Cooperative beneficence and the macroallocation of health care in the United States

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Cooperative beneficence and the macroallocation of health care in the United States
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Medical care -- Philosophy -- United States   ( lcsh )
Health planning -- United States   ( lcsh )
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Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1993.
Bibliography:
Includes bibliographical references (leaves 232-245).
Statement of Responsibility:
by Rory B. Weiner.
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Typescript.
General Note:
Vita.

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COOPERATIVE


BENEFICENCE
CARE IN


AND
THE


THE MACROALLOCATION
UNITED STATES


OF HEALTH


RORY


A DI
n rT mrnil


WEINER


SSERTATION PRESENTED TO THE GRADUATE SCHOOL
TThT-rrTn-OT.n nt' v /r T flTTTl TMT TfnY7f TAT. TTTT CTTT T.MtlrTrTr



































Copyright


Rory


1993


Weiner





































medically


needy
















ACKNOWLEDGEMENTS


wish


thank


dissertation


committee,


Drs.


Robert


Baum,


Robert


D'Amico


, Paul


Duncan,


and


Ray


Moseley,


their


willingness


to get


involved


proj


and


help


they


have


provided


me.


also


wish


thank


Ronnie


Hawkins


and


Anne


Cate


their


invaluable


editorial


assistance.


especially


Hare.


wish


thank


extremely


grateful


sser

for


station


supervisor,


opportunity


R.M.

work


with


such


eminent


philosopher


even


more


grateful


time


, the


patience,


and


encouragement


he provided


over


past


two


years.


also


Graduate


wish


School


thank


their


Philosophy


financial


Department


support.


and


Philosophy


Department


provided


with


teaching


assistantship


almost


entire


graduate


career


opportunity


to teach


areas


relevant


dissertation


topic.


Graduate


School


valuable


awarded


six


Humanities


months


support


Fellowship,


which


crucial


provide


stage


dissertation.


Finally


wish


to thank my


family


friends


who


were









had


faith


that


some day


would


finish.


am grateful


to my


brother,


Hilton,


for his support


, especially during some very


hard


times.


also


enjoyed


many


arguments


had


over


health-care reform.


My many friends who meet weekly at happy


hour


deserve


warm


thanks


their


discussions


camaraderie;

encouragement


particular,


was always appreciate


grateful

d. But of


Greta,


whose


the thanks,


strongest


goes


Dionna.


The


hardships


typically


associated with writing a dissertation were softened and made


manageable


her


perpetual


optimism


and


support


and


unwavering


belief


in my abilities.

















TABLE OF


CONTENTS


ACKNOWLEDGEMENTS


ABSTRACT


. . . viii


CHAPTERS


INTRODUCTION

REVIEWING HEALTH-CARE MACROALLOCATION ETHICS

Introduction


The Rights Approach


Justice


Fairness


Extending


Just


ice


Fairness


The Charity
Robert


Approach
Nozick' s


Libertarianism . .


Tristram Engelhardt'


Libertarianism


Enforced


Health


Charity
Care as


Approach
a Collective Good


Is Enforcing


IMMANUEL KANT


Charity


AND THE DUTY


Enough?


OF BENEFICENCE


Introduction


The Supreme Moral
The Groundwork


Principle


Formula
Formula


Universal


Respect


Law


Persons


* 5 0 5
. .


The Doctrine
Duties
The Dut


of Virtue
of Virtue


* a a a a a a S
. a a 0 0 .


of Beneficence


Enforcing
Conclusion


the Duty


Beneficence


JOHN STUART MILL AND THE DUTY


OF BENEFICENCE


Introduction


J.S.


Mill's


Utilitarian Moral


Theory


--


C CI









COOPERATIVE BENEFICENCE


Introduction


Limit


s of


Beneficence and Sup


ererogation


R.M.


Hare


s Two


Levels


of Moral


Thinking


A Principle


Challenges


Cooperative Beneficence


to Beneficence


The Dischargeability Thesi
Optionality Thesis
Responsibility Thesis


Enforcing Cooperative


S .


Beneficence


The Harm
Possible


Prevention
Objections


Principle


Conclusion


COOPERATIVE BENEFICENCE AND


HEALTH-CARE


REFORM


IN THE UNITED STATES.


Introduction


United States


Health-Care


"System"


The Medically


Needy


Uninsured


Underinsured
Uninsurable
Intermittently


Insured


Ethical


Criteria


Evaluating


Health


are


Reform Plans


Basic


Design


Principle


Fair Cooperative


Effort


Principle


The Reasonabl


Burden Principle


Evaluating
Market
Single
Single
Conclusions


Health


-Care Reform Strategi


Reform Strategy


-Payer
-Payer


, Canadian
, American


211


Style
Style


Strategy
Strategy


REFERENCE


LIST


BIOGRAPHICAL SKETCH
















Abstract


of Dissertation Presented


the Graduate School


:he University
Requirements f


Florida


the Degree


in Partial


Doctor


Fulfillment


Philosophy


COOPERATIVE BENEFICENCE AND THE MACROALLOCATION


CARE


OF HEALTH


IN THE UNITED STATES


Rory


August,


Weiner

1993


Chairperson:


Major


R.M.


Department:


Hare
Philosophy


This dissertation offers some arguments for amending both


theory


underlying


and


practice


associated


with


duty


of beneficence.


It develops a


principle of


cooperative


beneficence


evaluating


current


macroallocation


health


care


United


States.


The


first


argument


historical.


argues


that


both


Immanuel


Kant's


and


John


Stuart


Mill's


moral


theories


support


principle


beneficence that justifies enforcing plans


to help the needy.


This


principle


beneficence


requires


individuals


cooperate in such plans.


The second argument further develops


this


duty


cooperate


institutional


relief


efforts


distinguishing


from


acts


supererogation,


which


are


a - - )r r









reasonably

requires


require


individuals


everybody


follow.


cooperate


This


help


principle


needy


fulfilling


some


well-defined


equitable


role


toward


that


end.


The


third argument responds


to the charge


that a duty to help


the needy is too demanding


morality


and


so not a viable requirement of


This criticism is mistaken since


conflates what


a single


individual


can do with what


only a


collective effort


can


duty


help


needy


belongs


class


duties


that


requires


collective


efforts


fulfill


them.


Thus,


one


duty


to help


needy


does


require


endless


giving,


fulfilling


one'


role


principle


cooperative beneficence prescribes.


The fourth argument aims


justify


legally


enforcing


this


principle


using


example


legislating


universal


health-care


program


helping


medically


needy


(the


medically


uninsured)


Enforcement


both


necessary


effective


compelling


individuals


discharge


their


duty


and


overcoming


free-rider


problem.


Finally


the


dissertation


uses


this


principle


cooperative beneficence


to outline some ethical


criteria


evaluating


three


current


health-care


reform


strategies: a market reform strategy,


a single-payer


, Canadian


style


strategy,


and a


single-payer,


American style


strategy.


suggests


that


single-


payer,


American


style


strategy


best meets


these ethical


criteria and similar


strategies are
















CHAPTER


INTRODUCTION


We are discussing no
but how we ought


small


matter,


to live.


Socrates


in Plato'


Republic


The problem of providing satisfactory medical service to


all
meet


people of


the
*


pressing


United States


one


costs


which


present


they


time,


can
many


persons ao I
in quantity


receive


quality,


service which is adequate either


and


costs


service


are


inequably distributed.


The result is a tremendous amount


of preventable physical pain and mental anguish,


deaths,


economic


Furthermore,
unnecessary.
resources,


these


inefficiency,
conditions


United


organizing


States
ability,


social


are


has
and


the
the


needless
waste.
largely


economic
technical


experience to solve this problem.


(Committee


on the Costs


of Medical


Care,


1932:


This 1932 summary of the first comprehensive study of the


United


States


applicable


health-care


today--over


delivery


years


later.


system


Thus


entirely


reveals


long struggle


that


the United States has


faced trying to meet


health-care


needs


population.


those


sixty


years,


problem


numerous


attempts


access


have


health


been


care


made


(Jonas,


address


154ff)


fact


those


1932


findings


stimulated


serious


consideration


national


health


insurance


(NHI)


was


to be


incorporated


I -- I I











1984)


Still,


1938


and


again


1943,


Senator


Robert


Wagner,


New


York


introduced


maj or


health-care


legislation;

occasions, c


but


neither


opponentss


bill

legis


very


lation


far.


(e.g. ,


both


American


Medical


Association


[AMA]


"vigor [ously]


attacked"


proposals


1949.


(Jonas


Harry


, 154


Truman,


Legislation


reelected


was


introduced again


president


enjoying


Democratic


majorities


both


houses


Congress,


made


national health insurance a major goal


of his administration.


pharmaceutical


industry,


insurance


industry,


AMA


"mounted


furious


[and


successful]


attack


plan"


(154)


After Truman withdrew his support for NHI,


a new


campaign


began


that


eventually


1965


passage


Medicare--a


elderly--and


universal


Medicaid--a


health


insurance


health-care


program


assistance


program


welfare


recipients.


had


become


apparent


writes


Richard


Brown,

that private health insurance would not meet the needs of


the poorly paid,


families
-single


nonunionized working population or their


or those who were very poor and unable to work-


parent


households


with


very young


children,


blind and disabled,


and


the aged.


(1984


: 53)


Medicare


and Medicaid


were


only


"band-aids"


and the poor


(Brown,


1984)


By the end of


'60s,


problems


. .. I I












Today the


United States


still


faces


a crisis


health


care


delivery


and


continues


debate


what,


any,


comprehensive legislation should be adopted.


It is common now


cite


insurance,


that


that


almost


ove r


million


million


people


are


have


health


underinsured


that


annual


health-care


costs


will


soon


consume


country'


Gross


Domestic


Product,


over


one


trillion


dollars.


As in past debates over health-care reform


, the current


debate includes


in part a perennial moral


question:


access


health


care


right


privilege


(i.e.,


favor,


service) ?'


In other words,


access


to health care something


that


society


ought


guarantee,


even


that


requires


government


coercion?


access


health


care


only


praiseworthy


ideal,


and not


an enforceable


requirement?


rights advocates,


invoking individual rights to health care is


essential


step


justifying


comprehensive


health-care


legislation


, since rights language has traditionally expressed


demand


governmental


action,


i.e. ,


protection


individual


right.


opponents


rights


health


care,


however


, denying


individual


right


health


care











essential


step


for preserving


freedom in


distribution


health


care,


especially


economic


freedom.


call


strategy


that


attempts


establish


universal


right


health


care


"Rights


Approach"


macroallocation


of health


care.


According


this


approach,


individuals


have


positive


right


health


care


and


government


justified


enforcing


that


right


enacting


appropriate


legislation.


call


strategy


that


claims health care


is not a right


a "Charity Approach"


to the


macroallocation


health


care.


According


this


approach,


individuals do


not


have a


right


to health


care,


thus


government


never


permitted


force


anyone


participate


must


health-care


depend


planning.


voluntary


Health-care


associations


planning


charitable


persons

the next


(More details about these approaches will be given in


chapter


Interestingly,


the 1983 President


s Commission,


Securing


Access


to Health Care,


decided to avoid answering the question


whether health care is a right


Instead


, the report tries


provide


[ethical]


framework


within


which


debates


about


health-care


policy


might


take


place;"


framework


that


neutral


with


respect


whether


health


care


right


concluded


that


"society


a moral


obligation


ensure


(3)











that


everyone


access


adequate


care"


(22)


Commission did not believe that


establishing a moral


right


health


care


was


"necessary


foundation


appropriate


governmental


action


secure


adequate


health


care


all"


(32-33)


The


Commission


explains


that


" [it]


chosen


concentrate


on


nature


societal


obligation,


which


exists


whether


or not


people


can


claim a


corresponding


right


to health


care"


(32-33)


According to some,


the Commission implicitly


(and partly)


adopted what


can be


called an


"Enforced


Charity


Approach"


macroallocat ion


health


care


(Sass)


Allen


Buchanan


develops


this approach in a


paper written for the President


Commission


(Buchanan,


1983


According to Buchanan,


voluntary


associations of charitable persons will succumb to problems of


collective action


providing


that


health


will


care


undermine


group


their


charitable


s charitable


aim


aims.

then


enforcement is justified since it is necessary and suffi

for overcoming barriers to successful collective action.


cient


More


details


Buchanan'


arguments


will


given


next


chapter


For proponents of rights to health care


, the Commi


ssion'


decision to retreat from rights language,


which it used in its


1952


report,


was


setback


justifying


comprehensive











too


weak


purposes


passing


legislation


that


guarantees


universal


access


health


care.


claims


that


Commission


trying


use


traditional


concept


"imperfect duty,


" which he believes is a weak duty--associated


with voluntary acts of


charity or beneficence-


-as


compared to


"perfect


duty,


which


believes


strong


duty


associated with


Arrass


justice and


individual


criticism


part


rights.


justified.


Commission'


report


does


not


provide


much


support


strength


"ethical


obligation.


Nor,


fact,


does


Allen Buchanan.


The aim of this dissertation is to extend the


strategy of


the Enforced Charity Approach one step


further by


amending


both


theory


underlying


and


pract


ice


associated with


the duty of beneficence.


3 The


first argument


historical.


chapters


three


and


four


argue


that


both


Immanuel


Kant


and


John


Stuart


Mill


support


principle


beneficence that


justifies enforcing plans


to help the needy.


This


principle


requires


individuals


cooperate


such


plans.


The second part of the argument


(chapter five


further


develops


this duty


to cooperate


in efforts


to help


needy


should make clear that


the dissertation is not aiming


justify


report.


any
use


conclusions


report


President's


an example


Commission's


an approach


that


I- I -~ 1 I .











distinguishing


from


acts


supererogation,


which


are


praiseworthy,


but not universally required .


Using R.M.


