Luck, Choice, and Rationing Health Care

Posted on January 12, 2015 by

According to some philosophers, a feature that matters for assessing inequalities is how the inequality comes about. One theory that assesses inequalities in this way is presented by Ronald Dworkin in a position called “luck egalitarianism.” According to the luck egalitarian, a factor that matters when assessing inequalities in a given situation –and whether these inequalities are just or not– is whether they came about through calculated choice or not (Dworkin, 1981, p. 293). To clarify the view, if an inequality comes about as a result of an agents’ calculated choices, then according to the luck egalitarian, the inequality is just. The individual has presumably anticipated the consequences of her actions, and when those actions lead to her being worse off than others, then the inequality is fair. If a state of affairs comes about as a result of calculated choices, then this state of affairs is option luck, and is presumably fair. If the inequality comes about as a result of so called “brute luck,” then presumably the inequality is unfair. It is noteworthy that this view takes into account how a particular state of affairs came about, and does not simply assess a situation based on the “end state.” Presumably “brute luck” refers to a situation where an inequality comes about as a result of some relevant feature beyond a persons’ control (Dworkin, 1981, p. 293)⁠. For instance, impairment and certain social circumstances are cases of brute luck. Moreover, if an inequality comes about as a result of brute luck, then according to the luck egalitarian, we have reason to neutralize the bad effects through compensation (Hirose, 2015, p. 45)⁠. This view provides an ethical basis for addressing certain inequalities like a wheelchair users lack of access to buildings, or fixing particularly brutal neurological disorders. Indeed,  we often justify our moral actions when neutralizing bad effects by making appeals to whether the state of affairs came about through choice or not. When we think that features like brute luck or option luck are morally relevant in a given situation, I will call these luck egalitarian considerations. According to the luck egalitarian theory, when assessing any case of inequality, egalitarian considerations are applied to the case to assess whether the inequality is fair or not. Egalitarian considerations are principled reasons for acting a particular way in the given situation. If the situation features a relevant instance of brute luck, then presumably there is reason to neutralize the bad effects and eliminate the inequality.

Many individuals think luck egalitarian considerations are often sound for rationing certain goods. Consider a case where I only have enough juice to give to either my niece or nephew. My nephew was bad, because he stole some cookies from the cookie jar. This was his choice, and he rationally chose to take the cookies. My niece, on the other hand, was good. It seems a lot of people would give juice to my niece instead of my nephew. The inequality in juice was just, according the luck egalitarian. Consider another case where individuals can only give health care to one individual: a good person, who helps the poor and the weak, or an evil individual who calculatedly murdered a number of people. Many individuals would choose to give the health care to the good person, if we could so choose. But there are a number of objections to luck egalitarianism. Two of the most convincing are the harshness objection and the moralistic objection.

According to this objection, luck egalitarians have a harsh verdict about appropriate actions in certain situations. Consider a case presented by Anderson:

Consider an uninsured driver who negligently makes an illegal turn that causes an accident with another car. Witnesses call the police, reporting who is at fault, the police transmit this information to emergency medical technicians. When they arrive at the scene and find that the driver at fault is uninsured, they leave him to die by the side of the road. (Anderson, 1999, p. 295)⁠

The luck egalitarian, so the objection goes, must claim that the resulting inequality between the reckless driver and the other driver is not bad or unjust. Therefore, the luck egalitarian has no problem with leaving the reckless driver unaided. So, if luck egalitarianism is true –or if luck egalitarian considerations are sound–, it is morally permissible to leave the reckless driver unaided. But there is a problem with leaving the reckless driver unaided. We should help him, regardless if he was reckless or not. So, luck egalitarianism –and luck egalitarian considerations– is false.

Now, as Iwao Hirose points out, the value pluralist has a solution to this objection. The pluralist solution is to appeal to something else (another principle) in order to require the rescue of the reckless driver (Hirose, 2015, p. 59)⁠. This line of defence is presented by both G.A. Cohen and Shlomi Segall (Cohen, 2006; Segall, 2009)⁠. According Cohen and Segall, pluralism saves the day for the luck egalitarian. According to the luck egalitarian pluralist, considerations about option luck and brute luck do not constitute a comprehensive theory of justice, but are only a part of a general theory, which includes other principles of distributive justice. These additional principles allow the luck egalitarian pluralist to help the reckless driver in certain situations. Pluralism, as Hirose plausibly argues, suggests that two or more principles exist simultaneously (Hirose, 2015, p. 60)⁠. A few problems for the pluralist remain, according to Hirose.

