Skip to main content Accessibility help
Hostname: page-component-846f6c7c4f-xq4m6 Total loading time: 0.347 Render date: 2022-07-06T22:22:23.024Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Article contents

Meaning, Medicine, and Merit

Published online by Cambridge University Press:  23 September 2019

Andreas L. Mogensen*
University of Oxford
*Corresponding author. Email:


Given the inevitability of scarcity, should public institutions ration healthcare resources so as to prioritize those who contribute more to society? Intuitively, we may feel that this would be somehow inegalitarian. I argue that the egalitarian objection to prioritizing treatment on the basis of patients’ usefulness to others is best thought of as semiotic: i.e. as having to do with what this practice would mean, convey, or express about a person's standing. I explore the implications of this conclusion when taken in conjunction with the observation that semiotic objections are generally flimsy, failing to identify anything wrong with a practice as such and having limited capacity to generalize beyond particular contexts.

Copyright © Cambridge University Press 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1 Childress, James, ‘Putting Patients First in Organ Allocation: An Ethical Analysis of the US Debate’, Cambridge Quarterly of Health Ethics 10 (2001), pp. 365–76CrossRefGoogle Scholar.

2 Broome, John, ‘Fairness’, Proceedings of the Aristotelian Society 91 (1990), pp. 87101CrossRefGoogle Scholar.

3 Thanks to an anonymous referee for suggesting this example.

4 Skitka, Linda and Tetlock, Philip, ‘Allocating Scarce Resources: A Contingency Model of Distributive Justice’, Journal of Experimental Social Psychology 28 (1992), pp. 491522CrossRefGoogle Scholar.

5 McKie, John and Richardson, Jeff, ‘Social Preferences for the Inclusion of Indirect Benefits in the Evaluation of Publicly Funded Health Services: Results from an Australian Survey’, Health Economics, Policy and Law 6 (2011), pp. 449–68CrossRefGoogle ScholarPubMed.

7 Arneson, Richard, ‘Equality and Equal Opportunity for Welfare’, Philosophical Studies 56 (1989), pp. 7793CrossRefGoogle Scholar; Arneson, Richard, ‘Luck Egalitarianism Interpreted and Defended’, Philosophical Topics 32 (2004), pp. 120CrossRefGoogle Scholar; Cohen, G. A., Rescuing Justice and Equality (Cambridge, MA, 2008)Google Scholar; Dworkin, Ronald, Sovereign Virtue: The Theory and Practice of Equality (Cambridge, MA, 2002)CrossRefGoogle Scholar; Rakowski, Eric, Equal Justice (Oxford, 1993)CrossRefGoogle Scholar; Segall, Shlomi, Why Inequality Matters: Luck Egalitarianism, its Meaning and Value (Cambridge, 2016)CrossRefGoogle Scholar; Tan, Kok-Chor, ‘A Defense of Luck Egalitarianism’, Journal of Philosophy 105 (2008), pp. 665–90CrossRefGoogle Scholar.

8 Parfit, Derek, Equality or Priority? The Lindley Lecture (Lawrence, KS, 1991)Google Scholar.

9 Nozick, Robert, Anarchy, State, and Utopia (Oxford, 1974), pp. 30–3Google Scholar; Kamm, F. M., ‘Harming Some to Save Others’, Philosophical Studies 57 (1989), pp. 227–60CrossRefGoogle Scholar.

10 Walzer, Michael, Spheres of Justice: A Defence of Pluralism and Equality (Oxford, 1983)Google Scholar.

11 Walzer, Spheres of Justice, p. 75.

12 Brock, Dan, ‘Separate Spheres and Indirect Benefits’, Cost Effectiveness and Resource Allocation 1 (2003)CrossRefGoogle ScholarPubMed; Broome, ‘Fairness’; Kornhauser, Lewis and Sager, Lawrence, ‘Just lotteries’, Social Science Information 27 (1988), pp. 483516CrossRefGoogle Scholar.

