During the last several decades, egalitarians have splintered into factions along two major divides. The first concerns responsibility. According to luck egalitarians, what matters is not equality per se, but rather the opportunity for equality. If an individual squanders his or her opportunities or takes risky gambles that do not pay off, egalitarians need not compensate that individual for the loss. Although this view seems to capture some egalitarian intuitions, its opponents are quick to point out the instances in which it fails. For example, according to its opponents, luck egalitarianism would require us to abandon the reckless driver to his or her fate. Yet surely that is too harsh.

The second divide concerns the equalisanda: Setting aside the issue of responsibility, what exactly should we be equalizing (or prioritizing)? The traditional equalisanda—welfare and resources—strike few egalitarians as entirely satisfactory. Equalizing welfare, on the one hand, might require us to deny a wheelchair to someone who is unusually happy. Equalizing resources, on the other hand, ignores differences in what individuals are able to do with (or get from) their resources. In response to these and other objections, some egalitarians have worked on refining the welfare and resource approaches, while others have proposed equalizing an amalgam of welfare and resources or equalizing something in between welfare and resources (“midfare”). Two of the most prominent approaches are G. A. Cohen's equal access to advantage and Amartya Sen's capability to achieve functionings.

Shlomi Segall's Health, Luck, and Justice and Jennifer Prah Ruger's Health and Social Justice take up these two debates, respectively, with a particular emphasis on their implications for health policy. In his exceptionally clear and tightly argued book, Segall develops a comprehensive luck egalitarian account of health justice. After an introductory chapter, in which much of the argumentative work is done, the book is divided into three parts. The first attempts to rescue luck egalitarianism from the objection that it is too harsh on the imprudent. The second, in recognition of the small role that health care actually plays in determining health, explores the implications of luck egalitarian justice for health itself, including a chapter on enhancements. The third considers the significance of political boundaries and argues for cosmopolitan health justice.

Segall's response to the harshness objection is likely to create considerable interest, not merely because it potentially alleviates a luck egalitarian worry, but, more importantly, because of the conception of luck egalitarianism it puts forward. His argument proceeds in two steps. The first step claims that luck egalitarianism is properly concerned only with inequalities, not equalities. The second step argues that other moral considerations provide independent reason for helping the imprudent. Thus, although luck egalitarianism does not require us to help the imprudent, it is compatible with doing so.

The argument for the claim that luck egalitarians are properly concerned only with inequalities, and never equalities, goes by rather quickly (pp. 14–19). The basic idea, however, seems to be, first, that desert provides the only reason for deeming an equal distribution between differentially responsible individuals unjust, and, second, that luck egalitarians ought not appeal to desert-based reasons. Segall uses the following example (based on an example of Peter Vallentyne's) to illustrate: Prudence and Lazy are castaways on a desert island. Prudence spends her time fishing, while Lazy lies in the sun. As a result of her effort, Prudence catches a large fish. Lazy, meanwhile, is the beneficiary of good luck: A fish washes up next to him on the beach. Lazy's fish is smaller, but because he is better rested than Prudence, their overall well-being is equal. Segall then asks: On what basis could someone object to the equality between them? His answer seems to be that the only possible reason for objecting must appeal to desert (pp. 16–19).

Assume, for the sake of argument, that Segall is correct that luck egalitarians ought not appeal to desert. Even so, it is not clear that he has established the rest of his argument. To begin with, it is not enough to claim that egalitarians should be agnostic if differential brute luck establishes equality between differentially responsible individuals. Segall's response to the harshness objection requires the stronger claim that egalitarians should be agnostic about bringing about the equality themselves. It is not enough, then, for his luck egalitarian to say: “I would not have given Lazy the fish, but now that it is done, I won't interfere.”

Of course, if Segall is right that the only reason for objecting to the equality between Prudence and Lazy appeals to desert, then he might also be able to establish the stronger claim. But has he in fact ruled out reasons other than desert? Consider the following variation: Suppose that no fish washes up next to Lazy. Prudence, however, gives a small piece of her fish to Lazy (for either prudential or altruistic reasons). Because of her larger share, Prudence is better off than Lazy. If we were now able to distribute new supplies, a comparative desert theorist would presumably give a greater share to Prudence; after all, Lazy got more than he deserved. A luck egalitarian, in contrast, would distribute the supplies equally: Although Prudence is better off than Lazy, this reflects their freely made choices. Both allow the inequality to persist, but the fact that the desert theorist would give more to Prudence, while the luck egalitarian would insist on identical shares, suggests that the luck egalitarian is tracking something other than desert: namely, their free choices.

