, no. 4 (1981)Google Scholar; Cohen, G. A., “On the Currency of Egalitarian Justice,” Ethics 99, no. 4 (1989)CrossRefGoogle Scholar and Arneson, Richard J., “Equality and Equal Opportunity for Welfare,” Philosophical Studies 56, no. 1 (1989).CrossRefGoogle Scholar

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9 Scheffler, “What Is Egalitarianism?”

10 Pogge, Thomas, “Relational Conceptions of Justice: Responsibilities for Health Outcomes,” in Public Health, Ethics and Equity, ed. Anand, Sudhir, Peter, Fabienne, and Sen, Amartya (Oxford: Oxford University Press, 2011)Google Scholar; Schemmel, “Why Relational Egalitarians Should Care About Distributions”; “Distributive and Relational Equality.”

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13 Scheffler, “What Is Egalitarianism?”

14 The definition of health is itself a difficult and complex matter, and it is beyond the scope of this paper to discuss the many issues this question raises. We will simply adopt Christopher Boorse’s definition of health as the absence of disease. Disease, in turn is defined as a deviation from “normal species functioning,” where the relevant species functionings are those parts and processes of the organism that contribute to survival and reproduction. See Boorse, Christopher, “Health as a Theoretical Concept,” Philosophy of Science 44, no. 4 (1977).CrossRefGoogle Scholar

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19 Daniels, Just Health Care. See also Dworkin, Ronald, “Justice in the Distribution of Health Care,” McGill Law Journal 38, no. 4 (1993).Google ScholarPubMed In “What Is Equality? Part 1” and “What Is Equality? Part 2,” he also considers the question of the problem of handicaps or how to respond to irremediable health deficits.

20 For an overview of the current literature, see, for example, Braveman, Paula, Egerter, Susan, and Williams, David R, “The Social Determinants of Health: Coming of Age,” Annual Review of Public Health 32 (2011).CrossRefGoogle ScholarPubMed

21 For discussion and different interpretations of the empirical evidence and what it tells us, see for example, Deaton, Angus, “What Does the Empirical Evidence Tell Us About the Injustice of Health Inequalities?” in Inequalities in Health: Concepts, Measures, and Ethics, ed. Eyal, Nir, et al. (Oxford: Oxford University Press, 2013)Google Scholar, Michael Marmot, "Fair Society Healthy Lives," in Inequalities in Health: Concepts, Measures, and Ethics, ed. Nir Eyal, et al.

22 Whether the current evidence base is sufficient to allow the conclusion that interventions addressing different aspects of the social determinants of health do, in fact, have an impact on health and health inequality is another question that epidemiologists disagree on. For relevant discussion, see Kaufman, Jay S. and Harper, Sam, “Health Equity: Utopian and Scientific,” Preventive Medicine 57, no. 6 (2013)CrossRefGoogle ScholarPubMed, Schrecker, Ted, “Can Health Equity Survive Epidemiology? Standards of Proof and Social Determinants of Health,” Preventive Medicine 57, no. 6 (2013).CrossRefGoogle ScholarPubMed

23 Daniels, Just Health, 13.

24 The average number of years a person can expect to live in “full health” — in other words, life expectancy, as adjusted by subtracting years lived in less than full health due to disease, disability, or injury.

25 Defining the concept of health inequality is itself an inherently normative task, which raises a host of philosophical questions. We cannot address these questions in this paper. For discussion, see Harper, Samet al., “Implicit Value Judgments in the Measurement of Health Inequalities,” Milbank Quarterly 88, no. 1 (2010)CrossRefGoogle ScholarPubMed, Hausman, Daniel, “What's Wrong with Health Inequalities?Journal of Political Philosophy 15, no. 1 (2007)CrossRefGoogle Scholar, and Kasper Lippert-Rasmussen, "When Group Measures of Health Should Matter," in Inequalities in Health: Concepts, Measures, and Ethics, ed. Nir Eyal, et al.

26 Bakker, Martijntje and Mackenbach, Johan, Reducing Inequalities in Health: A European Perspective (London: Routledge, 2004).Google Scholar

27 Marmot, Michael, The Status Syndrome: How Social Standing Affects Our Health and Longevity (New York: Times Books, 2004).Google Scholar

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29 Mackenbach, Johan Pet al., “Socioeconomic Inequalities in Health in 22 European Countries,” New England Journal of Medicine 358, no. 23 (2008).CrossRefGoogle ScholarPubMed

30 Anderson, “What Is the Point of Equality?” 317, our emphasis. Scheffler argues along similar lines in “What Is Egalitarianism?” 23.

31 Plug, Iriset al., “Socioeconomic Inequalities in Mortality from Conditions Amenable to Medical Interventions: Do They Reflect Inequalities in Access or Quality of Health Care?BMC Public Health 12, no. 1 (2012)CrossRefGoogle ScholarPubMed; Black, Douglaset al., Inequalities in Health: Report of a Research Working Group (London: Department of Health and Social Security, 1980).Google Scholar

32 Sreenivasan, Gopal, “Health Care and Equality of Opportunity,” Hastings Center Report 37, no. 2 (2007).CrossRefGoogle ScholarPubMed See also Wolff, Jonathan, Ethics and Public Policy: A Philosophical Inquiry (London: Routledge, 2011), chap. 6.Google Scholar

33 Weinstock, “How Should Political Philosophers Think of Health?” 429.

34 Anderson, “What Is the Point of Equality?” 330–31.

35 Ibid., 331, emphasis added.

36 Anderson, Elizabeth S. and Pildes, Richard H, “Expressive Theories of Law: A General Restatement,” University of Pennsylvania Law Review 148, no. 5 (2000).CrossRefGoogle Scholar

37 See, for example, Daniels, Just Health Care.

38 For discussion of such problems as they have recently arisen in the New Zealand context, see Fenton, Elizabeth, “Mind the Gap: Ethical Issues of Private Treatment in the Public Health System,” Journal of the New Zealand Medical Association 124, no. 1334 (2011).Google ScholarPubMed

39 Pogge, “Relational Conceptions of Justice,” 146.

40 “Relational Conceptions of Justice,” 156–57.