Hare'


two-level


theory of moral


thinking,


I argue for a principle of


cooperative


beneficence


that


can


reasonably


require


everyone


follow.


This


principle


prescribes


duty


beneficence


collective


that


efforts


each


that


person


help


has,


VIZ.


needy,


cooperate


e.g.,


medically


needy


medically


uninsured)


, by


fulfilling


some


well-


defined


equitable


role


toward


that


end.


call


this


strategy


"Cooperative


Beneficence


Approach.


Chapter


six


will


attempt


illustrate


how


apply


this


approach


outlining


some


ethical


criteria


evaluating


three


current


health-care reform proposals.


Unfortunately,


the illustration


is extremely preliminary,


and


only makes


some


suggestions


about


the moral acceptability of


these proposal


but arrives


at no definitive conclusions.


beginnings


However,


understanding


hope


how


can provide


Cooperative


Beneficence


Approach


might


contribute


current


moral


debates over the macroallocation of health care in the United

States.
















CHAPTER


REVIEWING


HEALTH-CARE


MACROALLOCATION


ETHICS


Introduction


Currently


, moral


arguments


about


macroallocation


health


care


United


States


take


one


three


forms


Rights

Approac


Approach,


a Charity


According


to the


Approac,

Rights


and


Approach


an Enforced


Charity


individuals


have


a positive


moral


right


to health


care


, and


government must


protect


that


right


enacting


universal


health


-care


legis


lation.


According


to the


Charity


Approach,


individuals


not


have


a positive


right


health


care;


they


only


have


negative


rights


against


interference


their


life


plans,


e.g.,


rights


against


physical


harm,


theft


or fraud.


Thus


, the


government


never


permitted


force


anyone


participate


in health


-care


planning.


If universal


health


care


desirable


, then


may


achieved


through


voluntary


associations


of charitable


persons.


According


to the


Enforced


Charity Approach


, strictly voluntary association of


charitable


per


sons


will


succumb


to problems


of collective


actions.


Since


legi


slati


efforts


would


necessary


effect


* I- *


-1


I 1 1 -


1


1


I


|


11











The aim of


the chapter is


to further explain


these


three


approaches


and


critically


comment


them.


chapter


does not,


however,


attempt


to disprove a particular approach.


It merely aims


to provide


a sufficient map


that


explains


reason for developing another approach,


which will be outlined


later


chapters


(chs.


3-5)


This


new


approach--a


Cooperative Beneficence Approach-


-builds on the basic strategy


Enforced


Charity


Approach


further


developing


theory underlying and the practice associated with the duty of

beneficence.


The Rights Approach


The Rights Approach attempts to


justify a positive right


health


care


, "namely,


that


ought


have


access


adequate


health


care,


regardless


our


income


level"


(Daniels


, 1979


190)


While some proponents of


this approach


ground

justice


this


right


(Veatch,


1976


strict


Outka;


egalitarian


Gutman)


conception


, and while others argue


natural


right


health


care


(Boyle;


Dougherty


, the


most


systematic


attempt


to ground a


positive


right


to health


care


been


extend


Rawls'


conception


justice,


"justice


fairness"


A Theory


Justice


(1971


(Green,


1976,


1983;


Daniels,


1979,


1985)


After


briefly


summarizing












Justice


as Fairness


John


Rawls,


A Theory


Justice


(1971)


, develops


theory


justice


, "justice


fairness"


, as


basis


regulating


basic


structure


society,


e.g.,


political,


economic,


legal


and


social


institutions.


Rawls


aims


to find principles of


justice


that provide a


just


.e. ,


fair)


distribution


essential


life


prospects


"primary


Soc


goods,


" e.g. ,


liberty,


power,


opportunity,


income


wealth


self-respect.


According


Rawls,


such


"fair"


principles


necessarily


follow


from


"fair"


agreement


social


contract.


"They


are


principles,


" he


says,


that


"free


and


rational


persons


concerned


further


their


own


interests would accept


in an


initial


position


of equality


defining


fundamental


terms


their association"


The agreement,


or social


contract,


"fair"


because the


fundamental


terms


the agreement


are


fair


Each person


free,


prudently rational,


and most


importantly


"in an initial


position


equality,


" namely,


one


has


an advantage


over


another--no


one


superior


physically,


intellectually,


psychologically,


socially


economically.


According


Rawls,


this


"liberal"


conception


justice


seeks


to nullify


individual differences


that are arbitrary


"from a moral


point


S S *


--


__ *


C


C











guarantee


fairness,


Rawls


stipulates


that


contractors


choose


principles


while


under


"veil


ignorance.


This veil,


he claims,


"nullif [ies]


the effects of


specific contingencies which put men at odds and tempt them to


exploit


social


natural


circumstances


their


own


(136)


According to Rawls,


the contractors do not


know the


following


information:


[N] o


one


position <
fortune ir
abilities,


knows


social


place
status


distribution
intelligence


in society
nor does


natural


and


strength


know


assets


and


and


like.


Nor,


again,


does


anyone


know


conception


the
life,


such


;ood, tk
or the
his a


particulars


special
version


features


risk


rational


plan


is psychology
liability to


optimism
that th


pessimism.


More


parties


than


know


this,


assume


particular


circumstances


their


do not know its economic


own society.
: or political


That


they


situation,


level


civilization


and


culture


been


able


position
generations


achieve.


have


The


persons


information


they belong


original
S which


(137)


Assuming


that


veil


ignorance


original


position is


sufficient


to guarantee


fairness,


subsequent


agreed-to


principles


will


fair


(i.e.,


just


These


principles

influences


will

the


regulate th

distribution


e basic


structure


primary


goods


society


, e.g.,


that


liberty,


opportunity,


wealth and


so on.


These are


"things


that


every


rational


[person]


presumed


want


[and


they]


^ .


advantage"


I *^ ( /- r *I /^


I











chief


society
income,


are


primary


goods


liberties,


wealth


powers


the
and


[and self-respect]


disposition of
opportunities,


These


are


the social


primary goods.


Other primary goods such


as health and vigor,


intelligence and


imagination,


are


natural


goods;


influenced


they
303)


are


although


basic


directly


their


structure


under


possession i
[of society]
control. (62


Since Rawls'


theory is idealized,


the basic structure of


society


does


greatly


influence


distribution


"natural


goods.


He assumes


, in other words,


that


"the


first


problem of justice concerns the relations between citizens who


are


normally


active and


fully


cooperating members


society


over


complete


life"


(Rawls,


1982:


168)


Thus,


basic


structure


Soc


iety


does


regulate,


instance,


distribution


health


care


per


since


Rawls


idealization no one


is sick.


However


, the basic structure of


society

social


does

goods,


strongly


e.g. ,


influence

liberty, o


the distribution


opportunity,


"primary


income and wealth


and self-respect.


ince one'


health may be a prerequisite to


one or


these


primary social


goods,


Rawls'


principles


of justice may play a role in justifying a reasonable level


guaranteed


access


current


health-care


resources


and


technology


Rawls,


however,


silent


this


topic


(see


Green,


1976


Nevertheless,


some


believe


principles


just


can be extended to justify a positive right


to health











society


which


they will


subsequently


live?


According


Rawls,


they would


choose


following principles.


The


principle


greatest


equal


liberty:


each


person


extensive


basic


have a
liberty


Ln equal


right


compatible


with


most


similar


liberty


others


, see


also


201-205)


The principle of


fair equality of opportunity:


offi


ces


conditions


and positions


fair


[are to be


equality


open to all
opportunity


under


, 83-89)


The


Soc


difference


ial and economic


principle:


institutions are to be arranged


that


least


they


are


advantaged.


the greatest
, 75-83)


benefit


Contractors


in the


original


position


would


choose


these


principles


, argues


Rawls,


because


they


would


use


"maximin


reasoning


" namely


, reasoning that


"directs


our attention


the worst that can happen under any proposed course of action,


and


decide


light


that"


(154


free


and


rationally


prudent


contractors


original


position


believe that


choosing these three principles of


justice would


ensure each


will


receive


the greatest


possible minimal


share


of life prospects,


1i.e. ,


primary goods for constructing a life


plan


accordance


with


their


own


conception


good.


According to Rawls


, choosing these principles is more rational


than


gambling


with


one'


life


prospects


and


choosing











alternative


principles,


e.g.,


principles


that


maximize


overall


good.


Choosing


these


utility maximizing principles,


says,


would


permit


some


individuals


to benefit


greatly


expense


slavery


others,


overall


e.g.,


good


these


were


principles


maximized.


would


5 "In


condone


this


respect,


" he adds,


"the


[three]


principles


justice have a


definite


advantage.


only


parties


protect


their


basic


rights


they


insure


themselves


against


worst


eventualities"


(176


The first principle--the liberty principle--regulates the


distribution


basic


liberties,


e.g.,


liberties


expression,


property,


etc.


Whatever basic liberties a society


protects,


liberties.


citizens


These


negatively.


should be


protected


example,


society


equally


liberties


protects


entitled


are


one'


to similar


understood


s freedom


pursue political office by prohibiting others from interfering


with


that


goal.


first


principle


justice,


then,


justifies


negative


rights


to basic


liberties


compatible


with


similar


liberties


to all.


second


principle--the


principle of


fair


equality


opportunity--regulates the distribution of


opportunity,


power


and


authority


offices


and


positions


they


open


are


to all.


attached


This princi


institutional

ple prohibits











against


someone


based


characteristics


other


than


her)


abilities


and


skills.


But


principle


goes


beyond


prohibiting


formal


barriers


requires


society


assist


those


individuals


who


would


not


have


fair


chance


obtaining


institutional


positions


and


offices


misfortunes


arising


from


natural


social


lottery.


"Positions


Rawls


are


explains


to be

"but


not

that


only

all


open


should


[that]


have


forma

fair


sense


chance


attain


them"


emphasis


added)


"fair


chance"


Rawls


means


that


one'


chance


for a


certain position should not


affected by


[one


social


class.


for instance,


says


necessary


social


impose


system


further


[namely


structural


preventing


conditions


excess


accumulations of wealth and of maintaining


equal opportunities


education


all"


school


system,


adds,


"whether


public


private,


should


designed


even


class


barriers"


(73)


second


principle


justice,


then,


goes


beyond


first


one.


Besides


requiring


society


make


offices


positions

providing


open

the


all,


appropriate


makes


society


resources


that


responsible


individuals


will


have


fair


chance


those


offices


positions.


Justice,


then,


requires


that


society


take


positive


steps












justifies not


only negative rights against


formal barriers to


opportunity,


positive


rights


goods


services


appropriate


giving


one


"fair


chance"


opportunities


open


to all.


The third principle--the difference principle--regulates


distribution


wealth


and


income


permitting


inequalities


only


social


and


economic


institutions


are


arranged so as


to benefit


the worst


off.


instance,


Rawls


believes that


this principle permits inequalities between the


entrepreneurial


class


and


working


class


because


"the


greater


expectations


allowed


to entrepreneurs


encourage


them


things


which


raise


long


term


prospects


the]


laboring class"


The difference principal


would justify


some


positive


rights,


e.g.,


welfare


rights,


subsistence


rights.


this


case


, the


worse


have


right


some


increase


in wealth


income


result


unequal


economic


arrangements.


The


equality


principle


opportunity


liberty


takes


principle


priority


and


both


over


take


fair


precedence


over


difference


principle.


Thus


liberty


cannot


exchanged for greater opportunity and neither can be exchanged


greater


wealth


and


income


For


example,


just


society must


forbid


institution


of slavery


even


that











principle,


Rawls


stresses


that


"the


general


conception


justice]


simply


difference


principle


applied


primary


goods


including


liberty


and


opportunity.


suffices


to remark that


in one form or another


the difference


principle is basic throughout"


(83,


emphasis added).


That is,


justice requires society to improve the condition of those who


are worst


For Rawls,


terms


then,


liberty,


justice


opportunity


fairness.


or wealth.


Fairness respects


the basic


equality


persons--an


equality antecedent


any differences


that


arise


from social


contingencies


natural lottery.


To achieve fairness,


society is responsible


for guaranteeing the individual a fair share of primary social


goods necessary to pursue her


(or his)


conception of the good.


Thus


individuals


original


position


regard


"the


distribution


of natural


abilities


as a collective


asset"


structure society


so that


"each person can participate


in the


total


sum


realized


natural


assets


others"


(101


, 179,


523)


Each


person,


that


right


talents


and


assets


others


Se. ,


their


goods


and


services)


when


appropriate


to equalize


unmerited differences


resulting


from


unmerited


starting


points.


These


rights


flow


from


principles


justice


that


regulate


basic


structure


society and are necessary for securing fairness among persons.












for assistance or


for compensation for one's misfortunes


(see


Daniels,


1990)


As


shall


see,


one


obvious


morally


arbitrary factor that reduces one


s chances


to receive a fair


share


life prospects


is disease and disability.


The need


health


care,


one


might


surmise,


mitigating


these


factors


should


responsibility


just


society


conceived by


Rawls


Norman Daniels


believes


and


we will


now turn


to his


theory


justice


health


care.


Extendinsc


Justice


Fairness


Does


Rawls


theory


justice


justify


a positive


right


to health-care


services?


Given both the role of


ill health in


one


s prospects


enjoying


freedom,


opportunity


wealth


and the extent


to which ill health results from misfortunes of


the natural and social lottery


solid justification for requiring


Rawls'


access


theory should provide

to whatever services


are


available


(Green,


1976,


1983)


However


Norman


Daniels,


"Rights


to Health


Care and Distributive Justice:


Programmatic


Worries"


(1979)


, which


reviewed


attempts


extend Rawls


theory to


health


care,


concludes


that


such an


extension


so clear.


left


with


common


philosophical


embarrassment.


intuition


couched


have


taken


terms


fairly
right t(


simple
health


j 1 I 1


-- -- -- -- m E


I


1_ 1 _











According to


Daniels,


to extend Rawls


s theory properly,


two


questions must be


clearly


addressed.


