With this book, Shlomi Segall tackles some of the hardest issues in egalitarian theory. Applying abstract theories of justice to health policy is hard, and defending a luck egalitarian approach in this context is especially courageous given the strong presumption among critics that taking care of the sick and injured independently of their responsibility is a compelling moral obligation, with respect to which luck egalitarianism characteristically fails.
This book is, in a sense, a dialogue with two interlocutors. One is the group of critics of luck egalitarianism, with their charge that luck egalitarianism abandons the imprudent to their sad fate. The other one is Norman Daniels, who developed an important approach for which health is so basic a condition for the exercise of autonomy by individuals that it must occupy a special place in any refinement of Rawls's theory that takes account of health inequalities. But the book is not just a theoretical construction at the boundary of political philosophy and social policy. It also addresses some rather concrete questions, such as whether health care should be universal and opting out forbidden, whether enhancements should be covered by health budgets, whether regions may be allowed to have and manage their own health budget with substantial autonomy, and how to assess the extent of our obligation to other countries (or planets!).
Shlomi Segall's work reads very pleasantly and is written with remarkable clarity. All in all, the analysis is made at a very good level of rigor and complexity, with good care being taken of possible objections and alternative approaches. The organization of the text is very easy to follow and the reader is always reminded of where he is in the journey and of the direction of the next steps.
The book is divided into three parts. The first one is devoted to the study of health care. This is the key part, in which Daniels's theory is examined and criticized, while the objection of harshness made by the critics of luck egalitarianism is addressed and rebutted. It ends with the concrete problem of whether to organize health care as a universal service. The second part moves on to the problem of defining justice in the distribution of health itself, applying the theoretical conclusions obtained in the previous part to this broader context in which all factors of health, especially socio-economic determinants, are considered. It ends with the concrete issue of how to deal with enhancements. The third part directly tackles the more concrete problems of the spatial organization of health care across regions within a country and across countries in the world.
The main criticism that Segall raises against Daniels's theory is that, while it is clever to locate the problem of health care at the level of the fair equality of opportunity principle rather than the lexicographically inferior difference principle, this renders health considerations hostage to their contribution to life plans. As a consequence, Daniels's approach is ill-equipped to defend generous policies toward the elderly, who may be said to have largely completed their life plans. Only an extended notion of life plan (such as ‘living a long and painless life’) could accommodate such policies, but Segall argues that such extension is not compatible with assigning the fair equality of opportunity principle to health.
The approach Segall proposes is luck egalitarian in the sense that it accepts the idea that those who are responsible for their bad health should be given less priority than those who are not. However, he deflects the charge of harshness by casting fairness considerations, governed by luck egalitarian principles, into a broader scheme of social justice in which considerations of solidarity and basic needs may supplement fairness principles. The imprudent who ruin their health will be taken care of by health services but not out of fairness. They will be treated because meeting basic needs is a more fundamental principle than achieving a fair distribution. Segall even claims that luck egalitarian principles in and of themselves do not imply that the imprudent ought to be left to their own fate, but only that they may be so. In his opinion, therefore, there is no conflict between meeting basic needs and adopting luck egalitarian principles.
This is connected to his argument that only inequalities may be unfair, not equalities. This argument is the only one in the book that this reader could not understand. Segall claims that his version of luck egalitarianism sees no harm when individual outcomes happen to be equalized and do not reflect the exercise of responsibility, and associates the alternative view to the idea that outcomes should be apportioned to individual desert – an idea that he rejects. The thesis that equality is always acceptable for luck egalitarians is not convincing, because this implies that luck egalitarianism would have no objection against a full equalization policy. Even the luck egalitarian authors who do not refer to desert (e.g. Cohen) tend naturally to consider that the goal of eliminating the influence of circumstances for which the individuals are not responsible is connected with the idea that once this is done, redistribution should stop.
Once luck egalitarianism is restored in its original version that warrants inequalities due to legitimate exercise of individual responsibility, the conflict between luck egalitarianism and the principle of basic needs resurfaces, but Segall could certainly give priority to the latter and this would be a quite reasonable move.
A key element of Segall's version of luck egalitarianism is that an element of reasonableness determines when compensation is due. His central principle of luck egalitarianism is: ‘It is unjust for individuals to be worse off than others due to outcomes that it would have been unreasonable to expect them to avoid’ (p. 13). The reasonableness proviso is clever and very helpful in tackling hard cases. Obviously it leaves the theory incomplete because it only shifts the debate from the question of ‘who should be helped’ to the very similar question of ‘would it be reasonable to expect them to avoid such trouble’. But this is not exactly the same question, and in several examples the approach is very convenient to make distributive conclusions match our intuitions. In this respect it appears superior, for instance, to the alternative theory that advocates compensating the negative consequences of all ‘innocent’ choices.
In the application of luck egalitarianism to health, Segall proposes the broad principle that ‘it is always unjust for one person to be less healthy than another through no fault of her own’ (p. 109). This allows him, for instance, to say that the lower health expectancy of men compared to women is unjust independently of the fact that men enjoy other social advantages in most societies. It is not obvious how this reconciles with the general principle referring to well-being. If men are better-off and have lower health, can they be at the same time privileged and victims at the bar of justice? A policy that would improve men's health would reduce injustice in health and worsen the distribution of well-being. Segall argues that, apart from this case, justice in health and justice in well-being generally coincide, but it would be simpler to make justice in health derive from the broader picture rather than constitute an independent domain.
Another general feature of Segall's version of luck egalitarianism is his endorsement of prioritarianism and the avoidance of levelling-down policies. Redressing unfair inequalities should never be done by worsening the situation of the better-off without improving that of the worse-off. Segall sometimes criticizes other approaches for failing to avoid levelling down. This is the case in particular for an imaginary theory that would apply Rawls's fair equality of opportunity principle (which warrants levelling down if this is the only way to achieve equality) to health directly. Segall notes that Daniels's view seems sometimes close to such a theory, although in principle it is different because in Daniels's theory health policy serves the purpose of providing fair opportunities for life-plans, not for health. Segall claims that the luck egalitarians who are willing to compensate all forms of luck (including option luck) are guilty of approving levelling down, but there is little justification for this charge. One does not see why prioritarianism is not as much a possibility for this approach as for other variants of luck egalitarianism.
When discussing enhancement, Segall offers a complex but interesting and reasonable approach which can be summarized as follows. First, although there is a conceptual difference between health and enhancement, there is no reason to exclude enhancements from considerations of justice in health, because they cover a very similar area. Second, one should be prioritarian for health deficits but egalitarian in the allocation of enhancements, because allocating enhancements unequally would be, for the non-beneficiary part of the population, demeaning in a way that does not occur in the health context.
In conclusion, this book constitutes a very valuable contribution to the field of justice in health and health care, and one should praise its author for having remarkably managed to bridge the gap between general theories of justice and applied issues of health policy. This book is no doubt a ‘must read’ in the domain.