13 Henning, Tim, ‘From Choice to Chance? Saving People, Fairness, and Lotteries’, The Philosophical Review 124 (2015), pp. 169206CrossRefGoogle Scholar.

14 Anderson, Elizabeth, ‘What is the Point of Equality?’, Ethics 109 (1999), pp. 287337CrossRefGoogle Scholar; Anderson, Elizabeth, ‘The Fundamental Disagreement between Luck Egalitarians and Relational Egalitarians’, Canadian Journal of Philosophy 40 (2010), pp. 123Google Scholar; Scheffler, Samuel, ‘What is Egalitarianism?’, Philosophy and Public Affairs 31 (2003), pp. 539CrossRefGoogle Scholar; Scheffler, Samuel, ‘The Practice of Equality’, Social Equality: On What It Means To Be Equals, ed. Fourie, Carina, Schuppert, Fabian, and Wallimann-Helmer, Ivo (Oxford, 2015), pp. 2144Google Scholar.

15 Anderson, ‘What is the Point of Equality?’, p. 313.

16 Lippert-Rasmussen, Compare Kasper and Lauridsen, Sigurd, ‘Justice and the Allocation of Healthcare Resources: Should Indirect, Non-health Effects Count?’, Medicine, Health Care and Philosophy 13 (2010), pp. 237–46CrossRefGoogle ScholarPubMed.

17 Simon Blackburn, ‘Am I Right?’, The New York Times 21 Feb. 1999; Philip Pettit, ‘Doing unto Others’, Times Literary Supplement, 25 June 1999.

18 Scanlon, T. M., What We Owe to Each Other (Cambridge, MA, 1998), p. 391, n. 21Google Scholar.

19 Thurgood Marshall, ‘Concurrence-dissent’, in City of Cleburne v. Cleburne Living Center, Inc., 473 U.S. 432 (1985).

20 Grice, H. P., ‘Utterer's Meaning, Sentence-Meaning, and Word-Meaning’, Foundations of Language 4 (1968), pp. 225–42Google Scholar.

21 Anderson, Elizabeth and Pildes, Richard, Richard, , ‘Expressive Theories of Law: A General Restatement’, University of Pennsylvania Law Review 148 (2000), pp. 1503–75CrossRefGoogle Scholar.

22 Abell, Catharine, ‘Canny Resemblance’, Philosophical Review 118 (2009), pp. 183223CrossRefGoogle Scholar; Hopkins, Richard, Picture, Image, and Experience: A Philosophical Inquiry (Cambridge, 1998)Google Scholar; Hyman, John, ‘Depiction’, Royal Institute of Philosophy Supplement 71 (2012), pp. 129–50CrossRefGoogle Scholar; Peacocke, Christopher, ‘Depiction’, Philosophical Review 96 (1987), pp. 383410CrossRefGoogle Scholar.

23 As per Abell, ‘Canny Resemblance’, Hopkins, Picture, Image, and Experience.

24 Hellman, Deborah, ‘Racial Profiling and the Meaning of Racial Categories’, Contemporary Debates in Applied Ethics, 2nd edn., ed. Cohen, A. I. and Wellman, C. H. (Malden, MA, 2014), pp. 232–43Google Scholar.

25 Eidelson, Compare Benjamin, Discrimination and Disrespect (Oxford, 2015), pp. 173222CrossRefGoogle Scholar.

26 Hellman, ‘Racial Profiling and the Meaning of Racial Categories’, p. 237.

27 Goodman, Nelson, Languages of Art: An Approach to a Theory of Symbols (Indianapolis, IN, 1968), pp. 35Google Scholar.

28 Daniels, Norman, Just Health Care (Cambridge, 1985)CrossRefGoogle ScholarPubMed; Daniels, Norman, Just Health: Meeting Health Needs Fairly (Cambridge, 2007)CrossRefGoogle Scholar.

