Andreas Albertsen

During the COVID-19 pandemic, many countries introduced policies that disadvantaged unvaccinated individuals, including fines, restrictions on access to public spaces, and lower healthcare priority. This article examines whether such differential treatment constitutes wrongful discrimination. Drawing on prominent philosophical accounts of discrimination, we argue that these policies qualify as direct discrimination against the unvaccinated under pandemic conditions, because vaccination status became socially salient in this context. Additionally, it is argued that the policies may constitute indirect discrimination when vaccine hesitancy strongly correlates with socioeconomic and racial disparities. The article then assesses whether the policies constitute wrongful discrimination on prominent accounts of this. We argue that, even though the policies did make unvaccinated individuals worse off and may potentially express demeaningness, mitigating factors such as personal responsibility or respect for individual autonomy were also present. As a result, these policies can only be considered as direct discrimination under some accounts of the wrongness of discrimination, but not under others. In contrast, concerns about indirect discrimination are more justified, at least when the group of the unvaccinated overlaps with the individuals affected by socioeconomic and racial disparities.

In debates over organ markets, the so-called best option argument is often invoked to oppose prohibition. The argument stresses that for some individuals, selling a kidney would be their best available option. In earlier work, I argued that this argument does comparatively little justificatory work under conditions of distributive injustice, because the option is best only through a narrow comparison that leaves out even better options required by justice. Hendricks has recently criticised this view, claiming that organ markets are always part of the best option, even once justice-satisfying measures are in place. In this reply, I argue that Hendricks’s objection rests on a misunderstanding of the target and scope of my original argument. The disagreement is not about whether organ markets could coexist with justice, but about the justificatory significance of the best option argument under unjust background conditions.

As priority setting committees become commonplace in contemporary welfare states, it becomes increasingly important to understand how they operate. This article contributes to our understanding of contemporary priority setting by examining how the Danish Medicines Council (DMC) makes and justifies its decisions, as well as the role of different (and perhaps conflicting) concerns and values in these decisions. We conducted seventeen interviews with DMC members and observed three DMC meetings spanning five days. Firstly, we find that health-related effect is the most crucial factor in DMC members’ recommendations of newly proposed medicines and that discussions of effects take precedence over other considerations in council deliberations. Secondly, we find that the ability of DMC members to adequately assess the effect of newly proposed medicines is often significantly limited by poor data quality and a lack of sufficient documentation, which shifts the DMC’s task from making recommendations on an informed basis to providing estimated assessments of the expected effect. In these circumstances of uncertainty about effect, recommendations are influenced by considerations such as the age of patients and the rarity of the disease. This raises significant moral issues in which the DMC has no particular expertise.

Priority rules give priority to registered organ donors in the allocation of organs. Such rules might directly discriminate against non-donors or indirectly discriminate against those whose religious commitments prevent them from registering. However, while priority rules may qualify as discriminatory, they are not necessarily wrong for the reasons discrimination is usually thought to be wrong—for reasons related to harm and disrespect. While they can be so for reasons related to problematic mental states and demeaningness, they need not be.

Cost-effectiveness analysis (CEA) is a mainstay of contemporary health care priority setting. However, priority setting in reference to cost-effectiveness may discriminate against people with disabilities. The ethical literature on priority setting suggests that the permissibility of such discrimination varies with the reason why people with disabilities receive lower priority. In a vignette-based survey experiment (N = 1100) in the UK, we tested whether five justifications for prioritizing people without disabilities affect the views of the broader public on priority setting based on CEA. In our vignettes, a hospital denies a person with a disability treatment for a disease based on CEA, and respondents were asked to assess the moral permissibility of this. The vignettes varied in terms of the reason the hospital emphasized in the decision. We tested vignettes emphasizing lower expected lifespan, lower quality of life, higher costs of treatment due to disability, less efficient treatment due to disability, and lower productivity due to infrequent labor-market participation. Our study is an initial exploratory survey experiment, exploring participant’s responses to CEA with respect to disability. Discrimination against the patient with a disability was deemed impermissible across all experimental conditions, and there were no significant differences between the various reasons. This suggests a discrepancy between folk intuitions and those of many ethicists.