What


kind


SOC


good


health


care?


example,


health


care


SOC


good like liberty,


separate principle of


opportunity or wealth


justice


that


would require a


distribution?


How


should health care be ranked in


terms of priority relative


other


social


goods


(e.g.,


education)


and relative


to various


kinds of health care


Daniels believes that health-care needs


"behave


in peculiar


ways


compared


other


needs


and


wants"


(1979


190)


to extend Rawls


s theory


, Daniel'


believes


health-care


needs


help determine


require


whether


health


special

care -


analysis--one


Ls a primary


that


social


will

good,


one


that


will


help


rank


this


good.


Health


care as


protecting


opportunity


Norman


Daniels,


Just


Health


Care


(1985


, develops


theory


health-care


needs


determining


whether


health


care


is a primary


social


good and


developing


a criterion


for ranking health care relative


to other social


goods.


Such


a theory,


Daniels believes,


helps him to extend Rawls


s theory


of justice and to justify a positive right


to health care


argues that health


care is not a Rawlsian primary social


good


per


but some health-care needs are necessary prerequisites


to opportunity,


which is a primary social good.


That is,


some











care


resources


are


important


ensuring


that


everyone


fair equality


opportunity.


Like


education,


health


care


an important


role


in equal


zing


misfortunes


social


and


natural


lottery


that


undermine


one


fair


chance


opportunities


open


to all.


If justice guarantees


fair


equality


opportunity


, then


it would


guarantee


access


to health


-care


services


since


health


represents


a fundamental


barrier


fair

right


equality

to health.


of opportunity.

h care by placing


Thus


Dani


health


els derives


- care


a positive


institutions


under


fair


equality


of opportunity


principle.


Analyzing


impact


health


on opportunity


key


, according


Daniels,


explaining


importance


meeting


health


-care


needs.


Daniels


argues


that


fundamental


criterion


that


determines


relative


importance


health


impinge


- care


on one


needs


s fair


centers


share


extent


opportunity


which


range


they


relative


one


s society.


It is that


impact


on opportunity


that


makes


health


-care


needs


"special


Health


- care


needs


should


have


priority


over


other


needs


because


they


have


greatest


impact


attainment


normal


functioning


typical


of a member


one


s species.


That


, disease


disability


have


greatest


impact


on what


calls


"normal


species


functioning


" and


that


impact re


duces











normal


functioning"


and


"impairments


normal


species-


typical


functioning


reduce


range


opportunity


open


to an


individual

'conception


which

the


may


good'"


construct


Thus,


'plan


certain


life'


health-care


services


are


necessary


protecting


a person


from


departing


from

life


his

plans


"normal opportunity

reasonable persons


range,


[their


" namely,


society


"the

are


array

likely


construct


themselves"


(33)


Although


"range "


relative


key


features


society--e.g.,


its


material


wealth


technological


development


"and


even


cultural


facts


about


(attitudes


toward family and


careers)"


--nevertheless,


Daniels


argues


, failing


to meet


health-care


needs


represents


fundamental


impairment


opportunity.


N]ormal-species


functioning


provides


with


one


clear


parameter
normal i


relevant


?ange


to determining


open


a given


what


share


individual


and


functioning
constitute
opportunity


for


talents.


through
a fundamental


relative


moment,


Impairments
disease anm
restriction


tha t


portion


individual


normal


disability
individual


of the


normal


range


which


individual' s


particular


skills


and


talents


would


ordinarily


have


made


available


him"


(Daniels


, 1984:


107-108


approach


care,


abstracts


the maintenance


a central


species


function
-typical


of health
functional


organizati
effect on


and


function,


opportunity.


notes


Specifically,


its


central


diseases,


different


ways


opportunity


and


to different


available


degrees,


an individual


impair
relative


the
- S


normal


opportuni ty


range


- SI


Sfor


his


society.


holding
skills


constant,


1 ..











fair


allocation


health-care


resources,


then,


essential


for guaranteeing that everyone has fair equality of


opportunity,


since health-care services help minimize,


prevent


or compensate for departures from normal species functioning,


and


since


departures


from normal


species


functioning


(i.e.,


disease


disability)


constitute


important


barrier


fair equality of


opportunity,


understood for Daniels as one


fair


share


normal


opportunity


range


society


where


one


living.


For


Daniel


then,


"health-care


institutions


should


have


limited--but


important--task


protecting people against a serious impediment to opportunity.


On this view,


" he continues,


"shares of


the opportunity range


will be


fair when positive steps have been taken to make sure


that individuals maintain normal


functioning,


where possible"


(1985


"Moreover"


he


says,


account


not


equivocal.


The social


considerations


obligation I


justice


discuss


[and]


such


is rooted


obligations


will


correspond


rights


individuals"


(54)


Daniels


emphasizes


that


use


fair


equality


opportunity principle


Rawls'


health-care


more general use of that principle.


institutions parallels


Rawls's principle


important"


when pursuing


jobs


and


offices.


That


Rawls


supports


taking


itive


steps


increase


"strategically











action


and


Head


Start


programs.


point


23

stresses


Daniels,


accidents


"none


deserves


birth--either


advantages


genetic


social


conferred


advantages.


These


advantages,


continues,


"are


morally


arbitrary,


because


they


are


deserved,


and


them


determine


individual


opportunity--and reward and


success


in life--is to


confer arbitrariness on the outcomes"


(46)


Like Rawls


, then,


Daniels


believes


that


principle


fair


equality


opportunity


requires


that


society


arrange


institutions


provide


points


equal


resulting


opportunity


from


natural


face


different


and social


starting


lottery


Daniels


goes


further


than


Rawls


using


fair


equality


opportunity


principle


justify


mitigating


effects


disease on opportunity.


According to Daniels,


equally


disadvantages


important


use


induced


resources


disease.


to counter


(Since


social


natural


conditions,


which


differ


etiology of


class,


disease,


we are


contribute


significantly


reminded that disease is not


just


product


natural


component


lottery.


However


warns,


approach does


require


"levelling"


all natural differences.


"Health care has normal


functioning


goal:


concentrates


specific


class


obvious


advantages


and


tries


eliminate


them.


That












Problems


for Daniels


and


Rawlsian


justice


Daniels


s strategy


deriving


right


health


received


great


deal


critical


attention.


These


criticisms


fall


into


two


categories.


One


s critical


approach apart


from his Rawlsian account


of justice.


other


set


critical


account


because


reliance


on the


fundamental


nullifying


Rawlsian assumption


effects


natural


that


and


justice


social


requires


lottery


because


they


are


morally


arbitrary.


The


following


will


briefly


explain


each set


criticisms


respectively.


Regarding the first set,


Daniels


some worry that the vagueness of


s central concepts in his theory of health-care needs,


e.g. ,


normal


opportunity


range


and


species


typical


functioning,


will


undermine any explanatory power he hoped to


achi


eve.


For example,


Lawrence Stern concludes the following.


[Daniels'
the basis
unworkable


proposal


fair


distribute


equality of
3 concepts


health


care


opportunity


species


typical


activity and normal


opportunity


range


are unclear;


so is the relationship between them.


Daniel


concept


opportunity


iS SO


inclusive,


notion


balancing


theory


loses


opportunities
systematic power


vague,
339)


that


Stern


complains


that


there


necessary


relationship


between


species-typical


functioning


and


decrease


S A-- .- -.


F


1n~


__


* *.


I


I I


I


1 *











example,


certain


degree


impairment


may


normal


society,


or we may want


to alleviate what


is species


typical,


cancers


diseases


resulting


from


aging


immune


tem.


Thus


Stern


believes


Dani


s theory


incomplete


with regard to the distribution of health care when impairment

of species typical functioning and loss of opportunity are not


connected--consider


psychotherapy,


hypertension,


hysterectomies


(345ff


Others


complain


that


Daniels


use


fair


equality


opportunity principle


to ground a


right


to health


care


too


demanding


social


resources


(Moskop:


335;


Buchanan,


1989


: 315ff)


If we assume that this principle takes priority


over


other


principles


justice


(except


principle


that distributes basic liberties


in almost unlimited quantities of


then Dani


resources


els risks

" in the


"sucking

"name of


implementing


right


health


care"


(Buchanan,


1989:


315-


316)


Daniels


right


to health


care,


Buchanan


complains,


requires


that


we continue


to pump social


resources


into


bring


health


care


individuals


) long
closer


doing


continues


ideal


normal


species


life


functioning--which


free


disease


and


Ls nothing
disability


less


than


, since


latter
species


are


defined


functioning.


departures


from


normal


(315)


Daniels


, recall,


stressed


that


"Health


care


has


normal


functioning


goal:


concentrates


on a


specific


class












func


tioning-


-might


workable;


it might


too


broad


entitlement.


A right


that


broad,


argues


Buchanan,


would


make


health


-care


sector


a kind


"black


hole"


because


"there


virtually


limit


how


much


could


done,


granted


continuing


technological


advances,


to bring


[those


with


grave


disability


sease


closer


to the


goal


of normal


spec


functioning"


Thus


commitment


providing


resources


remedy


compensate


those


born


mentally


retarded,


blind


deaf


with


AIDS


or with


one


of thousands


genetic


or socially related medical


problems


consider mothers


who


harm


their unborn


children by


using


drugs


would


amount


limitless


right


to health


care.


only


constraint


would


be balancing


resources


necessary


fund


health


-care


system


with


guarantee


one


fair


share


fund


other


normal


programs


needed


opportunity


range,


e.g.,


education.


meeting


health


-care


needs


mitigates


deviations


from


the normal


opportunity range more


than meeting


educational


needs,


then,


Dani


view


sole


resources


Determining


should


which


spent


health


- care


health


care


resources


before


should


education.


funded


terms


priority


relative


other


social


resources


and


relati


to other


health


-care


needs


is a difficult


problem


anyone


writing


on this


issue.


However,


is not


clear


resources











second


set


objections


criticizes


Daniels'


approach

justice


because

requires


reliance


counteracting


on Rawls'


inequality


assumption

ies that r


that


*esult


from


natural


and


social


lottery


, since


they


are


morally


arbitrary.


Following


Rawls,


Daniels


believes


that


any


individual


social


who has had unfortunate draws from the natural and


lotteries has a legitimate claim--a right--against


more


fortunate


for assistance


or for


compensation


that


would


give him a


fair


chance


to construct a life plan he would have


otherwise constructed.


For Daniels,


individuals have a claim


against society to take positive steps to maintain and restore


normal


functioning resulting from disease and disability that


was


fault


their


own.


These


diseases


disabilities


are undeserved and impede one'


fair share of opportunity,


and


society


responsible


guaranteeing


that


appropriate


health-care


resources will


be available


those


with


such


health


care-needs.


This


social


obligation


correct


diseases


and


disabilities


deriving


from


natural


lottery,


says,


"binds everyone"


(119)


However,


claim


that


"morally


arbitrary"


factors,


e.g.


, disease


social


class,


should


limit


one


s fair


share


opportunity


leads


to practical


difficulties,


since


extent


which


morally


arbitrary


factors


affect


one'












takes


person'


talents


skills


fixed


baseline


fair


equality


opportunity.


Daniels,


the baseline


is hypothetical:


these are


talents


and skills


one


would


have had if


their development had not been impeded by dise


ase


disability


(Buchanan,


1989


: 317).


However,


both


Daniels


and Rawls admit


that


there are many factors


that might


impede


opportunity that are morally arbitrary.


"The most obvious of


these,


Buchanan


points


out,


one'


normal


genetic


endowment.


Neither


Rawls


nor


Daniels


gives


any


reason


efforts


achieve


fair


equality


opportunity


should


not


deal


directly


with


this


important


'morally


arbitrary'


determinant of opportunity"


(317


, emphasis added).


Given that


new


advances


genetic


engineering


may


soon


make


technically


feasible


extend


fair


equality


opportunity


this morally arbitrary determinant,


and


given


that


Daniels'


baseline


fair


equality


opportunity


includes


talents and skills one would have had except


some


morally


arbitrary


factor,


Daniels


s account,


Buchanan


concludes,


seems


"require


use


resources


increasing


opportunity


those


who


are


not


genetically


di sabled


diseased


but


who


are


nonetheless


genetic


disadvantage


relative


more


fortunate"


(317


, emphasis


added).












227;


Engelhardt,


1979,


1986)


natural


lottery,


they


argue,


something


that


"moral


agents


must


strive


correct,


rather


something


outside


scope


morality


least


strict


sense


of rights


and


duties


grounded in


justice"


(Moskop:


, emphasis added).


"Whether


people'


s natural


assets


are


arbitrary


from


moral


point


view


" Robert


Nozick asserts


"they are


entitled


them,


and


what


flows


from


them"


226)


Besides,


Nozick


points


out


nothing


moral


significance


could


flow


from


what


was


existence


arbitrary,
could be


which


many


then


moral
sperm


particular


significance,


cells


person's


since


succeeds


fertilizing


know)


arbitrary


from a moral


point


view.


(226)


Tristram Engelhardt


(1979)


argues


that


despite


fact


that


natural


and


social


lotteries


might


cause


most


diseases and disabilities,


these conditions and their


effects


are


unfair


unjust,


simply


unfortunate


(116)


According to Engelhardt,


there is no social duty to ameliorate


these conditions since no one is responsible for causing them.


Is up


to communities


to choose


to help the sick


or not and


decide


what


extent.


Helping


those


less


fortunate,


according


these


libertarians,


is not


a matter


justice,


but a matter of


charity--a voluntary,


not a required practice.


- -





1. I -


I


q











believe


that


peoples'


assets


and


abilities


are


common


property at


the disposal of


others who by the accidents of the


natural lottery received less.


libertarians,


individuals


are


entitled


their


natural


assets


and


abilities,


justice functions only to protect


those entitlements.


