Better in theory than in practise? Challenges when applying the luck egalitarian ethos in health care policy
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SCIENTIFIC CONTRIBUTION
Better in theory than in practise? Challenges when applying the luck egalitarian ethos in health care policy Joar Björk1,2 · Gert Helgesson1 · Niklas Juth1
© The Author(s) 2020
Abstract Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, luck egalitarianism encounters several difficulties. We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. Keywords Responsibility · Priority setting · Luck egalitarianism · Clinical ethics · Smoking
Introduction Luck egalitarianism (LE) is a theory of distributive justice, first elaborated during the 1980s (Knight and Stemplowska 2011). While it shares the strong emphasis on equality common to all brands of egalitarianism, LE provides a justification for pockets of inequality—if the inequality has arisen in a way that meets certain desiderata. One may thus speak of LE as a kind of tempered egalitarianism. The desiderata in question concern issues of choice and risk taking, and so (voluntary) choice has a special place in LE theory as the normative force distinguishing LE from outcome egalitarianism. Whereas outcome egalitarianism holds that inequality between individuals should be neutralized (ceteris paribus), * Joar Björk [email protected] 1
Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Tomtebodavägen 18 A, 171 77 Stockholm, Sweden
Department of Research and Development, Region Kronoberg, PO Box 1223, 351 12 Växjö, Sweden
2
LE holds that this rule applies except when the inequality has arisen due to the individuals’ voluntary choices. The term “luck” in “luck egalitarianism” derives from a pivotal 1981 article by Ronald Dworkin, which discusses the policy implications of what Dworkin calls “brute luck” and “option luck”, respectively (
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