Declining turnout rates and political disengagement have spurred many proposals to reform contemporary democracies. Some proposals aim at electoral participation, while others seek to create alternative non-voting forms of participation in politics. This article explores a third route, where elections are used to foster democratic non-voting engagement: that is, engagement in elections, but not as voters. We propose that society actively seek to engage citizens and resident non-citizens, who are either by choice or by law currently non-voters, to participate in the different administrative aspects of elections as poll workers. Our proposal concerns paid positions for which people volunteer, rather than unpaid positions into which people are drafted, whether they want to or not. Hence, this article proposes a novel form of electoral participation that is voluntary, open, and appropriate for those unable or not yet ready to vote.

The world has experienced a shift in the prevalent pattern of disease, with noncommunicable diseases now representing more than half of the leading causes of death. Costs related to such diseases put a considerable strain on already challenged healthcare budgets. This brings to the fore questions concerning the efficient and fair allocation of health resources. This chapter discusses equality of opportunity for health adopting a luck egalitarian approach. Luck egalitarianism is a responsibility-sensitive theory of distributive justice. It includes both a commitment to eradicating unchosen circumstances and respecting voluntary choices and argues that distributions are unjust, if and only if some people are worse off than others through no fault of their own. First, the chapter elaborates on the reasons why a responsibility-sensitive approach applies in the discussion of equality of opportunity for health. Next, the core of luck egalitarianism and key disagreements in the literature are presented. The theory is then discussed in the context of health, and central facets of this approach are clarified: what is the role of responsibility, how is this perceived, and do other aspects of a person’s life or supplementary values matter in this discussion? The chapter moves forward to critically discuss critiques already raised against this responsibility-sensitive theory of distributive justice, like the harshness and the shameful intrusiveness objection, and finally to sketch out a novel critique: the discrimination objection.

Philosophical accounts of discrimination distinguish the question of what discrimination is from the question of its wrongfulness. This article addresses these two questions in the context of anti-homeless hostile design of public spaces. Regarding the first question, all forms of anti-homeless hostile design amount to discrimination, with typical cases (e.g., anti-homeless spikes or benches) being direct discrimination, but with some cases (e.g., CCTV not intended to target the homeless) being indirect discrimination. Regarding the second question, it is argued that all major accounts of the wrongness of discrimination identify the usual, directly discriminatory hostile design as wrongful on account of its harmful or disrespectful character. Most accounts also consider the less common indirectly discriminatory hostile design to be possibly wrongful, especially given the severe disadvantages faced by the homeless in contemporary cities.

In Massachusetts, a proposed bill would reduce the sentence of those incarcerated who become living donors of either organs or bone marrow. We outline two concerns with such a proposal, which relate directly to the content of the proposal (as opposed to broader debates about payment for organs and validity of consent obtained from the incarcerated). The first of these concerns is about equality of opportunity. The proposal provides the opportunity for a sentence reduction for some but not for others – and the distribution of these opportunities reflects circumstances largely beyond the control of the incarcerated. The second concern is that the proposal may conflict with why we punish in the first place. The proposal is at odds with the non-consequentialist general deterrence defended by Tadros, retributivism, and communicative theories of punishment. Among the theories examined, only the purely consequentialist version of general deterrence might find the practice palatable. The upshot of the latter observation is that the proposal presupposes the truth of a purely consequentialist theory of punishment and sets aside others.

Socialism is a large and diverse political tradition, unified by opposition to capitalism. Economically, socialists also typically support common ownership or some form of social, democratic control over the bulk of the means of production. There are various views on whether this requires central planning or is compatible with some form of market economy. Others understand socialism as a set of values, and either way, those who understand socialism in economic terms are often motivated by what they see as the ills of capitalism and the values that can be realized in a socialist society in their pursuit of these economic changes. Socialist values include ending exploitation and alienation and replacing them with human flourishing and self-realization, community, distributive justice, equality, and freedom. Some also see socialism as the way to environmental sustainability, gender equality, and racial justice. The question of socialist strategy—how to achieve socialism—has often been posed as a dichotomy between reform and revolution. This inadequately captures the content of fundamental disagreements among socialists. Instead, the disagreement can be understood as varying views on the use of parliamentary democracy in a capitalist state, the pace of social change, and the nature of the envisioned changes.