We will


now


turn


this


contrasting


conception


justice


implications for the distribution of health care in the United


States.


The


Charity


ADDroach


According


Charity


Approach,


justice


does


guarantee a positive moral


right


to aid;


only functions


secure every person'


antecedent right


to liberty,


especially


the liberty to choose how to distribute what


flows


from one


natural assets and


talents,


e.g.,


one'


property.


Violations


this


basic


negative


moral


right


noninterference


constitute


an injustice.


The government'


central function is


securing justice,


and thus


forbidden to


force anyone by


participate


helping


others,


including


any


social


planning,


e.g.,


health-care


planning.


Health-care


planning,


libertarians,


must depend on the voluntary associations of


charitable persons.


To narrow the


scope of


the discussion


will


discuss


Robert


Nozick'


(1974)


original


argument












Robert


Nozick


s Libertarianism


Robert


Nozick,


Anarchy.


State,


and


Utopia,


develops


individual


libertarian


rights


theory


private


justice


property


that


emphasizes


basic.


These


individual


rights determine the legitimate role of government


fundamental


principles


individual


conduct.


Nozick


s libertarian


theory


justice


explicitly


challenges


Rawl


sian


notion


that


justice


demands


extensive


redistribution


goods


and


services


direction


equality,


i.e. ,


benefit


worst


off.


Moreover,


Nozick


challenges


government


corollary


is to assist


thesis


in this


that


legitimate


redistribution,


e.g.,


role


through


such means


progressive


taxation.


According


to Nozick


government


(whose authority is derived from the consent of the


governed)


may never tax unconsenting


persons


for purposes


redistributing goods and services to aid the needy,


including


the medically needy.


Nozick


s challenge centers on a different moral


view from


Rawls.


Although


both make


individual


primary


and


both


argue


that


role


government


protect


individual


rights,


they disagree


with


regard


to what


rights


individuals


have.


Rawls justifies an extensive government


to rectify the


S~ S S I-


1


* II I -












other


resources


when


necessary


equalize


arbitrary


outcomes


from the natural


lottery.


Nozick,


however


, the


arbitrariness


natural


lottery


does


not


justify


redistributive


justice,


.e. ,


entitlement


assets


others.


"Things


come


into


world


already


attached


people


having


entitlements


over


them,


says


(160)


"From


point


view


entitlement conception of justice in holdings


, those who start


afresh


complete


each


according


treat


objects


they


appeared


from


nowhere


out


nothing"


(160)


But


these


objects,


goods


and


services


that


Rawl


sian


theory aims


to redistribute,


should


treated,


Nozick argues,


as if they


"fell from heaven like manna,


and no


one had any


special


entitlement


to any portion


and no


manna


would


fall


unless


agreed


particular


distribution"


(198)


"Individuals


have


rights


their


assets],


" he


proclaims,


"and


there


are


things


person


group


may


them


(without


violating


their


rights


Nozick'


s main argument against a Rawlsian redistribution


this:


People


are


entitled


their natural


assets.


people


are


entitled


something


, they


are


-


I I -< 1


r^ ^


F- .











presumption
holdings).


equality


(225-226,


emphasis


there


may


about


added)


Nozick'


"entitlements,


rights,


include


strong


negative


(deontological)


right


to life,


liberty and property.


They


are


(roughly)


Lockean


rights


: to


free


from


force


fraud directed against


one'


"life


, liberty


, or possessions"


In particular,


people are entitled to


(have a right to)


their natural assets,


and this right permits them to use these


assets


they


wish


and


protects


them


against


others


might


interfere with that


choice.


For Nozick,


these negative


rights


are


scaffolding


important


theses:


The


only


legitimate


state


a minimal


state--one


that


protects


citizens


from


fraud


and


theft


and


enforces


contracts.


" [A]


state


more


extensive,


" he argues,


"violates


people'


rights"


149)


The


only


legitimate


theory


distributive


justice


"justice


holdings,


" namely


people


have


property


rights


themselves


and


whatever


holdings


they


legitimately


distributive


redistributing


acquire


justice


peoples'


(150ff


(like


holdings


Thus,


Rawls'


any


that


violates


their


theory


requires


rights.


Together


these


two


theses


forbid


coercive


redistribution of


8This


argument


aimed mainly


staunch


anarchist


who


believes


state


can


ever


justified.


Nozick


argues


I ** 1 r -% -^ _^ --


1- -r~ .. .











personal


property.


following


will


briefly


explain


Nozick


moral


justification


these


negati


rights,


and


theory


distributive


justice--


"justice


in holdings"--


which


they


support.


will


comment


on his


moral


justification


these


rights


below.


Rights


as strong


deontoloqical


side


constraints


Nozick


teleological


develops


theory


deontological


rights


rather


justifying


than


minimal


state.


prot


That


section


reason


anarchist


may


minimal


argue

state


that

still


seeking

violates


individual


right


since


redistributes


resources


some


ultimate


goal,


protection.


avoid


anarchist


criti


cism


, Nozick


see


deontological


rather than


teleological


reasons


minimal


state.


That


constructs


deontological


view


rights,


view


that


"forbids


you


violate


your


these


moral


goals"


side


constraints


rather


than


right


teleologi


the

cal


pursuit


view


rights,


view


that


builds


side


constraints


rights


into


some


long


term


goal.


Nozick


s deeper


motivation


deontological


rights


centers


on the


moral


importance


protecting


an individual


ability


According


to shape


Nozick


her)


, this


life


"moral


way


importance"


wishes.


grounded











then,


fails


respect


moral


importance


separateness


persons,


i.e. ,


individuality--the


fact


that


each


individual


separate


person


with


own


plan


life


, or ends.


For Nozick,


Immanuel Kant'


second formulation


categorical


imperative


expresses


the moral


importance


"respect


persons,


respect


ends


rational


being.


"Act


such


way


that


you


always


treat


humanity,


whether


in your


own


person


in the


person


any


other,


never simply as a means


, but always at


the same time


an end


says


Kant


(quoted


in Nozick,


Nozick


explains,


Side


Kantian


constraints


principle


upon
that


action


reflect


individuals


are


underlying


ends


and


merely means;
achieving o


Individuals are


they may not be sacrificed or used for the


other


ends


inviolable.


without
30-31)


their


consent.


Side


constraints


"express


inviolability


of persons"


such


that


person


may


never


forced


sacrifice


himself


another person


or the


overall


social


good.


For


instance,


says,


use


a person


sufficiently


that he i
he has.
sacrificE


-s


this


way


respect


[for
and


a separate person,


sake


take
that


others]


account


this


is the only


does
fact
life


He does not get some overbalancing good from his
2, and no one is entitled to force this upon him.


, emphasis added)


Nozick,


then,


moral


side


constraints


(the


Lockean


rights)


, which


express


inviolability


persons,


protect


not












freedom


to make


such


plans.


moral


importance,


then,


freedom


to plan


one'


life


without


interference,


Nozick


concludes,


prohibits


"leads


aggression


libertarian


against


side


another"


constraint


(33)


that


This


"nonaggression


principle"


secures


each


individual


possibility


leading


meaningful


life.


Moreover,


this


"nonaggression


principle,


believes,


derives


from


following


argument:


Thus we have a promising sketch of an argument from moral


form to moral


content:


form of morality


includes


(moral


side


constraints);


best


explanation


morality' s


being


strong


statement


distinctness of persons)


and from p follows a particular


moral


content,


namely,


libertarian


constraint.


(34)


Nozick


notes


exceptions


nonaggression


principle:


"innocent


innocent


threat"


threats


innocent


says,


someone


shields


who


threat.


innocently


a causal agent in a process such that he would be an aggressor


had he


chosen


to become


such an agent"


(34)


someone


pushed


cliff


falling


you,


may


disintegrate him


you have a


gun)


"Innocent


shields


of threat" are "innocent persons who themselves are nonthreats


but who are


so situated that


they will be damaged by the only


means available


stopping


that


threat"


(35)


, you may


blow up a person who is strapped onto a


tank if your aim is


-- -


IrFI I I


- ~ _


1


lr F











Justice


in holdings


Nozick


property justify


arguments


a type


strong


individual


of distribution he


calls


rights


"justice


holdings.

briefly s


" It consists of three major principles,


;ummari ze


which I will


(150-182)


The


[princiole


original


acquisition


holdings.


This


principle


specifies


way


individual


comes


own


things


without violating anyone'


account by arguing that


a natural


rights.


He follows Locke'


object becomes one'


own by


one mixing


one


labor with


improving


through


one


labor


(174-178


includes


Lockean


proviso.


appropriate as much as one likes provided


"the position of


others


longer


liberty


use


thing


natural


obj ect


[not


thereby


worsened;"


one


pays


compensation

worsened" as


"[another


mentioned in


situation


178)


thereby


He assures us that


"the


free operation of


a market system will not actually run afoul


Lockean


proviso"


(182)


[DrinciDle of]


transfer of holdings


This principle


allows


one


transfer


one


s legitimate


holdings


another


through


sale,


gift,


trade


inheritance.


That


one


entitled


whatever


one


receives


those


means,


provided the individual from whom it was received legitimately











[principle


rectification


injustice


holdings.


two principles above are violated,


then the


principle of


rectification


comes


into play.


This principle uses historical information about previous


situations and injustices done in them


(as defined by the


first


principles


justice


and


rights


against


interference)


and information about the actual course of


events


that


flowed


from


these


injust


ices,


until


present,
holdings


and


yields


in society"


description


descriptions)


152)


The


principle


makes


best


guess


regarding


what


would


have


occurred


injustices did not


take


place and


recommends


corrections


for them.


"Justice


holdings"


differs


from


other


theories


justice,


according


to Nozick,


in one very


important


respect;


is a nonpatterned


following


theory.


formula:


A patterned distribution


each


takes


according


blank may include


"need,


" "desert,


" "noble blood,


" "I.Q.


whatever.


To think that a theory of distributive justice must


fill


the blank


, he argues,


"be predisposed to search


pattern"


(160)


Such


search,


argues


Nozick,


constant


source


injustice,


or rights violation.


only


acceptable distributive


justice


theory,


according


to Nozick,


is his nonpatterned theory justice in holdings:


"From each as


they


choose,


to each


they are


chosen"


(160)


Problems with


"respect


for persons"











Nozick' s


book


generated


much


critical


discussion


since


its


appearance.


9 My


critical


comments


will


focus


Nozick'


use of


which,


the Kantian expression


Nozick,


commands


"respect


for persons"


interfere


with


individual'


choices


(especially choices about discarding his


property


Such


interference,


argues,


undermines


one'


ability


pursue


meaningful


life.


will


argue


that


Nozick'


s use


this


concept


should


include,


exclude,


duty


(as an enforceable requirement)


that people have,


in some


cases,


redistribute


their


holdings


help


needy


that


government


should


instrument


that


redistribution.


This


argument


will


not


complete.


merely


beginning


longer


argument


that


developed


later


(see


especially


chapter


five)


On the face of


it seems


that


libertarian side


constraint


possibility


presupposes


pursuing


moral


importance


meaningful


life--the


securing


freedom


shape


one


plan


life--then


should


justify


using


government


assist


individuals


who


would


otherwise


able


to pursue a meaningful


arguments,


a Nozickean


life.

and a


Consider the


Weinerian


following two


(W):


this


rob,


cheat,


world,
rape,


some


murder


people


and


will


harm


You


you


(e.g.


ought


protected.


A government


should


provide protection;


however,


.- -z- -- 1a- I-- ..r


, ^ I


,,,1


.... .11


1


q


L-. 4











protection
meaningful


essential


securing


possibility


life.


In this world,


some people will not help you when you are


starving,
government
assistance
essential
meaningful


sick,


should


on.


provide
overall


You


ought


assistance;


goal,


securing


but


however,


because


possibility


helped.


not


because


assistance
c pursuing


life.


Both


and


rely


on the moral


importance Nozick assigns


"respect


persons


Accepting


seems


respect


persons


sufficiently


sense


that


Nozick


uses,


namely,


securing


them


possibility


pursuing


meaningful


life.


sufficiently


respects


another,


then,


not


only


refraining from aggression against him


(or her


, but,


in some


cases


, by assisting


him


her)


as well.


Nozick


might


complain


that


person


being


sacrificed


to benefit


another.


Yet


that


complaint


begs


question


what


"sacrificing


person


benefit


another"


means


Suppose


banker,


John,


plan


life


that


includes


purposes


defrauding


economic


gain


clients,


According


particular


to Nozick'


Tim,

view,


libertarian


constraint


justifies


interfering


with


John's


plans,


since


Tim has


right


against


fraud.


Now


Tim benefits


from


prohibiting


"sacrificing


John


John's


actions


to benefit


Tim"


but


For


that


prohibition


consistency,


Nozick


would have to say that John was not sacrificed to benefit Tim.











Similarly,


determine


that


failing


prevent


serious


harm


about


befall


another


part


legitimate


life


plan,


then


forcing


someone


save


another


will


not


other.


necessarily


Recall


that


sacrifice


"right


that


violation"


person


involves


benefit


undermining


one'


ability


to pursue a meaningful


life.


one


can also


undermine


another'


ability


pursue


meaningful


life


failing


prevent


some


serious


harm


that


will


befall


him.


Suppose


John


fails


tell


Tim


that


investments


will


lost


and


will


able


feed


family.


John's


inaction seriously


affects


Tim's


life


plan,


independently


whether


John


violated


Tim'


s rights.


failing


prevent


harm that will befall


another part


of a legitimate


life plan?


is not,


then


forbidding


individuals


from such


failures


would


not,


even


on Nozick


terms,


sacrifice


one


benefit


another.


other


words,


individuality


morally


important


Nozick


believes,


then


legitimate


life


plan


should not


include aggression against people


(violating their


rights)


and


should


also


include


failing


prevent


similar


harm


that


will


befall


them.


