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Health, Luck and Moral Fallacies of the Second Best

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Abstract

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal responsibility would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts.

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Notes

  1. A recent study from RTI/Centers for Disease Control and Prevention estimates that in the United States, the healthcare costs of obesity alone may be as high as $147 billion annually. See Finkelstein et al. (2009).

  2. Veatch (1980), Rakowski (1991), Arneson et al. (1990), Roemer (1993), Cappelen and Norheim (2005).

  3. Segall (2010).

  4. A 2006 Wall Street Journal/Harris poll found that 53% of Americans believe it is “fair” for those take risks with their health to pay more in insurance premiums, deductibles and co-pays. Wall Street Journal Online/Harris Interactive Health-Care Poll (2006). West Virginia recently implemented reforms to its Medicare system that entail inferior access to care for those who are deemed responsible for their healthcare needs. See State of West Virginia (2009). For a discussion of the West Virginia plan, see Steinbrook (2006) and Bishop and Brodkey (2006). See also Schmidt (2007) and Meulen (2008).

  5. Other forms of public accountability might include lower priority in the rationing of scarce health-related goods, such as transplantable organs. My argument against financial liability tells equally against these other forms of accountability; the argument is framed in terms of financial liability for ease of exposition.

  6. Omran (1971).

  7. While the current debate reflects developments of the past century, the topic of moral responsibility for health has a considerably longer history. See Reiser (1985), Leichter (2003), Brandt (1997).

  8. Knowles (1997).

  9. Crawford (1979).

  10. Wikler (2007).

  11. Wikler (2004).

  12. Dworkin (2002).

  13. (1) The reasonableness clause, in this form, is owed to Segall and seems to be the most elegant way of capturing the underlying intuitions (Segall 2010, p. 13). (2) The “limit or…” language is necessary to accommodate Dworkin—who has sought to dissociate himself from the “luck egalitarian” label. He emphasizes that his goal is “not to eliminate the consequences of brute bad luck…but only to mitigate it to the degree and in the way that prudent insurance normally does. The strategy aims to put people in an equal position with respect to risk, rather than to negate risk altogether.” [Dworkin (2000) p. 341 ff].

  14. Sen (1992); Roemer (1993); Roemer (1998); Cohen (1989); Arneson (1989).

  15. Rakowski (1991).

  16. Arneson (1990, p. 187).

  17. Roemer (1993).

  18. Cappelen and Norheim (2005).

  19. Segall (2010, Chap. 5).

  20. Dworkin (2000) p. 491 fn 4

  21. Anderson (1999) p. 295; Scheffler (2003) p. 19.

  22. Segall (2007), Arneson (2002), Dworkin (2002) p. 114.

  23. Arneson (1997 p. 239), Rakowski (1991), Dworkin (2002, p. 114).

  24. See Cappelen and Norheim (2005).

  25. A 2001 Rand Corporation study found, for example that “obese individuals spend approximately 36% more than the general baseline population on health services, compared with a 21% increase for daily smokers” and “not only does obesity have more negative health consequences than smoking, drinking, or poverty, it also affects more people. Approximately 23% of Americans are obese. An additional 36% are overweight. By contrast, only 6 percent are heavy drinkers, 19% are daily smokers, and 14% live in poverty.” See Sturm (2002); Sturm and Wells (2001).

  26. I also assume for simplicity that demand is inelastic relative to price.

  27. The main point of structural disanalogy is that while we assume that meters can accurately identify moderate users, there is no socially acceptable means of identifying non-risk takers (i.e., of distinguishing them from undetectable risk takers). Thus, to tighten up the analogy, we can imagine that the moderate users on the east side are treated just as everyone on the west side is treated—and that these three groups pay $.40 per day for water, while the big users on the east pay $1.00 per day.

  28. See n. 26 above.

  29. I note again the disanalogy: there are no identifiable winners under an option-luck add-on system because no one can be publicly identified as a non risk-taker. However there are identifiable losers, and that suffices to make the point about publicity.

  30. It could be objected that, by parity of reasoning, it would be better to audit no tax returns, or to punish no tax-cheats, since only a small minority of them can be detected and punished through any viable system of audits. It is impossible to treat like cases alike if we punish only that minority. There are two crucial differences. First, tax audits are (compared to an honor system) a relatively effective deterrent to cheating. This is presumably their main justificatory basis—a forward-looking reason of the sort that I have already acknowledged can in principle justify a role for personal accountability in matters of health. Second, the tax cheat is guilty of a criminal offense, and thus the imposition of fines or punishment can perhaps be justified on retributive grounds. By contrast, the imprudent individual (like the big user of water) has done nothing worthy of retribution (and it would, in any case, seem perverse to use the healthcare system to mete out retributive justice). Thanks to Ole Norheim for this objection.