While the trade of human organs are illegal and widely condemned, a black market flourishes. Estimates indicate that 10% of kidney transplants from living donors involve illegal payments to the kidney seller. This paper presents a typology for approaches aimed at curtailing the black market in human organs. The policies are evaluated from two perspectives: their ethical permissibility and their expected efficiency in ending and minimizing the trade in human organs. To end or minimize organ trading, we must reduce the organ shortage in order to reduce demand for organs, alleviate poverty to reduce the supply of organs, and disincentivize brokers and medical facilitators through a concerted effort to reduce the profit rate of the international organ trade.

The global inequality in the distribution of vaccines is unjust. As countries scrambled to ensure enough vaccines, the world’s poorest were left to fend for themselves, and the generosity meant to mitigate this through COVAX was not sufficiently forthcoming. In light of this, I proposed a vaccine tax, which obligates those willing and able to pay to protect their own population to contribute to protecting those residing in the world’s low-income countries. Petrovic has offered an important critique of this proposal, questioning both the fairness and the efficiency of the tax. However, when properly specified, the vaccine tax is not vulnerable to these critiques.

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the ‘best option’ argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one.

According to many theorists, discrimination either requires a better treated comparator or can occur only if the discriminator belongs to a socially salient group different from that of the discriminatee. Both claims are philosophically important since they have important implications for which account of the moral wrongness of discrimination is correct, e.g., if no comparator is required, the wrongness of discrimination cannot result from treating different people as unequals since the unequal treatment of persons is not an essential feature of discrimination. Most theorists who have written on the topic see their account as articulating the folk concept of discrimination. However, none have subjected their putative articulations thereof to experimental testing. This is what the present study does. Its results are mixed, interesting, and call for further studies. Regarding comparativity, surprisingly, respondents are more disposed to classify a situation as discriminatory when there is no comparator than when there is one. Regarding reflexivity, respondents are more likely to classify our vignettes as involving discrimination when the discriminator is from another socially salient group than the discriminatee as to ethnicity but not when it comes to gender. Hence, non-reflexivity does not appear to be a conceptual requirement on discrimination. Remarkably, our study also shows that the mere reference to a majority, outgroup person in our vignettes makes respondents more likely to classify the vignette as involving discrimination against a minority person, even when the majority group person does not play the role of a comparator.

While standard forms of discrimination are widely considered morally wrong, philosophers disagree about what makes them so. Two accounts have risen to prominence in this debate: One stressing how wrongful discrimination disrespects the discriminatee, the other how the harms involved make discrimination wrong. While these accounts are based on carefully constructed thought experiments, proponents of both sides see their positions as in line with and, in part, supported by the folk theory of the moral wrongness of discrimination. This article presents a vignette-based experiment to test empirically what, in the eyes of “folks”, makes discrimination wrong. Interestingly, we find that, according to folks, both disrespect and harm make discrimination wrong. Our findings offer some support for a pluralistic account of the wrongness of discrimination over both monist respect-based and monist harm-based accounts.

Across Europe, countries are reducing CO2 emissions and energy demand by lowering the temperature in public office buildings. These measures affect men and women unequally because the latter prefer and, indeed, perform better under higher temperatures than the standard temperature. Lowering the temperature thus further increases an already existing inequality. We show that the philosophical literature on discrimination provides an interesting theoretical approach to understanding such measures. On prominent understandings of what discrimination is, the policy would be considered direct discrimination against women if it could be shown to reflect a broader inattentiveness to the needs of women in society. Alternatively, and more straightforwardly, the policies can be considered indirect discrimination because of their disparate effects on men and women. The final part of the paper shows that the policies are also wrong for the reasons it is often argued that discrimination is wrong—to wit, that it harms or disrespects those who are discriminated against. The final section suggests a range of measures to offset the discriminatory aspects of the policy.