There


is a passage


where Nozick seems


recognize


that


failing to prevent great harm from befalling others


is a good


reason


for forcing


some


to help


others.












Does violating a side constraint--a Nozickean right


--to "avoid


catastrophic


moral


horror"


mean


that


Nozick


recognizes


moral


importance


helping


to prevent


harm?


The


answer


unclear,


since we


find Nozick


s comment


in a


footnote and not


more


ser


iously discussed.


Nevertheless,


the comment


opens an


important


issue with regard to whether allowing great harm to


befall another,


or millions who are in need of


food or medical


treatment,


is part


of a legitimate


life


plan.


also


important


to note


that


Nozick'


reference


Kant


implicit


authoritative


support


libertarian


side


constraint


misleading.


Throughout,


Nozick


assumes,


without textual support,


interpreted narrowly,


that Kant


where


s second formulation may be


"sufficiently respecting persons"


forbids

chapter


forcing


will


them


present


help ax

textual


other


evidence


need.

that


reveals


next

that


Kant


Kant,


s second

ignoring


formulation


others


should

distress


read


fails


differently.


respect


them


persons,


autonomous


beings


with


rational


life


plans.


Contrary to Nozick,


Kant


argues,


It i


every


[person's]


duty to be beneficent


--that is,


promote,


according to his means,


the happiness


of others


who are in need,


and this without gaining anything by it.


(Doctrine


Virtue,


120)


Another libertarian,


Tristram Engelhardt


(1986)


, attempts


A-- --_ _- ^-- 7 2 -1- __ 1 _1_ _


*_ I


I-


1 I


I I-


r


-- L 1.. IL


__ I__I_













Tristram


Encelhardt


s Libertarianism


Tristram


Engelhardt,


Foundations


Bioethics,


constructs


what


he calls


foundations


of a "general


secular


bioethics"


He offers


says,


"what


could


seen


transcendental


argument


Robert


Nozick


s principle


freedom


side


constraint"


Like


Nozick,


Engelhardt


supports


strong


principle


nonaggression


rejects


basic


human


right


to health


care.


"A basi


human


right


to the


delivery


health


care,


even


delivery


decent


minimum


health


care


" writes


Engelhardt,


"does


exist"


Unlike


Nozick,


however,


claims


that


positive


right


health


care


can


created


and


government


may


enforce


"Positive


rights


to the


delivery


of health


care,


arise


only


insofar


they


are


created


particular


communities


"communal


redistributive


or nations


property"


policies


Engelhardt


see


attempts


below)


establishing


use


a notion


justify


a two


tiered


some


health-


care


system


like


present


one


, e.g.,


Medicaid


program.


After


explaining


arguments


moral


foundation


and


how


supports


principle


nonaggression,


will


critically


The


comment


transcendental


on them.


argument












this


foundation


response


myriad


moral


views


current


in bioethics,


and


need


for a


criterion


that


does


presuppose


particular


substantive


moral


view.


seeks


neutral


framework


address


moral


problems


biomedicine


[where]


individuals generally hold a diversity of


moral


views"


(11-12


, emphasis


added)


[Secular bioethics]


a logic
good 1.


is an ethics that aspi


for a pluralism of


ife


that


professions,


whose
world


grounds
(26)


can


legal


beliefs,


res


to provide


a common view of


transcend particular
jurisdictions, and


for authority


are


immanent


r communities,
religions, but
to the secular


Engelhardt finds the foundations of


(bio)ethics by finding the


necessary


argues,


condition


that


moral


"ethics


discourse.


enterprise


assume,


controversy


resolution


bases


other


than


direct


indirect


appeals


to force"


, then


finding


the necessary


condition


resolving


controversies


(which


not


presuppose


substantive moral view)

for resolving moral di


will reveal the foundational criterion


sputes.


presents


four


candidates


resolving


moral


conflicts:


other


procedures"


" (1)


force


viewpoint,


conversion


sound


Appeals


argument,


force


one


and

are


party


agreed-to


automatically


eliminated,


and


both


and


cannot


neutral,


- I -


- a


_ I _


.I. -


,,1


1 FI ~n rrm n n C ()


II L. 1^


in











establishment


such


viewpoint


itself


presupposes


moral


viewpoint,


and


that


is exactly what


is at


stake)


then


the only mode


resolution


is by


agreement.


Such


agreement


can be either


free


or forced.


Free agreement


can either be on the basis of


which ge
basis of


mneral


justification


nonmoral


mechanism


sharing moral


cannot


considerations


for


that


giver


lead


premises
i, or on


one


negotiating


to agree
disputes.


For this to succeed generally,


one will need to discover


an inescapable


procedural basis


for


ethics.


This


basis


[is]


one


without


in the very nature of


interested


recourse


in resolving
force as the


ethics


moral


itself.


controversies


fundamental


basis


agreement,
negotiation


process


for


then


among


one


will


members


attaining


have


accept


of the controversy
resolution of the


peaceable


concrete


moral


controversies


(40-41;


emphasis added)


"By appealing


to the minimum notion


ethics


as a means


peaceably


negotiating


moral


disputes,


" he


argues


"one


can


disclose as a necessary


condition


ethics


requirement


to respect the freedom of participants in a moral


controversy"


(42,


emphasis added)


However


, he warns:


This view of
conditional


based


community. I
disclosure, t
transcendental
possibility of


ethics


should not


seen as


concern for peaceableness.


interest


should,
borrow


condition,
a general


establishing


instead,


Kantian


a necessary


grounded


on a


It is not simply
the peaceable


recognized
metaphor,
condition f


domain of human life and of the


life


persons


generally.


disclosure


minimum grammar involved in speaking rationally of blame


raise,


and
moral


emphasis


and


commitments,


establishing


other


than


any


particular


through


force


set
(


added


- - ,


procedure


If


in-


1 I ^


I E


I | --











Engelhardt,


then,


ethics


procedural


mutual


respect


a necessary precondition


adjudicating


between


substantive


moral


views.


Everyone


moral


views


must


respected


equally


and


views


that


result


from a


peaceable


agreement


participants


are


morally


substantive


views


that


each


participant


committed


obey.


Moral


authority


, he


says,


"acquired


through


mutual


agreement"


(42)


, "with


the consent


of all


those


involved"


one


s to


have


reasons


actions


that


can


accept


argues


Engelhardt,


"one


must


have


reasons


tha t


have


endorsed"


(43,


emphasis


added)


"Authority


health


care,


concludes,


therefore


contractual"


(49)


Thus,


says,


"The


foundations


moral


point


view are


thus best


expressed not in


terms of


disinterest with


respect


to personal


advantage


but


rather


terms


mutual


respect"


(49)


which can be


"summarized under the rubric of


negative principle of autonomy"


(41,


emphasis added)


"It is


here


" he


continues,


"that


one


also


discovers


fundamental


equality among


persons"


(42)


"In


short,


" he


concludes,


form of


moral


discourse


secured for


secular


ethics


even without


establishing the correctness of any particular


moral

The D


sense"


irinciDl


(45)


of bioethics











sketch of


each principle,


aiming to determine how they justify


conclusions


for the macroallocation


health


care.


principle


autonomy.


The


principle


autonomy


derives


from


formal


property


of morality


and


is a


strong


negative


principle


forbearance.


expressed


following maxim:


others


that


which


they


would


have


done


unto


them,


them


that


which


one


contracted


provides


to do"


moral


For public


grounding


policy,


defending


says,


innocent"


" [it]


and


"grounds what can be termed the morality of autonomy


as mutual


respect"


(86)


The principle of autonomy


required for the


very


coherence


the moral


world and


justifies praising


and


blaming


others.


basic


right,


then,


interfered


with


when


pursuing


one'


plans


provided


one


does


interfere


with


others


does


not


break


agreed-to


contracts.


principle


beneficence.


The


principle


beneficence provides the content of morality.


It is expressed


following


maxim:


others


their


good"


Beneficence,


says,


"reflects


circumstance


that


moral


concerns


encompass


pursuit


of goods and


avoidance


harms"


However,


"since no particular ordering of


goods


harms


can


established


there


contentful












principle of beneficence to which one can appeal"


(86)


Thus,


one


cannot


held blameworthy


nonbeneficence


since


principle


beneficence


"not


required


very


coherence


moral


world"


(68)


principle


beneficence


obliga tory


only


when


"there


will


agreement


between


giver


receiver


regarding


nature of


the good"


(77)


principle of


ownership.


principle of


ownership


also


derives


from


morality


mutual


respect


(134)


person


free


own


almost


whatever


and


however


much


wants.


Following Locke and Nozick,


comes to own objects by mingling


Engelhardt


labor wit


claims a person

h the object.


What


enters
follow
object


suggested


thing,


have


into a
Locke'


, the object


is that,
refashions


suggestion,


comes


insofar


individual


remolds


mingles


into his


sses


labor


sion


and,
with


130)


Engelhardt


interprets


Locke'


account


ownership


differently


than


interpretation


Nozick.


allows


believes

"[solve]


him


that


this


problems


different


clearly


soluble by Robert Nozick,


" namely,


how to


justify unconsented


tax


collection


which


does


fall


within


scope


Lockean


Proviso


(131)


departure


from


Nozick


this.


Engelhardt


argues


that the


"thing"


or matter that one transforms,


or mingles his


1- --


A


I


I


1


_^ __ ^ -1 1 ^


I, ,-,,


-- L-


' 1 ^ _


a











"common


ownership,


" he


believes,


justifies


collecting


taxes


provide


funds


individuals


purchase


health


care


from


those


"who


have


fact


agreed


that


tax- -


that


agreed


individually


each


every


one"


131)


fact,


this


ownership


IS SO


"common"


that


is partly


owned


everyone


level"


on earth,


"([Sluch


and


even,


a tax


says,


[due


"common


an intergalactic


ownership"],


concludes,


would


need


to reflect


a fair


rent


on such material,


apart


from


considerations


status


as a product"


131)


at all


clear


what


"material"


he is referring


what


"a fair


rent"


includes


and


how


that


would


be determined,


will


discuss


these


problems


below.


any


rate,


this


argument


"common


ownership"


appears


crucial


justification for taxing unconsenting


individuals


to guarantee


a minimal


level


health


care


all.


Apart


from


this


limit


ownership


, the


right


ownership


beneficent


is extensive.


them)


young


can


own


children


animal


(provided


(provided


one


one


produced


them)


, and


persons


generally


(provided


they


agreed


Moreover,


he claims,


"Since


principle


of autonomy


holds


rights


precedent,


even


one


under


should


such


moved


conditions


respect


tension


property


within


principle o:


beneficence


(i.e.


between


giving


individuals












life) "


(135)


Finally,


argues,


right


ownership


includes


fundamental


moral


right


participate


black market"


(135)


The principle of political authority.


Morally justified


political


authority


governed"


(144


, he claims,


, and


derives


morality


"from


consent


mutual


respect.


Political authority protects the innocent from unconsented-to


force,


enforces contracts, and develops welfare rights through


use


"communal


property"


(144)


Aside


from


those


powers,


governmental


authority


extremely


limited.


instance,


argues


that


"the


unquenchable


markets


pornography,


prostitution and drugs


must be tolerated because


of the basic human right to the black market"


(142)


Besides,


says,


"the


data


suggest


on prudential


grounds"


there


are


more harms


Problems


in their proscription


Enqelhardt'


(142)


Libertarianism


Engelhardt


principles


claims


autonomy


that


and


book'


beneficence


"analysis


entitlements


property


support


two-tiered


system


health


care"


361)


two-tiered


respects


system


health


compromise.


care,

one


" he

hand,


says,

" he


says,


many

this


tem]


provides some amount of health care


for all,


while on


-


*, I -i


I











other


hand


allowing


those


with


resources


purchase


additional


health


care"


(361)


This


two-tiered


system,


Engelhardt


claims,


mixed


justification:


a free market tier,


justified in terms of the respect


free


choices


supported by
vision of th


and


communal


e good


private
funds,


life and of


property,


and


justified in


terms


tier
some
364,


emphasis added)


Does


this


mixed


justification


support


proposal?


will


argue that his principles of bioethics--autonomy, beneficence,


and ownership--do not justify his two-tiered proposal.

his principles do not follow from their foundation. S


First,


econdly


if "[moral] autl

is contractual"


hority in health care


[and in ethics generally


, he presents no explanation why everyone


would


consent


to his


proposal,


especially


beneficent


action which requires,


in his view,


mutual


consent.


Thirdly,


concept


"communal


property"


(which


allows


taxing


unconsenting


rich)


too vague


for practical


purposes.


First,


do his principles


of bioethics


follow


from their


foundation,


an agreed


"mechanism or procedure for negotiating


disputes"


will


first


focus


principle


autonomy,


principle


non-aggression,


1.e.,


mutual


respect.


This principle,


like Nozick's concept of


freedom as


side


constraint,


substantive


moral


principle


that


beneficent action.











fundamental


principle of


morality.


Engelhardt


, recall,


claims


that


"the


negati


principle


of autonomy,


or mutual


respect,


"neutral


framework"


, "the


logic


a pluralism of


belief


"inescapabi


"objective and


conceptual


procedural


core"


"minimal


basi


grammar


moral


mutual


language"


respect


rational


formal


moral


condition


discourse.


moral


Yet,


discourse--


neutral


with


resp


ect


any


substantive


moral


view--then


failure


satis


not


moral


error,


intellectual


one.


mutual


respect


logic


pluralism


beli


efs,


then


why


with


strong


libertarian


beliefs?


Who


agreed


them?


procedure


requires


one


to respect


moral


beliefs


, but


he has


decided


without


providing


any


arguments


such


decision.


consider


substantive


The most


equally


libertarian


neutral

moral


view,


procedure

views, wh:


others


can


ich


require

would ir


as well.


that


iclude


Alone


, the


procedure


cannot


recommend


which


moral


view


to adopt.


accept


procedure


, then


we are


morally


bound


to the


agreed -


to moral


conclusions.


