Lydia Tsiakiri

Contemporary societies face pressing ethical and policy challenges that require politically legitimate decision-making processes. This paper comparatively assesses how two public decision-making procedures – referendums and the empirical bioethical method of Collective Reflective Equilibrium in Practice (CREP) – perform in generating politically legitimate policymaking, using personal responsibility for health in healthcare resource allocation as a case study. While referendums appear to ensure political legitimacy through direct public voting, they often produce merely coarse-grained outcomes that fail to capture the nuanced reasoning underlying public preferences, risking oversimplification and ‘tyranny of the majority’. By contrast, CREP integrates lay and expert judgments, elicited through empirical methods such as surveys, focus groups, and citizen juries, with ethical theories, principles, and guidelines in an effort to arrive at ethically justifiable and publicly defensible policy recommendations. The paper argues that political legitimacy requires not only procedural participation but also alignment with nuanced, reason-sensitive, and bias-filtered public views that constructively accommodate disagreement. Against this background, the analysis concludes that by examining conditional and context-specific opinions, eliciting justificatory reasons behind judgments, screening for bias and prejudice, and constructively incorporating disagreement into policy synthesis, CREP can provide stronger substantive political legitimacy than referendums, something of particular importance especially in ethically contentious domains like healthcare.

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.

The epidemic of noncommunicable diseases is currently responsible for 74% of the global death toll. Since modifiable individual behaviors partly determine risk factor exposure, it may seem reasonable to suggest that individuals can take some responsibility for their health by adopting healthier lifestyles. In this paper, I consider whether certain types of responsibility-sensitive healthcare policies, namely policies that treat certain groups of people differentially because they are considered responsible for their health-related choices and subsequent condition, constitute cases of direct and/or harmful discrimination. Specifically, I reflect on the potentially discriminatory nature of backward-looking responsibility-sensitive healthcare policies (RSHPs) and their specification built around the idea of golden opportunities (GOs). To provide a plausible response to this puzzle, I initially examine these policies’ compatibility with Benjamin Eidelson’s and Kasper Lippert-Rasmussen’s definitions of non-moralized direct discrimination. Then, I discuss whether these policies impose unjustified harm on imprudent individuals by harmfully discriminating against them.

The prevalence of non-communicable diseases, the related increased medical costs, and the recent public health emergency bring out more forcefully pre-existing dilemmas of distributive justice in the healthcare context. Under this reality, would it be justified to hold people responsible for their taken lifestyle decisions, or would it constitute an instance of unjustified disrespectful treatment? From a respect-based standpoint, one could argue that a responsibility-sensitive healthcare system morally disrespects the imprudent ones engaging in disadvantageous differential treatment to their detriment. In contrast, however, we might also have luck egalitarian reasons that explain why this differential treatment is not unjust. Luck egalitarianism is a responsibility-sensitive theory of distributive justice, which argues that it is bad if some people are worse off than others through no voluntary fault of their own. In this paper, I clarify the concerns about disrespect raised against the luck egalitarian viewpoint and offer possible respect-based reasons for why this might not be the case grounded in deontological concepts. First, I employ a revised Double-effect case to support responsibility-sensitive rationing. In the last part of the paper, these are further supported through the Kantian Formula of Humanity supplemented by the concept of duties.

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.

The medical developments and their subsequent influence on the duration of human life have brought in the limelight various moral questions. The pathological conditions do not constitute anymore the decisive causes of death, whereas an ascending number of people suffer more by being maintained in life. In this reality, the euthanasia debate seems more apropos than ever. The following article examines the aforementioned issue through the supportive argument of autonomy in contrast to a Foucauldian approach. In essence, based on the Kantian concept of autonomy, several scholars have advocated in favor of the legalization of euthanasia in order that our ability to define not only the course of our life and its duration, but also the way of our death is ensured. However, on the other side, a Foucauldian approach of the issue seems to be equally worth cited and taken into consideration. In accordance with that, the domination of Foucault's concept of biopower would deterministically imply that our choices are totally determined by a form of power that targets at the absolute control over our lives through medicine and legislation. In such a context, euthanasia could not constitute a promoter of autonomy. On the contrary, it would contribute to the absolute escalation of the governmental power that would be imposed on every inch of our lives being exclusively interested in its own prosperity!