Even if this is right, Segall could still argue that, for independent reasons, luck egalitarianism is properly concerned only with inequalities. His view that luck egalitarians should be concerned only with inequalities is at least plausible. Like many other arguments in this significant contribution to the egalitarian literature, it is certain to spark considerable debate.

Ruger's highly ambitious book engages with the second divide: What exactly should we be equalizing? Drawing on literature from a wide range of disciplines, she argues that the capability approach, originally put forward by Sen and Martha Nussbaum, should be preferred to all other theories. After an exceptionally clear explication of the capability approach, she then undertakes the important task of identifying the health policy implications.

Ruger builds her case for “the profound need for an alternative paradigm” (p. 19)—namely, the capability paradigm—by identifying flaws in alternative approaches. Her discussion of other theories, however, is marred by several apparent misreadings. For example, although Cohen's equal access to advantage approach is surely relevant to a consideration of the capability approach, Ruger dismisses Cohen's view in one sentence: “[Norman] Daniels (2001) counters that [Cohen's approach] places too little emphasis on choice or responsibility and raises problems for public policy” (p. 26). In fact, however, Daniels says precisely the opposite: “I argue … that [Cohen's approach] gives too much centrality to choice or responsibility” (“Justice, Health, and Healthcare,” The American Journal of Bioethics 1 [Spring 2001]: 2–16, at p. 5). Given Ruger's view that individual responsibility is “a crucial element to any theory of health and social justice” (p. 82), had she accurately read Daniels—or, better still, Cohen—she might have been less quick to dismiss Cohen's view.

In a subsequent discussion, Ruger explicitly considers luck egalitarianism, but here she makes the opposite mistake, attributing to Thomas Scanlon the luck egalitarian view that compensation should track individual choice (p. 136). Scanlon's goal in the very article she cites, however, was to undermine this claim. According to Scanlon, the reason we mistakenly think choice should play this role is because the concerns over which individuals are thought to have choice are generally peripheral ones. It is their peripheral nature and not choice, then, that is doing the work (“Preference and Urgency,” Journal of Philosophy 72 [November 1975]: 665–69).

Ruger's lack of serious engagement with the philosophical literature is further evidenced by her quick dismissal of Ronald Dworkin's hypothetical insurance approach, which argues, roughly, that society should cover those conditions against which prudent individuals would insure. Echoing Elizabeth Anderson (“What Is the Point of Equality?” Ethics 109 [January 1999]: 287–337), Ruger claims that Dworkin's theory “is biased against individuals with rare conditions, which most people might not insure against or treat” (p. 137). As Dworkin has pointed out, however, since the cost of covering a rare condition is likely to be negligible precisely because it is rare, individuals would not decline coverage for that reason (“Sovereign Virtue Revisited,” Ethics 113 [October 2002]: 106–43). Ruger might perhaps still argue that treatments for rare conditions would be neglected because they are likely to be more expensive (e.g., because of the absence of economies of scale) or less efficacious (e.g., because of fewer market-based incentives to research such interventions). The problem with the latter argument, however, is that her own proposals might be vulnerable to the same charge.

The bulk of Ruger's book is aimed at spelling out implications of the capability approach, and here she might be on firmer ground. Nonetheless, although much of what she says is eminently sensible (e.g., “wasted resources undermine important health goals” p. 160), the connection between her proposals and the capability approach is not always apparent. Indeed, they sometimes seem at odds. For example, Ruger promotes evidence-based medicine, noting its success in reducing disparities in treatment (pp. 177–83). She does not, however, acknowledge the many problems with evidence-based medicine. Because market-driven research disproportionately focuses on the diseases of the rich—no matter how trivial the condition—prioritizing coverage according to the existence of evidence is heavily skewed against basic capabilities. Of course, Ruger could respond by restricting the role of evidence-based medicine to the more modest one of ensuring that no one receives substandard care or, more radically, by realigning research incentives to track basic capabilities. In either case, however, it would be helpful to say more.

Because of the vast territory her book covers, Ruger is rarely able to provide the careful, in-depth analysis readers might desire. Nonetheless, both policymakers and scholars are likely to glean insights from her far-reaching book. Perhaps of greatest value, she begins the important project of translating theory into practice.