According to Hirose, the response is not really directed to the abandonment objection (Hirose, 2015, p. 60)⁠. Many pluralists agree that if one has luck egalitarian considerations, then they abandon the reckless driver. As Hirose states, “They are free to support as many principles as they wish. But the bottom line is that luck egalitarianism abandons the reckless driver.” (Hirose, 2015, p. 60)⁠ The problem, according to Hirose, is that this intuition seems just plain wrong.

The second reason the pluralist response is unsatisfactory, according to Hirose, is that “even if the advocate of luck egalitarianism is confined to the domain of distributive justice, luck egalitarian considerations cannot provide a satisfactory treatment of the most basic cases, such as the reckless driver case.” (Hirose, 2015, p. 60)⁠ After all, the luck egalitarian theorist cannot provide a reason to save the reckless driver. The general dissatisfaction with the pluralist approach, for Hirose, is that luck egalitarian pluralist principles are not comprehensive distribution principles at all.

The harshness objection, for many, is a disturbing objection to luck egalitarian considerations, but what about the moralism objection? According to this line of objection, luck egalitarianism results in the unattractive consequence of adopting a sort of moralism as a basis for distributing basic goods like health care. Consider the following case presented by Greg Bognar and Iwao Hirose in “The Ethics of Health Care Rationing”:

Imagine that you are feeling well, and you worry that you might have a severe illness. So you go to your doctor, and your worry is confirmed. You do have a serious condition. But before your doctor discusses treatment options, he takes out a long questionnaire and starts asking you a series of questions about your lifestyle: Do you, or have you ever smoked? How often do you exercise? What sort of diet do you eat? How many sexual partners have you had recently, and how often do you have unsafe sex? (Bognar & Hirose, 2014, p. 134)⁠

Now, such a series of questions seems overly invasive, and disrespectful, but suppose that the doctor is asking these questions to determine whether or not you will get treatment. Thinking about distribution of health care in this way seems to be justified on luck egalitarian grounds. After all, if the condition was a result of your own calculated choice and was somehow your own fault, then it is possible for you not to be offered certain treatment. The problem is that if egalitarianism is true and luck egalitarian considerations are used to govern distribution of health care, then it is entirely possible to see health care rationing take this moralistic form. Yet any principle for governing the distribution of health care should not allow health care rationing to take this form. Thus, egalitarianism is false.

Luck egalitarianism, as a principled view, appears to suffer from a number of theoretical problems. Yet, in some cases, many want to save luck egalitarian considerations. Consider the juice case we initially entertained. Or consider another modified reckless driver case. Consider a case where you are an ambulance driver, on your way to help a moral saint who has recently been in a car accident. The person has insurance, was not intoxicated, and is generally a careful driver. He was simply in the wrong place at the wrong time. On your way there, you encounter a man who has been in a different car accident. He was under the influence, is a known risky driver, doesn’t have insurance, and knew exactly the risk he puts himself in by doing so. You can help only one person. You decide to help the person you were originally planning to help, on the basis of luck egalitarian considerations.

Are luck egalitarian considerations really wrong in this situation? Many would say they aren’t wrong. Moreover, suppose one were passing a responsible driver instead of a reckless one, and there are no other drivers to consider saving. Does not the fact that the driver was responsible provide an additional reason to save him? Many would say that it does. So, luck egalitarian considerations seem to be relevant in particular cases, but luck egalitarianism seems to face a number of formidable objections. How might one save luck egalitarian considerations? Is it a failed view? Should we really abandon luck egalitarian principles when rationing health care? What’s your take?

You can follow Ray on twitter here.

Works Cited

Anderson, E. (1999). What is the Point of Equality. Ethics, 109, 287–337.

Bognar, G., & Hirose, I. (2014). The Ethics of Health Care Rationing. New York: Routledge.

Cohen, G. A. (2006). Luck and Equality: A Reply to Hurley. Philosophy and Phenomenological Research, 72, 439–46.

Dworkin, R. (1981). What is Equality? Part 2: Equality of Resources. Philosophy of Public Affairs, 10, 283–345.

Hirose, I. (2015). Egalitarianism. New York: Routledge.

Segall, S. (2009). Health, Luck, and Justice. Princeton: Princeton University Press.