However


, this


deci


sion


procedure


never


occurs.


Minimally,


then,


procedure


commits


respect


everyone


s views.


However


, Engelhardt


never


says


how











everyone agree


to unlimited property rights?


At one point


discussion,


Engelhardt


complains


that


Rawls


theory


inadequate because some


cultures


(BaMbuti


pygmies)


would not


rank

never


liberty more

considers


highly

whether


than

all


other societal

cultures would


goods.

rank


private


property


so highly


(consider American Indians)


Moreover,


how


many people


market


would


whereby


agree


a basic


prostitution,


drugs,


human


and


right


black


pornography


can


obtained

procedure?


without


constraint?


smuggled


basic


followed


right


his

the


own


black


market


part


because


smuggled


strong


moral


principle


autonomy.


Consequently,


this strong principle of autonomy severely


limits


politi


principle


authority.


beneficence


instance,


and


principle


says


, "Since


principle of


autonomy holds precedent,


one should be moved to


respect property rights even under such conditions of


tension


within


principles


beneficence


i.e. ,


between


giving


individuals


their


property


and


giving


others


what


necessary for


life)"


(135)


Beneficence is


limited,


however,


only


because


assumes


principle


autonomy


strong.

strong


mentioned,


principle.


Engelhardt


Agreeing


never


justifies


procedural


such


bioethics











autonomy that allows property


rights always


to take


precedence


over


human


lives.


Likewise,


this


principle


autonomy


limits


political


authority


government


may


not


restrict


"the


unquenchable markets


for pornography


prostitution,


and drugs"


Again,


until


we all


agree


to such


a strong


principle


autonomy


these


substantive


conclusions


follow.


Since


no arguments


exist


this


strong principle


of autonomy


remaining


principles


are


unconvincing.


then


provides questionable moral


support


two-tiered health-


care


system.


In fact


, his


principle


of beneficence


cannot


support


bottom


moral


tier.


actions


instance,


in beneficence


Engelhardt


requires


claims


mutual


that


to ground


agreement


among


benefactors


beneficiaries.


Therefore,


morally


justify


taxing


citizens


bottom


tier


we need


mutual


agreement


of all


participants.


anyone


does


not


wish


participate,


(legal)


right


beneficence


can


created.


everyone


will


wish


to participate


, according


Engelhardt,


that


why


develops


concept


"communal


property,


unconsentinq


a concept


rich.


which


So beneficen(


allows

ce can


taking

never


money

justify


from

the


bottom


tier,


as he claims


can


(361)


notion


"communal


property,


" then


, is


only











Moreover,


he said


that


because


of communal


property,


"not


property


privately


owned.


Nations


and


other


Soc


organizations


may


invest


their


common


resources


insuring


their


members


against


losses


natural


social


lotteries"


However,


questions


remain:


What


this


"matter"


that


remains


after


things


are


transformed


into


products


How


much


can


taxed?


flat


tax


progressive


athletic


transform


myself


into


marketable


baseball


player,


then


what


"matter"


left


over?


body?


skill


a skill


"matter"


or something


else?


rate,


this


notion


"communal


property"


left


taxation


unpersuasive


exceedingly vague--too


vague


to make


clear


what


exactly


is available


taxation.


Engelhardt


attempted


compromise:


defend


Nozickean


conception


justice,


and


justify


some


redistributive


care


all.


policies


to guarantee a minimum level


arguments


of health


nonaggression


principle


are


incomplete


unpersuasive


support


substanti


conclusions.


will


now


turn


attempt


tify


redis


tributive


policies


independent


of considerations


justice.


The


Enforced


Charity


ADDroach











be guaranteed


access


to health


care


the government


would


be justified in enacting the appropriate legislation.


On the


other


access,


hand,


then


justice


everyone


does


would


guarantee


be guaranteed


right


access


this


only


resulted


from


voluntary


associations


charitable


persons.


However,


Allen


Buchanan


argues


that


strictly


voluntary


association


would


succumb


common


barriers


successful collective action,


e.g.,


the free-rider problem and


assurance


problem.


health


care


morally


fundamental


collective good--a good whose production requires


efforts


many


charitable


individuals--then enforcement


necessary


and


sufficient


achieving


and


thus


government


prima


faci


justification


enact


appropriate legi


slation,


independently of whether individuals


have a moral


right


to health


care


(1984,


1989)


This


Enforced


Charity


Approach


aims


challenge


assumptions


Approach


that


and


underlie


Charity


debate


Approach:


between


that


Rights


establishing


antecedent moral right to health care is a necessary condition


justifying


universal


health-care


legislation;


that


governmental


coercive


power


morally


justified


only


purposes


securing moral


rights.


Moreover,


subscribing


assumptions


and


led,


according


to Buchanan,


to a












moral


right"


health


care


(Buchanan,


1989


:322,


Talmadge


and


Chapman,


1977


The


Enforced


Charity


Approach


then,


represents


a kind


"end-run


around


conc


eptual


asse


created


deadlock


rival


theory


distributive


justice"


It


is a strategy


justifying


universal


health


-care


policy


that


avoids


burden


justifying


universal


rights


to health


care


, without


having


conclude


that


Charity


Approach


* .e. ,


libertarian)


triumphs


default.


mentioned


introduction


, the


most


recent


President


Commission,


Securing


Access


Health


Care,


apparently


adopted


Buchanan


Enforced


Charity


Approach,


retreating


from


discussing


a right


to health


care


, which


1952


Commission


supported


Sass)


Instead


of speaking


terms


'rights


' II


explains,


"the


current


Commiss


beli


eves


conclusions


are


better


expressed


terms


"ethical


obligations"


Commission


argues


that


"society


level"


an ethical


health


obligation"


care


to provide


that


"adequate


ultimate


responsibility


and authority


implementing


appropriate


14Other


without


writers


invoking


who


rights


argue


arguments


universal


include


health


Moskop


care


Siegl


* ,*


Al ,I "


r I


"1


I












legi


slation


lies


with


federal


government


following


will


discuss


Buchanan


s argument


Health


Care


as a Coil


ectiv


Good


Allen


Buchanan


, in hi


"The


Right


to a Decent


Minimum


Health


Care


argues


that


"enforced


beneficence16


approach


h" justifi


providing


an adequate


leve


of health


care


1984


see


hanan


, 1989)


Hi


argument


modified


libertarian


position.


thesis


that


even


libertarians


do not


accept


rights


to health


care


, if


they


are


rational


and


genuinely


beneficent


.e.,


they


discharge


their


personal


duties


charity)


, then


they


would


acce


enforcing


universal


health


-care


policy


necessary


effective


achieving


their


charitable


alms


Buchanan


presents


two


arguments


to support


that


thesis.


first


argument


resembles


traditional


public


goods


problem


, where


some


externality


encourages


a person


to take


free


ride


contributions


others.


This


free-


rider


problem may


block


efforts


at coordinated,


collective


charity.


instance


rational


and


genuinely


beneficent


person


could


contribute


number


small


charity


local


Cross


, th


March


Dimes


, and


could


-I ft *


_1*


_


-I


1


*. 1 *











charity


is negligible


and


could be better


spent


on the


small


charities.


That


might


reason


follows:


either


enough others will


contribute


to the large charity to make it


work,


even if


I do not


contribute


to it;


or not enough others


will


contribute to the large one to make it work,


even if


I do


contribute.


Either way my


contribution


large


charity


makes no difference and could be used better toward the small


ones.


rational


course


beneficent


person


undertake


some


individual


act


beneficence


whose


success


does


not


depend


actions


others,


and


contribute

beneficent


collective


person


encouraged


project.


take


free


genuinely


ride


contributions


others


towards


collective


project.


everyone,


or a sufficient number of people,


reasons this way,


then relying on strictly individual voluntary contributions to


universal


health-


care


system


will


fail.


Thus


enforcing


beneficence


is needed


to overcome


free-rider problem.


The second argument

for achieving goals of cc


focuses


on the more general


collective action


, i.e.,


problem


for achieving


a collective good.


"collective good"


"simply


any


state


affairs


whose


production


requires


efforts


many


individuals


and


from which


least


who


contribute


will


benefit"


(Buchanan,


1987


: 363).


If universal health care is











take


free


ride


(363)


Here


rational


genuinely


beneficent person has no desire to free-ride but


assurance that others will not free-ride.


only desires


If assurance is not


given,


will


reason


that


contribution


will


wasted,


and could be better spent elsewhere,


even though he knows that


other


enforcing


beneficent


efforts


contributions


are


program


effective.


helps


overcome


assurance


problem.


These two arguments are distinct.


In the first argument,


the benevolent person reasons that he should not contribute to


collective


program


even


assurance


that


others


will--his


contribution


will


make


difference


and


can


benefit


from


collective


program,


1. e. ,


free-ride,


while


helping


in other beneficent


causes.


second argument,


benevolent


person


reasons


that


without


assurance


that


others


will


free-ride,


would


waste


beneficent


efforts


collective


project,


even


though


there


are


other projects he would rather contribute to.


Buchanan stresses


Both arguments,


, assume that people want to help others,


that


their


laudable


desire


beneficent


may


self-


defeating where e

For Buchanan


.nforcem(

, then,


ent


lacking.


if universal health care is a morally


fundamental


collective


good,


and


strictly


voluntary











sufficient


achieving


this


collective


good,


and


thus


government


appropriate

individuals


prima


legi

who


faci e


slation,

receive


justification


independently

health-care


enact


whether


services


have


antecedent


moral


Buchanan


right


anti


them


cipates


and


1989:


-323


responds


following


criti


cisms.


First,


some


will


claim


assumes


that


moral


principles


government


continues,


can


may


then


obtain


legislate


that


status


and


morality.


inappropriately


thus


criti


compromises


cism


individual


liberty.


"only


But,


contends]


Buchanan


that


replies


one


, the


important


enforced


moral


charity


principle


argument


[not


moral


principles


may


enforced


absence


enforcement


, familiar


problems


coordinated


joint


action


would


arise


1984


Secondly


, some will


complain


that


"enforced charity"


misuses


traditional


concept


"the


duty


charity


Traditionally


, moralists


understood


"duty


of charity"


imperfect


duty.


Imperfect


duties


allow


benefactor


latitude


"play


-room"


with


regard


duty'


content


what


how


much


aid)


and


object


(whom


to aid


Since


"enforced


charity"


requires


giving


aid


all


, the


"duty


charity"


cannot


provide


proper moral


foundation.


Buchanan


: 73)











needs are identical,


which is counterintuitive.


Depending on


how


handle


this


problem,


argues,


might


find


appropriate


revise


traditional


concept"


(74)


Nevertheless,


argues,


more


plausible


reason


benefactor


s discretion seems


to be a practical


rather than a


conceptual


moral


one


(74)


reason


discretion is practical


then the notion of


collective charity


rather


than


individual


charity


resolves


any


practical


concerns.


Even


the duty


charity


has been


optional,


Buchanan


argues,


can


demand


an explanation


that


feature.


instance,


what justifies aiding some people and not all?


The


traditional


explanation


, he


says,


does


moral


theory or an analysis of the concept of beneficence,


but in an


appreciation


facts


about


circumstances


which


individual--as


opposed


collective--beneficence


occurs"


(75)


First,


an individual'


limited resources require him to


be selective,


unless he prefers excessive burdens.


Secondly,


people

their


enjoy

efforts


controlling


are


their


effective.


contributions,


However


which


enforced


ensures

charity


satisfies


both


these


conditions,


thus


consistent


with


traditional


concept


the duty


charity.


Finally,


Buchanan believes a libertarian may raise a more











Buchanan


"agrees


wholeheartedly"


with


this


qualification


However,


adds,


this


libertarian


qualification


serious


criticism


unless


libertarian


violated


specifies


applied


which

to health


important


care)


moral


and


rights


plausibly


will


justifi


them.


Regarding


latter,


says,


one


successfully


executed"


that


proj ect


instance,


rule


enforcing


charity,


libertarian


needs


justify


unlimited

private


right


property.


against


interference,


Neither


can


or an


be done,


unlimited


he believes


right


without


"begging


question


appealing


intuitions


that


nonlibertarian


opponent


does


share"


-77)


Without


sound


Buchanan


theoretical


concludes,


justification


"the burden


such


of proof


unlimited


on the


rights,


libertarian


substantiate


claim


that


enforcement


question


violates

He

nonright

specify:


important

concludes

s based,

na the cc


moral


rights"


noting


enforced


charity


intent


dec


important

ty approach

:ent minimi


implication


issue


health


care.


For

must


instance,

determine


guidance.


determinate


any I

the


After

with


rights-based


content


all,


regard


arguments


t


rights

to their


.he

are


a decent


right


typically


content. H


minimum


is to give

thought of


however ,


little











Buchanan explains,


because duties of beneficence by their very


nature


"are


precisely


delineated


the


advocates


the enforced beneficence approach can warmly welcome


the lack


principled


specification


vindication


view


rather


than


accept


begrudgingly


embarrassing


theoretical


Is Enforcing


lacuna"


Charity


-78)


Enough?


universal


health-care


policy


debates


that


avoid


burden of having to settle the


issue over whether a universal


right


health


care


exists


are


more


constructive


debates,


then


Buchanan


strategy


important


contribution.


However,


libertarian


duty


charity,


or beneficence,


Buchanan presents


may


too weak


to provide a basis


justifying a universal health-care system.


Two reasons can be


given:


Currently


our


society


does


contain


enough


rational


and


genuinely


beneficent


individuals,


i. e


, persons


who


either by the force of their conscience or social pressure


(not


legal


think


about


ways


discharge


their


duty


charity;


The


libertarian


duty


charity


s always


voluntary,


and


that


detracts


from


moral


importance


necessary

importance


for

that


invoking


enforcement--the


libertarians


assign


kind

the


moral


duty











plans


life.