29 Walzer, Spheres of Justice, pp. 64–83.

30 Aneurin Bevan, ‘Proposals for a National Health Service’, Cabinet Memorandum, 13 December 1945, <>.

31 Bevan, Aneurin, In Place of Fear (London, 1952), p. 76Google Scholar.

32 NHS Constitution for England, p. 3.

33 A notable exception being Miller, David, Principles of Social Justice (Cambridge, MA, 1999)Google Scholar.

34 Bamfield, Louise and Horton, Tim, Understanding Attitudes to Tackling Economic Inequality (York, 2009)Google Scholar.

35 McKie and Richardson, ‘Social Preferences for the Inclusion of Indirect Benefits’.

36 Boehm, Christopher, Hierarchy in the Forest: The Evolution of Egalitarian Behavior (Cambridge, MA, 1999)CrossRefGoogle Scholar.

37 Ball, Richard and Chernova, Kateryna, ‘Absolute Income, Relative Income, and Happiness’, Social Indicators Research 88 (2008), pp. 497529CrossRefGoogle Scholar.

38 Marmot, Michael, ‘Health in an Unequal World’, The Lancet 368 (2006), pp. 2081–94CrossRefGoogle Scholar.

39 Brennan, Jason and Jaworski, Peter Martin, ‘Markets without Symbolic Limits’, Ethics 125 (2015), pp. 1053–77CrossRefGoogle Scholar.

40 Kamm, F. M., Morality Mortality, vol. 1: Death and Whom to Save From It (Oxford, 1993)Google Scholar.

41 Brock, ‘Separate Spheres and Indirect Benefits’.

42 Cohen, G. A., Self-Ownership, Freedom, and Equality (Cambridge, 1995), pp. 239–40CrossRefGoogle Scholar; Parfit, Derek, On What Matters, vol. 1 (Oxford, 2011), pp. 212–13CrossRefGoogle Scholar.

43 Horton, Joe, ‘The All or Nothing Problem’, Journal of Philosophy 114 (2017), pp. 94104CrossRefGoogle Scholar; MacAskill, William, Doing Good Better: A Radical New Way to Make a Difference (London, 2015)Google Scholar; Pummer, Theron, ‘Whether and Where to Give’, Philosophy and Public Affairs 44 (2016), pp. 7795CrossRefGoogle Scholar; Singer, Peter, The Most Good You Can Do: How Effective Altruism is Changing Ideas about Living Ethically (New Haven, CT, 2015)Google Scholar.

44 Jamison, Dean, Gelband, Hellen, Horton, Susan, Jha, Prabhat, Laxminarayan, Ramanan, Mock, Charles, and Nugent, Rachel (eds.), Disease Control Priorities: Improving Health and Reducing Poverty (Washington D.C., 2018)Google ScholarPubMed; Ord, Toby, ‘Considering Cost-Effectiveness: The Moral Perspective’, Priority Setting in Health: Building Institutions for Smarter Public Spending, ed. Glassman, Amanda and Chalkidou, Kalipso (Washington D.C., 2012), pp. 1519Google Scholar.

45 Piaget, Jean, The Child's Conception of the World, trans. Tomlinson, Joan and Tomlinson, Andrew (London, 1929)Google Scholar.

46 Cimpian, Andrei and Salomon, Erika, ‘The Inherence Heuristic: An Intuitive Means of Making Sense of the World, and a Potential Precursor of Psychological Essentialism’, Behavioral and Brain Sciences 37 (2014), pp. 461–80CrossRefGoogle Scholar; Gabbenesch, Howard, ‘The Perception of Social Conventionality by Children and Adults’, Child Development 61 (1990), pp. 2047–59CrossRefGoogle Scholar.

47 For valuable comments on previous drafts of this article, I am grateful to Hilary Greaves, William MacAskill, Tom Sinclair, Christian Tarsney, and Teru Thomas, as well as the audience for my presentation at University College Dublin on 25 October 2018. I'd also like to thank two anonymous referees at Utilitas for their helpful comments and suggestions.

Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Meaning, Medicine, and Merit
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Meaning, Medicine, and Merit
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Meaning, Medicine, and Merit
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *