Theorists of the justice of egalitarian inclinations have argued that one of utilitarianism's weaknesses is its failure to treat people with disabilities fairly. Since utilitarianism accords them the extra resources needed to offset or reduce the disadvantage that results from their disability only if doing so maximizes aggregate welfare, individuals with disability do not have secure claims to those resources. Paraplegics will be denied wheelchairs if they have resigned themselves to their disability, or if they are bad utility converters and the money could be better spent on subsidizing opera for opera aficionados. So say anti-utilitarians. Mark Stein's aim in Distributive Justice and Disability is to turn the tables and argue that it is egalitarianism, not utilitarianism, that stumbles on the challenge of how to respond satisfactorily to disability. In a nutshell, the book's main argument is that egalitarianism swings between giving either too much or too little to the disabled, and that when it gets close to the right answer, this is because it has adopted, tacitly or explicitly, utilitarian commitments. Utilitarianism, Stein claims, is ‘the golden mean’ on the issue of disability (p. 41).
The book opens with an introduction and an interesting chapter on methodological preliminaries in which Stein declares his commitment to using intuitions as a testing board and warns against the use of unrealistic and stipulative examples that elicit certain intuitions by trading on the resilience of our responses to their realistic counterpart. An illustration is the example of Robert Nozick's utility monster. Usually, a situation in which a lot of resources are given to a single individual to the detriment of many others is a situation in which aggregate welfare is reduced. But Nozick stipulates that the utility monster's efficiency at generating utility from resources is so great that his utility gain would increase aggregate welfare. Like Nozick, we balk at transferring massive amounts of resources to the utility monster. But, Stein warns us, we can't be sure that our reaction does not in fact reflect our resilient intuition that, in any realistic scenario, giving all resources to one individual will depress aggregate welfare. So we should test our principles against examples, real or imaginary, that are not stipulative in this way.
This methodological observation plays a substantial role in Stein's arguments, starting with his case in favour of utilitarianism's ability to yield prescriptions that match our intuitions about when compensation is owed to those with disability (chapters 3 and 4). Throughout, disability is conceived, broadly, as any ‘health-related conditions that might be expected to reduce welfare’ (p. 23), and welfare is understood ecumenically, either hedonically or in terms of preference-satisfaction. Stein reviews the psychological research into the effects of disability on people's welfare, and remarks that on balance it vindicates the ordinary view that most forms of disability do reduce welfare. With those remarks in mind, he proceeds to show that utilitarianism will typically recommend compensating for disability. In support of this claim Stein makes some familiar remarks, such as the one that utilitarianism can take into account the beneficial effects of relief of disability for people other than those with disability.
But the most interesting part of this discussion concerns the significance of utilitarianism's commitment to the ‘greater-benefit criterion’, which recommends that ‘resources should be distributed to the people who would most benefit from those resources’ (p. 34). Applying this criterion requires that we focus on the effect of distributing resources on the comparative increment of utility that people would get from an additional unit of resources. Once we focus on the increment in utility, rather than on people's overall utility, utilitarianism reveals itself to be more generous towards the disabled than we thought at first, for two main reasons. First, it seems true that money spent on relieving a disability will generally bring a greater increment in utility for someone with a disability than that same money's being spent on providing other types of goods for someone without a disability: a paraplegic's increase in welfare as a result of getting a wheelchair is likely to be greater than the increase in welfare a physically able person will get by spending the wheelchair money on other goods. The greater-benefit criterion then tells in favour of providing the wheelchair, something we tend to overlook if we focus on the (probably true) fact that a paraplegic person's overall welfare is lower than the mobile person's. Second, individuals with a disability, however well-off, will have to spend on resources to alleviate their disability and have as a result an income level at which considerations of diminishing marginal utility apply in their favour: they will benefit more from additional resources spent on them than many others who do not have to incur medical expenses.
Having established utilitarianism's credentials, Stein goes on, in chapters 5–9, to argue that egalitarianism does less well (both than utilitarianism, and generally) at dealing with disability. Stein divides the egalitarian territory into two camps, those of equality of welfare and equality of resources, and then lays bare the dynamics of an unsatisfactory egalitarian pendulum (though Stein's detailed discussion of individual egalitarian views actually reveals that this oscillation does not dovetail with the welfare/resource distinction). Welfare egalitarians are committed to giving too much to individuals with disability, to the point that, in order to bring a disabled person a tiny bit closer to equality, they will sacrifice substantially the welfare level of many other people. Resource egalitarians, by contrast, give individuals with disability too little, even when they could benefit greatly from extra resources, as all they are committed to providing is a minimum income (p. 65); may deny people compensation relief for life-threatening disabilities once they have received their fair life-time share (p. 68); and will force poor people who lack insurance to pay for their own medical care (p. 68). Stein then goes on to argue that some egalitarian views, like Ronald Dworkin's equality of resources, a version of John Rawls's theory, mixed views like Amartya Sen's and G. A. Cohen's, and prioritarianism, all avoid these objections only by dint of adopting some utilitarian commitments.
The last two chapters of the book are dedicated to testing the respective merits of utilitarianism and egalitarianism in areas where the former is notoriously under attack: cases involving aggregation, and cases in which the distribution of life-saving medical resources is at stake. Stein's strategy here, as in the rest of the book, is to show that utilitarianism emerges surprisingly victorious compared to its rival once we pay close attention to the details of our test-cases, and once we take into account all the consequences that would result from adopting certain policies. So, for example, those cases in which aggregation seems clearly wrong turn out, on reflection, to be cases in which it is in fact not true that the sum total of the small benefits (e.g. free capping teeth procedures for many people) produces more welfare overall than a larger benefit for fewer people (e.g. free appendectomy for a few individuals). And while utilitarianism is thought to favour individuals without disability as recipients of life-saving medical resources, since this will maximize quality-adjusted life years, the adoption of a discriminatory policy of this sort would have adverse effects which would lower aggregate welfare. Stein closes the book with some remarks about the value of theory even for those who, like him, endorse an intuitionistic approach to ethics.
The topic of Stein's book is undoubtedly a timely one which is now attracting increasing attention among political and moral philosophers (e.g. see K. Brownlee and A. Cureton (eds.), Disability and Disadvantage, 2009). Stein's innovative idea that we should treat it as an important test-case for assessing competing theories seems absolutely right, and is a welcome contribution. Moreover, Stein's own treatment of this test-case proceeds through a crystal-clear and comprehensive critical examination of a wealth of contemporary views, and shies away from dogmatic or fanatical affirmations. At various points Stein is ready to highlight the tentativeness of his conclusions, or to identify areas where he suggests we should be ready to depart from what utilitarianism recommends (e.g. p. 9 and ch. 11).
Many of the arguments that Stein airs in this book will sound familiar to readers who know the internal disputes within the egalitarian family. Dworkin, for example, charges defenders of equality of welfare for being committed to giving too much to a few individuals (Dworkin, Sovereign Virtue (2000), pp. 60–2); critics of equality of resources reply that Dworkin's scheme is not sufficiently generous (M. Otsuka, ‘Luck, Insurance, and Equality’, 2002). But Stein's contribution lies in weaving these worries together and bringing them to bear against egalitarianism as a whole: if no theory of equality gives a satisfactory answer to the question of disability, hadn't we better look elsewhere?
Although egalitarians – and indeed any theorist of justice – should take Stein's challenge seriously, in my view we may doubt Stein's more specific conclusions. Consider, first of all, Stein's case for why utilitarianism is unlikely, in practice, to yield results that are intuitively offensive when it comes to compensation for disability. Stein's main test example here, which he borrows from Peter Singer, is one in which we face a choice between saving the toe of a person who has already lost a leg and saving the leg of a hitherto physically able person. Here we will agree with Stein that we should save the second person's leg, even though this person is better-off than the one whose toe is at risk. Stein generalizes from this example, and seems to assume that whenever we face a choice between a smaller benefit to someone who is worse-off and a larger benefit to someone who is better-off, we will either agree that the better-off person should be benefited, or that, if we think that we should help the worse-off, this is a reflection of the fact that the example is a stipulative one (as with Nozick's utility monster).
But this does not seem to do justice to all our intuitions. Consider the case of an Alzheimer patient who lives in mere subsistence conditions and can, in welfarist terms, benefit negligibly, if at all (Stein will, I think, agree), from an improvement in her life conditions, but to whom we nonetheless think these conditions should be guaranteed. Or consider the case in which we have to decide whether to give adequate shelter (in which one is safe from extreme but not life-threatening weather conditions) to someone who will, even with this benefit, lead a life on the brink of poverty, or to give to someone else who lives securely above the poverty line free higher education. It is certainly possible that the facts will be such that utilitarianism will favour free higher education; but many of us will disagree. We may disagree even more starkly if adequate shelter will be denied so as to provide free music education for very many people who live above the poverty line.
Focusing on these examples rather than the Singer case also casts doubt on a second main conclusion Stein defends in this book, that egalitarians can only meet the claims of disability adequately by incorporating elements of utilitarianism. As some have argued, a Dworkinian resource egalitarian could adopt a pluralist approach in which the claims of dignity supplement those of equality, and tell in favour of compulsory insurance and the provision of a decent minimum to Alzheimer victims and indigent people (P. Bou-Habib, ‘Compulsory Insurance Without Paternalism’, 2006). Furthermore, it is unclear why pointing to the plausibility of an egalitarianism that endorses the demands of welfare maximization alongside those of equality is supposed to constitute a victory for utilitarianism, as Stein implies. The pluralist egalitarian view is arguably superior to the utilitarian view, both because it yields the right conclusions in the Alzheimer case and because, even when it rules in favour of not helping those who are worse-off, it can, plausibly in my view, still register the fact that regrettably some claims have gone unmet.
Utilitarians claim that resources should be distributed with a view to benefiting people who can benefit most from them, regardless of how well-off they are. Egalitarians reject this claim, and Stein's arguments will not convince them that they are wrong to do so. But Stein's book succeeds in showing that egalitarians should articulate explicitly, and examine the implications of accommodating, the view that resources should be distributed with a view to benefiting people, and also that, sometimes, they should be distributed to those who can benefit more from them, even if they are not the worse-off.