Such


enforcement


presupposes


that


these


persons


entirely


not


necessarily


rational


and


live


genuinely


community


nonmalevolent


made


people.


Nonaggressive


behavior


enforced


(individuals'


negative


rights are protected)


because some individuals might decide to


act malevolently;


they might not respect the rights of


others.


If libertarian


duties


charity are


weak


duties


i.e.,


always


overcoming


voluntary


barriers


compared


achieving


duties


charitable


justice


aims


then


might


necessary,


sufficient,


moral


reason


coercing


cooperation.


will


not


sufficient


justifying


coercing


those


individuals


who are not


genuinely beneficent,


who do not wish


to voluntarily help others.


Buchanan assumes


that coercing cooperation is justified only because he assumes


that


those


cooperating


desire


universal


health


care


collective good.


He assumes that legislating is necessary and


effective


to coordinate


those


who are


rational


and


genuinely


beneficent,


but whose altruistic


impulses would be undermined


by the actions


(or inactions


of others.


Yet,


imagine arguing


for enforcing collective efforts to end racism and sexism only


among


genuinely


nonracist


and


nonsexist,


enforcing


collective efforts


to reduce


industrial


pollution


only


among


genuinely


nonmaleficent.


Libertarians


would


justify











aims,


to compel


individuals to discharge


their respective


duties,


since many may not


voluntarily


Enforcing


principle


nonaggression


, then,


not


only


necessary


overcoming


barriers


successful


collective


incentives


action


i.e.,


, but


legal


also


sanctions


providing


necessary


proper


compelling


individuals


cooperate


who


would


otherwise


Likewise,


need


justify


enforceable


principle


beneficence


that


requires


individuals


help


prevent


serious


harm


that


might


befall


others


(e.g.,


preventing


starvation,


relieving


medical


poverty)


Assistance


these


cases


would


morally


urgent


protecting


individuals against others


' aggression.


This principle might


justify a level


of beneficence


that


we can reasonably


require


everyone


come


independently


whether


they


are


genuinely beneficent


are not.


, and especially because many individuals


This principle of beneficence would prescribe duties


that


individuals


have as a moral


requirement,


and not merely


charitable


(voluntary


ideals.


next


three


chapters


will


attempt


develop


enforceable


principle


beneficence by providing some arguments


for amending both the


theory underlying and the practice associated with the duty of


beneficence.


The first argument


is historical.


I argue that


SO.


so.












some


cases,


this


principle


requires


individuals


to cooperate


large


scale


relief


efforts.


second


part


argument further develops this duty to cooperate in efforts to


help


needy


distinguishing


from


acts


supererogation,


which


are


praiseworthy,


not


universally


required.


Using


R.M.


Hare'


two-level


theory


moral


thinking,


argue


for a


principle


cooperative beneficence


that


can


reasonably


require


everyone


follow.


This


principle

beneficent


requires i

efforts by


individuals

fulfilling


cooperate


some well-defined


collective

equitable


role


toward


their


success.


However,


will


more


about


this argument


in chapter five


The next


two chapters will be


occupied


discussing


moral


theories


Immanuel


Kant


and


John


Stuart


Mill


and


their


respective


arguments


enforceable duty


of beneficence.
















CHAPTER


IMMANUEL


KANT


AND THE DUTY


OF BENEFICENCE


every


promote,


man'


duty


according to his


beneficent


means


--that


, the happiness


of others


are


need


and


this


without


hope


gaining


anything by


Immanuel


Kant"7


Introduction


Does


Immanuel Kant'


moral


theory support an enforceable


duty of beneficence--one that requires all members of


society


cooperate


institutions


that


help


needy,


e.g.,


medically needy?


As noted in


the last


chapter,


Robert Nozick


provided


dubious


use


Kant


second


formulation


categorical


imperative


("respect for persons")


to support his


libertarian


(negative)


rights


, or


nonaggression


principle


(34ff)


Besides


Nozick


, Allen Buchanan


interprets


Kant as a


libertarian


well


(1982


43ff)


Kant,


explains


Buchanan,


beneficence i


only a virtue


, "whose


fulfillment


left


discretion


individual


or to


voluntary


'7Immanuel


Metaphv sics


Kant,
Moral


he Doctrine
(hereafter ]


Virtue


, trans.


Part
Mary


p Gregor


I- SI -I I -r I A *F -%


I


1


-- d


A


rrn











associations


individuals


support


charitable


institutions"


(43)


However,


recent


study,


Roger


Sullivan


argues


that


Kant


would


probably


support


libertarian


view.


since


human


beings


[for


Kant]


are


imperfectly rational by nature but al


not


only


infected by


propensity to
e libertarian


evil,
ideal


can
an


have
"empty


confidence
yearning"


that
that


Kant


never


seriously


considered


(242-243)


This chapter does not intend to resolve this dispute,


nor


develop


any


new


interpretation


Kant'


s moral


philosophy.


Its aim is merely to provide some textual evidence that Kant'


moral


theory supports


is distinct


an enforceable duty of beneficence


from libertarian beneficence


charity)


that


, which


is always voluntary.


requires


Kant


members


s duty of


civilized


beneficence,


society


I believe,


cooperate


institutions


necessary,


that


should


aid


needy,


forced


to do


and


requires


so by


law.


that


This


they,


evidence


will be provided by reconstructing Kant


s argument


for a duty


of beneficence as he presents it in both the Groundwork of the


Metaphvsic


Morals


(hereafter


GMM)


, and


"Doctrine


Virtue"


: Part


The MetaDhvsic of Morals.


In the


former


work


Kant


indicates


how


two


formulas


Categorical


Imperative


(the


formula


of Universal


Law,


formula


Respect


Dignity


Persons


Persons


Ends-In-












Kant,


we are


forbidden


ignore


rational


ends


of others,


and


duty


beneficence


requires


that


help


them


achieve


those


ends


, if


can.


Since


duty,


Kant


prescribes


what


should


and


what


want


enforcing


this


duty


law


can


justified,


Kant,


since


would


accept


that


duty


followed


our


reason


rather


than


our


desires.


Supreme


Moral


Principle


Kant


s moral


philosophy


centers


what


calls


supreme


moral


principle:


"Act


only


tha t


maxim


through


which


you


can


same


time


will


tha t


should


become


universal


law"


GMM:


"We


must


able


will


" he


says,


"that


a maxim


our


action


should


become


a universal


law-


-this


general


canon


moral


judgement


action"


GMM:


424)


Kant


calls


this


principle


the Categorical


Imperative.


And


although


describes


other


formulations18


Formula


of Universal


Law,


of Respect


the Dignity


Persons,


of Legislation


a Moral


Community)


Kant


only


one


moral


law


exists.


points


out:


" [T] he


aforesaid


three


ways


representing


principle


of morality


are


18Paton,


Categorical


ImDerative


(Hutchinson


I f A r, -, r, tr' \ --- -_- i


2 _


r ----- -, A-


- t, .. r-


--


1


i A -












bottom merely


so many


formulations of precisely the same law"


(GMM:


436)


The


content


(moral)


(the


ends


mankind,


happiness


(GMM:


399,


CPR:


, 119;


19220


comes


out


more


clearly


second


formulation


Categorical


Imperative


(Respect


Dignity


Persons,


or Persons


as Ends-In-Themselves


This formulation,


and


content,


(discussed more


fully


below)


are


central


Kant


argument


duty


beneficence,


enforcing


it by


law.


Kant


Categorical


Imperative


prescribes


duties.


"A duty, "


221)


says,


Moreover,


an action


"all


which


duties


are


contain


obligated"


concept


necessi tati on


law"


393)


Therefore,


categorical


imperative


law


which


either


commands


prohibits;


it sets


forth as a duty the commission or omission


action.


action


that


neither


commanded


nor


forbidden


is merely


permissible"


(DV:


221;


DV:


395)


According to Kant


, then,


we are obligated to perform some


actions and obligated


to refrain from others.


Moreover


, some


19Immanuel


Kant,


Critique of


Practical


Reason


(hereafter


CPR)


, trans.


Lewis


White


Beck


(Indianapolis:


Merill,


1965)


20Immanuel Kant Lectures on Ethics


(hereafter LE)


trans.


Loui


Infield


refer


(New York:


Infield's


Harper and Row,


translation


1963)


and


Page numbers
he Prussian


T---_--- A- i-i--


r t a -


6119


I_ *











obligations


can


discharged


with


less


discretion


than


others.


instance,


one


little


discretion


way


one


keeps


promises


, while


there


may


many


ways


one


may


help


another


person


follows


need.


perfect


Kant


duties,


schematizes


like


keeping


these


promises


duties


and


committing


cide


, are


"narrow"


duties


duties


that


"admit


exception


favor


inclination"


GMM:


421n)


and


imperfect


duties,


like


promoting


needs


oneself


and


others,


are


"wide"


duties


duties


that


allow


"play


-room


latitude


free


choice


following


observing


law"


Kant


definition


perfect


duties


Groundwork


exceptions


However


seems


and


that


that


imply


they


believe


are

woul


that ir

optional


d


perfect


like


duties


acts


be a misreading


allow


charity


of Kant.


following


will


stinction


that a

duties


1 though


show

the


one has


act


that


Kant


Doctrine


clears


Virtue


some discretion


of discharging


them


perfect/imperfect


where


in discharging


is not


emphasizes

imperfect


optional


GMM:


422n)

involves

Gregor,


obligatory

Kant


Thus


perfect


-imperfect


the narrow-wide distinction"


Hill,


strength.


also


-58)


will


and


return


stinguishes


distinction


Cummisky,


"essentially


607;


distinction


to thi


between ben


see


between


distinction below.


Levolence











Benevolence


in practice


(beneficence)


is voluntarily


helping


others--possibly


some


more


than


others.


The


duty


beneficence,


however,


concerns a


"maxim of


action"


(DV:


449)


"conduct"


(DV:


that


one


required


perform


certain circumstances


They are not acts we can wish to do or


not wish


to do,


ones we are obligated to do.


will


also


say more


about


this distinction below.


The Groundwork


Formula


Universal


Law


Groundwork,


Kant


presents


four


famous


illustrations


Categorical


Imperative.


The


last


four generates an imperfect


The illustration is used twice.


duty


to aid another


The Formula


in need.


of Universal


Law


is applied


first,


followed by the


Formula


of Respect


for the


Dignity


Persons.


I shall


discuss


each separately.


Formula


Universal


states:


"Act


only


that maxim through which you can at the same time will


that it


shall


become


a universal


law"


(GMM:


421)


Kant


then applies


the principle to the following example.


A man is flourishing,


sees


"others


who


have


struggle


with


great


hardships


(and whom he could easily help ) ;"


and he


thinks


"What


does












it matter


can


to me?

make


every


himself


one

won'


be as happy

t deprive


as Heaven


him


wills


anything;


won' t


even


envy


him;


only


have


wish


contribute


anything


to his


well-be


ing.


" (GMM:


, my emphasis


Although


this


man


does


"wish


contribute"


needy


person


well-being,


neverthel


ess,


says


Kant,


obligat


so.


That


cannot


will


following


maxim,


ought


aid


another


need


, when


aid


could


easily


given.


Kant


provides


following


reasons.


although


s possible


that


universal


nature


yet
hold


could


it is


subsist


oss:


ible


in harmony


to will


everywhere


that


with
such


nature


this


maxim


a principle


For


should


will


decided in
since many


needed
such a


love


law


himself


this


way


would


situation


and


sympathy


nature


of all


conflict


might
from


sprung


hope


of the


arise
others


from


help


with


itself


which


and


own


man


in which,


will,


he wants


he would
himself.


(GMM:


This


illustration,


whose


derivation


says


Kant


from


demonstrates


single


principle


"actual duti


leaps


eye"


(GMM:


He


calls


this


duty


"wider


meritorious


duty"


compared


"narrow


rigorous


duty"


GMM:


The


duty


wide


imperfect


because


one


cannot


will


this


maxim


to be a universal


nature


without


contradicting


one


s own


rational


ends


, and


thus


one


cannot


from


as a


principle


of morality.


application


this


formula


I- t a -a n 44-


II


LA~~V1: AAl


c.L


Lk


rrn


L- L











this


moral


judgement.


"The


proof


our


obligation


beneficence,


" says Mary Gregor,


"turns on the impossibility of


willing


our


However


maxim


she


selfishness


says,


Kant


not


universal


law"


stressing


(194)


logical


contradictions


source


'moral


force.


Rather,


Kant


explaining


teleological


consistency


between


our


maxim and


our


objective,


rational


ends"


(203f)


Since


one


would


want


one'


obj ective


rational


ends promoted


and since


one'


objective


rational


ends


are


ends


humanity


shares,


when


one


easily


can,


one


must


promote


objective


rational


ends


others


in need.


neglect


these


[ends]


says Kant,


"can admittedly be compatible with the maintenance


of humanity as an end in itself


, but not with the promotion of


this


end"


(GMM:


430)


With this application of the categorical imperative,


Kant


generates a duty to aid


(when aid can easily be given)


"so far


type


obligation


concerned


(not


object


dutiful action)"


(GMM


: 424)


For instance,


he has not told us


whom


are


aid


(minimally,


anyone


who


can


easily


helped)


, how to aid,


nor how much.


Nevertheless,


the point i


23Cf.


arguments


Paton' s


are


based


comment:


logical,


view


opposed


that


Kant


teleological


consistency,
[of Kant] of


says Paton,


all"


(quoted


is "the most serious misunderstanding


in Gregor,












that


ignoring


this


obligation,


when


are


in a position


discharge


would be


wrong.