  31. Lipsey and Lancaster (1956).

  32. Jon Elster, Robert Goodin, Geoffrey Brennan, Bruce Talbot Coram and others have discussed in more general terms the problem of the second best as it applies to normative political theory. See Elster (1993, 1997), Brennan (1993), Goodin (1995), Coram (1996).

  33. There are salient interpretations of P on which both (1) and (2) are true. That is what can lend this fallacy its air of plausibility. For example, a system of criminal punishment subject to appropriate due-process protections seems to satisfy this schema. Yet as we have seen, (2) does not follow from (1).

  34. Dworkin emphasizes that the logic of holding individuals strictly responsible for their option-luck outcomes—what he at one point calls “the bare idea of equality of resources”—presupposes not only that background conditions are just, but also that individuals are equally situated in ways that could never actually obtain (e.g., all are ignorant of their degree of physical and mental ability/disability, of the market value of their talents and of their risk factors for illness; and all are fully informed of the options available to them). Thus, Dworkin’s account never applies the “bare idea” directly. Even as ideal theory he proposes a system of taxation and benefits that would mirror a hypothetical insurance model designed under the foregoing suppositions. See Dworkin (2000, pp. 307–319).

  35. The conclusion of this section can be generalized to cover fairness-based arguments that may not be wedded to the luck-egalitarian framework. Indeed, any fairness-based argument that proceeds from the formal Aristotelian conception of fairness or equity will be vulnerable to the same criticism.

  36. In a society with perfect intergenerational elasticity (i.e., no overall wealth advantage or disadvantage conferred on children by class background), we would expect exactly 20% of the members of each “origin” quintile to end up in each “destination” quintile. By contrast, in the United States over the period 1979–2000, an average of 72% of individuals whose parents were in the lowest two wealth quintiles were themselves in the lowest two wealth quintiles. [Author’s analysis of data taken from Keister (2005), p. 57 Table 2.10]. These numbers provide a fairly straightforward measure of the degree to which opportunity in US society is, by common egalitarian standards, unfairly distributed by class background: 32% of those in the lowest two quintiles would, instead, be in a higher quintile. The data for the United Kingdom are comparable, and the correlation between family socioeconomic background and socioeconomic status is robust even in the most egalitarian societies. See Blanden et al. (2005).

  37. Dworkin does. See note 35 above.

  38. Equality of Opportunity, p. 52

  39. Equality of Opportunity, p. 43 ff. Roemer does not advocate holding individuals fully liable in all cases. The extent of personal liability in his account is a complex matter that need not concern us here.

  40. This is true even for a theory such as Arneson’s “Responsibility Catering Prioritarianism.” According to Arneson, the moral value of helping an individual is greater the worse off she is, but decreases the more responsible she is for her misfortune. Thus, the condition of being worse off does not by itself establish a superior claim to social resources. The most that we can say is that for those who are equally responsible for their condition, the worst off have the strongest claim. See Arneson (2000).

  41. See Wolff and de Shalit (2008).

  42. Keister (2005), p. 57, Table 2.10. See note 37 above for discussion of these data.

  43. Blanden et al. (2005).

  44. This systematic deprivation of the social bases of self esteem is suffered not only by those who, given equality of opportunity, would occupy a higher socioeconomic position than they do, but also by those whose distributive share—measured in narrowly economic terms—is no worse than it would be had they enjoyed perfect equality of opportunity. For the ability to provide for and to anticipate a good future for one’s children is an important basis of self esteem, and the worst off of actual societies are unjustly disadvantaged by the knowledge that their children do not enjoy opportunities equal to those of the children of the better off.

  45. A 1998 study of American adults estimated that smoking, alcohol consumption, body mass index and level of physical activity together accounted for 12–13% of the predictive effect of income on mortality (Lantz et al. 1998). See also Black et al. (1988), Marmot et al. (1984), Davey-Smith et al. (1990).

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Cavallero, E. Health, Luck and Moral Fallacies of the Second Best. J Ethics 15, 387–403 (2011). https://doi.org/10.1007/s10892-011-9109-z

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