In 1970, Stewart advocated disenfranchising everyone reaching retirement age or age 70, whichever was earlier. The question of whether senior citizens should be disenfranchised has recently come to the fore due to votes on issues such as Brexit and climate change. Indeed, there is a growing literature which argues that we should increase the voting power of non-senior citizens relative to senior citizens, for reasons having to do with intergenerational justice. Thus, it seems that there are reasons of justice to disenfranchise senior citizens, or at least to grant them a lower voting weight than non-senior citizens. In this paper, we investigate whether there are democratic reasons to do so. To answer this question, we turn to the boundary problem in democratic theory, i.e., the question of who should be included in democratic decision-making. Two prominent solutions, and a more recent one, are particularly relevant: the all-affected principle, the all-subjected principle, and the relational egalitarian principle. When it comes to the all-affected principle and the all-subjected principle, we argue that there is reason to grant most senior citizens a lower voting weight than most non-senior citizens in most decisions. Whether that is the case on the relational egalitarian principle depends on how people relate to each other in society. Indeed, it is sometimes in accordance with the relational egalitarian view to grant senior citizens a greater voting weight than non-senior citizens.

There has been considerable debate over regulated organ markets. Especially current markets, where people sell one of their kidneys while still alive, have received increased attention. Futures markets remain an interesting and under-discussed alternative specification of a market-based solution to the organ shortage. Futures markets pertain to the sale of the right to procure people’s organs after they die. There is a wide range of possible specifications of the futures market. There are, however, some major unaddressed efficiency concerns. This article presents this class of concerns and discusses the implication for organ futures markets. It identifies a number of inefficiency sources pertaining to crowding out, bad organs, costs and missed opportunities, family refusals, moral hazard and strength of the provided incentive. However, a complete assessment of futures market requires better knowledge regarding the potential reaction from donors, families and health professionals.

Luck egalitarianism is a responsibility-sensitive theory of distributive justice. Its application to health and healthcare is controversial. This article addresses a novel critique of luck egalitarianism, namely, that it wrongfully discriminates against those responsible for their health disadvantage when allocating scarce healthcare resources. The philosophical literature about discrimination offers two primary reasons for what makes discrimination wrong (when it is): harm and disrespect. These two approaches are employed to analyze whether luck egalitarian healthcare prioritization should be considered wrongful discrimination. Regarding harm, it is very plausible to consider the policies harmful but much less reasonable to consider those responsible for their health disadvantages a socially salient group. Drawing on the disrespect literature, where social salience is typically not required for something to be discrimination, the policies are a form of discrimination. They are, however, not disrespectful. The upshot of this first assessment of the discrimination objection to luck egalitarianism in health is, thus, that it fails.

The discussion on mandatory turnout, which controversially introduces coercion at the heart of the electoral process, illustrates a dilemma between increasing voter turnout on the one hand and avoiding coercion on the other. If successful, a recent proposal by Elliott solves this dilemma as it removes the compulsory element of mandatory turnout. Specifically, Elliot reinterprets the policy’s purpose as (a) a pre-commitment device for those who believe that they have a duty to vote and (b) a nudge to the surveillance of politics for those who do not believe this. We critically evaluate Elliott’s novel intervention in the debate and argue that it is ultimately unsuccessful. Mandatory turnout can be interpreted as neither a pre-commitment device nor a nudge. Moreover, we present a more promising and novel solution to the dilemma: a genuine state-administered pre-commitment device with respect to voting that also nudges citizens to vote and seems _prima facie_ attractive.

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities.

Should priority in the allocation of organs be given to those who have previously donated or declared their willingness to do so? This article examines the Israeli priority rule in light of two prominent critiques of priority rules, pertaining to failure to reciprocate and unfairness. The scope and content of these critiques are interpreted from the perspective of equality of opportunity. Because the Israeli priority rule may be reasonably criticized for unfairness and failing to reward certain behaviors, the article develops an adjusted priority rule, which removes and adjust the elements in the Israeli priority rule deemed problematic. However, such a priority rule is complex to the extent that it may fail to increase donation rates and furthermore introduce new concerns of fairness, as the better off may be better able to navigate the complex adjusted priority rule.

A comprehensive understanding of the ethics of the COVID-19 pandemic priorities must be sensitive to the influence of social inequality. We distinguish between ex-ante and ex-post relevance of social inequality for COVID-19 disadvantage. Ex-ante relevance refers to the distribution of risks of exposure. Ex-post relevance refers to the effect of inequality on how patients respond to infection. In the case of COVID-19, both ex-ante and ex-post effects suggest a distribution which is sensitive to the prevalence social inequality. On this basis, we provide a generic fairness argument for the claim that welfare states ought to favour a healthcare priority scheme that gives particular weight to protecting the socially disadvantaged.

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old.