41 “Relational Conceptions of Justice,” 156.

42 “Relational Conceptions of Justice,” 156, n. 48.

43 “Relational Conceptions of Justice,” 135.

44 “Relational Conceptions of Justice,” 156, emphasis in original.

45 Ibid.

46 On the question as to whether this assumption might hold in the real world, see Deaton, Angus, “Health, Inequality, and Economic Development,” Journal of Economic Literature 41, no. 1 (2003).CrossRefGoogle Scholar

47 Schemmel, “Why Relational Egalitarians Should Care About Distributions,” 371–72, our emphasis.

48 Pogge, “Relational Conceptions of Justice,”156, emphasis in original.

49 See, for example, Anderson, Elizabeth, The Imperative of Integration (Princeton, NJ: Princeton University Press, 2010).CrossRefGoogle Scholar

50 For example, Daniels, Norman, Kennedy, Bruce, and Kawachi, Ichiro, “Justice Is Good for Our Health,” in Is Inequality Bad for Our Health? ed. Cohen, Joshua and Rogers, Joel (Boston: Beacon Press, 2000)Google Scholar; Peter, Fabienne, “Health Equity and Social Justice,” in Public Health, Ethics, and Equity, ed. Anand, Sudhir, Peter, Fabienne, and Sen, Amartya (Oxford: Oxford University Press, 2004).Google Scholar But see Sreenivasan, Gopal, “Ethics and Epidemiology: Residual Health Inequalities,” Public Health Ethics 2, no. 3 (2009)CrossRefGoogle Scholar and Anand, Sudhir and Peter, Fabienne, “Equal Opportunity,” in Is Inequality Bad for Our Health? ed. Cohen, Joshua and Rogers, Joel (Boston: Beacon Press, 2000)Google Scholar for further discussion of this distinction.

51 Peter, “Health Equity and Social Justice,” 95.

52 For an overview, see Braveman, Egerter, and Williams, “The Social Determinants of Health.”

53 For example, Anderson, “What Is the Point of Equality?” 326; Miller, “Equality and Justice.”

54 Scheffler, “What Is Egalitarianism?” 24.

55 Anderson, “What Is the Point of Equality?” 326.

56 Anderson, The Imperative of Integration.

57 Racism is believed to affect health primarily through socioeconomic factors and material pathways, such as low income, lower quality housing and residential neighborhood, higher exposure to environmental health risks, and so on. See Braveman, Egerter, and Williams, “The Social Determinants of Health.” Some of the negative health effects of being subjected to discrimination have also been attributed to increased stress; see Pascoe, Elizabeth A and Richman, Laura Smart, “Perceived Discrimination and Health: A Meta-Analytic Review,” Psychological Bulletin 135, no. 4 (2009).CrossRefGoogle ScholarPubMed

58 Schemmel, “Why Relational Egalitarians Should Care About Distributions,” 370.

59 Braveman, Egerter, and Williams, “The Social Determinants of Health.”

60 Cutler, David M, Lleras-Muney, Adriana, and Vogl, Tom, “Socioeconomic Status and Health: Dimensions and Mechanisms,” in Oxford Handbook of Health Economics, ed. Glied, Sherry and Smith, Peter (Oxford: Oxford University Press, 2008).Google Scholar

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62 Blacksher, Erika, “Redistribution and Recognition,” Cambridge Quarterly of Healthcare Ethics 21, no. 3 (2012): 326.CrossRefGoogle ScholarPubMed

63 This section draws on Kristin Voigt, “Paternalism and Equality,” Thomas Schramme, ed., New Perspectives on Paternalism and Healthcare (Amsterdam: Springer, forthcoming).

64 Anderson, “What Is the Point of Equality?”

65 Husak, Douglas, “Paternalism and Autonomy,” Philosophy and Public Affairs 10, no. 1 (1981), 4041.Google Scholar

66 Shiffrin, Seana Valentine, “Paternalism, Unconscionability Doctrine, and Accommodation,” Philosophy and Public Affairs 29, no. 3 (2000), 220.CrossRefGoogle Scholar

67 Husak, “Paternalism and Autonomy,” 41.

68 Arneson, Richard J., “Paternalism, Utility, and Fairness,” Revue Internationale de Philosophie 43, no. 170 (1989)Google Scholar; “Joel Feinberg and the Justification of Hard Paternalism,” Legal Theory 11, no. 3 (2005).

69 Voigt, Kristin, “‘If You Smoke, You Stink.’ Denormalisation Strategies for the Improvement of Health-Related Behaviours: The Case of Tobacco,” in Ethics in Public Health and Health Policy: Concepts, Methods, Case Studies, ed. Strech, Daniel, Hirschberg, Irene, and Marckmann, Georg (Amsterdam: Springer, 2013).Google Scholar

70 Also see Kukla, Rebecca, “Ethics and Ideology in Breastfeeding Advocacy Campaigns,” Hypatia 21, no. 1 (2006)CrossRefGoogle Scholar, for information on and discussion of this and similar breast-feeding campaigns.