As Roger Sullivan


points


out,


"imperfect


obligations do not admit


of exception,


only a wide


range


ways


fulfill


them"


Moreover,


"These


questions


[regarding


duties


virtue]


says


Kant,


not


yield


so many different kinds of obligation


(for there


only


one


kind


many


ways


applying


[the


one


principle


virtue]


(corollaries) "


(DV:


468,


underline


added)


Formula


Respect


Persons


The


formula


respect


dignity


persons


also


generates


positive


duty


aid


others


need


GMM:


430;


MEJ:


221;25


448-51)


Groundwork,


Kant


uses


same


example


illustrate


application


this


formula.


The


formula


this:


Act in such a way that you always treat humanity,


whether


in your own person or
simply as a means, but
(GMM: 429)


For Kant,


the person of


any other,


always at the same time


respecting the dignity of a person


never


as an end.


treating


that


person only


as an end,


and never


as a means to an


25Immanuel


Part


Kant,


The


Metaphysics


Metaphysical


Morals


Elements
(hereafter


Justice:


MEJ)


trans.


-


-r -II'


. -


S] fr-


I Ak I In -~ -r -. -, -r r% I Ir .1 stL. n It S I1- 5


1I 1 J -


r 'I












end.


Moreover


, it


to consider


that


person


as an equal


one


s rational


life


plans,


that


considering


rational


ends


others


, as


best


one


can,


one


s own.


Robert


Wolff


comments,


"Presumably,


what


Kant


means


treating


humanity


an end


that


must


keep


mind


that

invol


they

ves


[rational


respecting


moral

their


agents]


purposes


have

rather


purposes


than


too.


ignoring


This

them.


[I]t


becomes


clear


that


[Kant]


does


mean


treat


other


agents'


ends


as our


own"


-176


Commenting


on imperf


duties


to others


Kant


says


Now


humanity


contributed


same


time


could


nothing


refrained


doubt


to the


from


subsist


happiness


deliberately


eve


of others


impairing


rybody
at the
their


happiness.
and not D


unless


This


positive


everyone


is, however,
Iv with hun


4


endeavors


merely
vanity a


also


so far


agree
n end


negatively
in itself


as in him lies,


further


ends


others


ends


subj


who


have


ends


an end


full
(GMM


himself


effect


must,


this


, be al


conception


, as far


as poss


: 430


According


Sullivan,


" [For


Kant


fully


respect


others


we should


we do


not


make


their r


interest


our


own


and


help


them


insofar


can;


are


therefore morally


obligated


to sacrifice


part


our


own


well-


being


others"


(207


emphasis


added).


In his


Lectures


Ethics


, Kant


concludes


Every


one


therefore


enj oying


good


things


-1


__


* ( I ^


1 .


1


II











Thus,


respect


dignity


persons


respecting


their interests


, their rational ends,


"which is always


[their]


happiness,


" according to Kant


DV: 490


One must give these


ends


Kant


equal


other


consideration,


s ends must be my


least


ends


ignore


agree


them.


positively with


humanity


itself,


that


agree


that


persons should have


their ends promoted,


rather than


"merely"


harmed.


Moreover,


humanity


could


subsist,


says


Kant,


one


contributed anything to the happiness of others.


not be a rational existence


Yet it would


, since one would not be willing to


live


world


where


one


ends


were


promoted,


where


one


s fundamental needs


for a decent life were ignored--where


one


was


treated


person,


with


respect.


"This


principle


humanity


as an end in itself


says


Kant,


supreme


action"


(GMM:


lim


431,


iiting condition of ev

second emphasis added)


ery man


Hence


s freedom of

, we are not


free to ignore the needy,


since they too must be treated as an


end and be given equal

interprets Kant to mean


positive

to seek


, duty to

Sthe


respect.


the following:


further


happiness


Finally


ends


of other


H.J.


Paton


"We have an imperfect,

S. in others--that

?rs" (34)


Hence,


formulation


respect f


dignity











universality


our


moral


maxims,


formula


respect


dignity


persons


brought


out


object


telos,


ends


of persons--their


rational


life


plans.


Moreover


, to


respect


persons


requires


we treat


them as


ends-in-themselves,


giving


their


rational


ends


as much


consideration


as our


own,


least


ignoring


them.


Although


respecting


persons


tells


give


"appropriate


practical


consideration"


persons,


Kant


not,


in the Groundwork,


said


"wha t


counts


appropriate practical


consideration"


Cummisky,


We will


now


turn


Kant


more


fully


worked


arguments


imperfect


duty


to aid


others,


or a duty


of beneficence


, as he


calls


in his


Doctrine


Virtue.


The


Doctrine


Virtue


Paton,


Doctrine


comments


Virtue]


that


should


"attentive


clear


study


many


[The


serious


misunderstandings


Kant's


moral


ideas]--for


example,


that


ends


action must


be ignored,


and


that


no place


can


allowed


to moral


feeling"


Gregor,


fact,


Kant


focus


on the


ends


persons


their moral


feelings


provides


more


developed


account


duty


beneficence.


The


Doctrine


of Virtue,


says


Paton,


essentially


concerned


with


ends


which


are


also


duties.


Indeed


[Kant


ethics


can











when


interpreting


Kant


s moral


philosophy


that


reason


The


Doctrine


Virtue


supreme


interest


Of special


interest


here


Kant


applies


supreme


moral


principle


outlined


Groundwork


pra


ctical


problems


like


aiding


needy


What


surfaces


a rationale


morally


requiring


one


to sacrifice


some


of one'


means


aid


others


in need


52)


Moreover


, passages


from


"The


Metaphvsical


Elements


Justice"


Part


Two


"Metaphysics


of Morals"


indicate


that


this


requirement


may


(morally


enforced


a government


(MEJ


: 326


Duties


of Virtue


For

different.


Kant,


" IS


"duties


"virtue"


s Kant,


virtue"


strength


are


man


maxims


fulfilling


duty"


(DV:


Virtue


having


strength


act


accordance


with


formal


morality,


overcoming


obstacles


that


would


conflict


with


moral


law


However,


what


virtuous,


says


Kant,


necessarily


a duty


virtue


proper


sense"


393).


"The


practice


of virtue


" he


continues


, "can have


to do merely


with


formal


aspect


our


maxims


, while


a duty


virtue


"Virtue












concerned


with


their matter--that


, with


an end,


which


also


conceived


as a duty"


(DV:


For


Kant


first


principle


doctrine


virtue


(for


generating


duties


virtue


this


"act


according


a maxim


ends


which


can


be a universal


everyone


to have"


: 394


According


to this


principle


, Kant


argues


"man


an end,


to himself


and


to others


.and


.his


duty


to make


man


[humanity]


as such


end"


394)


principle


instructs


act


ways


aid


oursel


ves


and


others


, that


on maxims


that


make


man


and


humanity


end


goal,


giving


them


equal


respect.


This


first


principle


says


Kant,


"deduction


from


pure


practical


reason


end


What


pure


a person


practical


seeks


reason.


herself


Pure


and


practical


others


reason,


continues,


indifferen t


power


to ends


ends


or to take


such


interest


, and


for


in them


would


contradiction"


intentions


: 394


originate


, emphasis


in practical


added


reason


Since


(since


our


goals


every


maxim


contains


an end


, it


must


have


some


concern


with


them.


Kant,


"pure


reason


can


prescribe


an end


a prior


only


in so


declares


to be


also


duty.


And


this


duty


then


those


called


ends


"duty


shared by


virtue"


humanity


: 394)--a


, happiness


duty


being


to promote


primary











have


respect


dignity


persons,


treat


persons


ends-in-themselves.


doctrine


virtue


merely applying that


formulation to the ends of humanity.


have


respect


dignity


persons


one


must


not


ignore


their ends,


or rational life plans.


Importantly,


not ignoring


others'


life


plans


does


necessarily


mean


adopting


those


plans


as your


own and promoting


them.


required


to do


only


that


end


can


adopted


universal


law


everyone

virtue).


have

so,


(the

then


first

that e:


principle


nd must


doctrine


be promoted:


that


which


same


time


duty.


Says


Mary


Gregor


"obligatory ends are properly called duties of virtue"


xvii)


Kant


schematizes


duties


virtue


did


Groundwork with some differences.


He acknowledges


, as before


perfect


(narrow)


duties


oneself,


and


imperfect


(wide


duties to one


s self and to others.


However


, Mary Gregor


comments


that


Kant


"does


not


return


traditional


distinction


perfect


and


imperfect


duties


terms


poss


ability or impossibility of external compulsion"


(emphasis


added)


In addition,


in The Metaphysics of Morals,


Kant makes


point

same


emphasizing that


imperfect


obligatory strength;


(wide)


"latitude"


duties


is not


are of


meant


allow


exceptions


duty;


instead,


according


to Gregor,











to the maxim of actions


" says Kant,


"but only


as a permission


limit


one


maxim


duty


another


(e.g. ,


love


one'


neighbor


that


in general


actually


widens


love


one'


field


s parents)--a


practice


permission


virtue"


: 388)


The duty is


imperfect because the object and the content


duty


cannot


perfectly


determined


prior,


because


its fulfillment


can be accomplished in a wide variety


ways,


depending


circumstances.


instance,


one


cannot know a prior


certain empirical


circumstances like the


extent and kind


need


(required)


and resources


(available)


aid


another.


Imperfect


duties,


then,


are


same


obligatory strength and not necessarily excluded from external


compulsion.


These


characteristics


imperfect


duties


are


relevant


issue


enforcing


duty


beneficence,


which


will


return


to below.


The Duty


Beneficence


Kant


divides


duties


virtue


others


into


duties


love


and


duties


respect.


Duties


love


include


beneficence,


gratitude


and


sympathy.


duty


respect


renders what is due to the other


(DV:


447


Although love and


respect


"are the feelings that accompany the practice of these











consequent"


(DV:


448)


Similarly,


respect


not


taken


feeling


that


comes


from


comparing


one'


worth


with


another's"


(like a child'


respect for a parent)


Respect,


says,


rather to be


taken in a practical


sense,


Sas a


maxim of


limiting


our self-esteem by the dignity


of humanity


another


person"


448)


Thus,


part


our


duty


beneficence


to show


respect


well.


instance,


Kant


points


out:


Thus


poor man


shall
but


recognize


obligation


help


since our favor humbles him by making


his


welfare dependent


on our


generosity,


is our


duty t
merely
and sc


behave


due


to him


spare


our


or but


him


help iU
slight


humiliation


either
service


and


what


love


maintain


self-respect.


( DV:


447)


duty


respect


to others


a negative


one.


This


duty


forbids


one


exalt


oneself


above


another


: 448


However,


duty


love


(which


includes


beneficence


positive one.


This duty requires one to contribute something


to the welfare of another.


Hence,


"the duty of love for one


neighbor


can also be expressed as


the duty


of making


other'


ends my

(DV: 44


own


.9)


The


duty


these e

respect


inds

for


are


only not


another


immoral)"


demands


that


another


not


"degrade


himself


order


slave


end"


449)


Importantly,


Kant


distinguishes


between


benevolence












man.


According


Kant


, benevolence


our


wishes


can


"greatest


in its


extent,


smallest


in it


degree"


instance


, one


may


care


one


person


because


one


s love


of mankind


, yet


another person


one


may


only


indifferent


to his


needs.


Kant


explains


take


interest


this


man


welfare


only


keeping
interest


can
him


with


take


unive


in him


only


rsal


love


is as slight
indifferent


man,


as an interest


with


regard


: 450)


Benevolence


practi


benefiti


cence


voluntarily


helping


some


more


than


others


According


Kant,


although


one


can be


benevolent


everyone


, one


can


wish


everyone


well


and


love


mankind,


one


can


only


practi


benevolence


beneficence


some


more


than


others.


"Love


your


neighbor


your


fellow man)


as yourself


Kant


explains


, does


mean


one


is expected


literally


to love


one


s fellow


man


as himself


(since


one


would


love


everyone


same


Rather


, he


says


refers


active,


practical


benevolence


eneficence


, which


consists


in making


another


well-being


can


and


happiness
benevolent


end.
eve


For
ryone


in wishing
. whereas


acting


can,


without


violating


universality


my maxim,
different


vary tn
objects


degree


greatly


love


one


according


whom


to the


concerns


me more


closely


than


another)


DV: 451


Finally


duty


action"


beneficence


conduct)


that


concerns


some


"maxims


circumstances


-~~ aA -- -r -I


-- -21--A--- -C


equally


I


__


r% . -' _- _


1


-.,, ~,,.,,,


I


L1











rather


about


duties


concerned


with


"active


benevolence


that


with


maxims


action"


emphasis)


explains.


duty


"Bu t


love


benevolence


logically


. as conduct


impossible,


" he


" he emphasizes,


"can


brought


under


law


duty"


(DV:


400,


emphasis


added)


some


circumstances,


beneficence


required:


helping


other people


is not


an act


we can


wish


to do


or not


one


according


we are


our


obligated


ability,


to do.


" explains


help


Kant,


other


a duty


[people]


, whether


we love


them


or not;


and


even


turns


that


human


species,


closer


acquaintance,


does


not


seem


particularly


lovable,


this


would


not


detract


from


force


[emphasis


added]


our


duty


to help


others"


(DV:


Continuing


writes


Helping
a man p
his pur
those h


love


others


practices


pose,


you r


should


(afterwards)


good t
fellow


to achieve


often


their


and


eventually


helped.
neighbor


Hence


immediately
through the


him


-man,
i (as


means,


and
an


this


will


aptitude


ends


succeeds


comes
the


yourself,
(first)
medium of
rather:


give
of


is
in
fee.


saying:


does
love
this


rise
the


a duty. If
realizing


1 ov
you


not
him
love


good t
to love


inclination


ought


mean:
and
to do


your


man
to


beneficence


in general)


: 400


Regarding


amount


help,


Kant


short


on answers.


Nevertheless,


he asks


"How


should


we expend


our


means


practicing


beneficence?"


"Surely


extent


that


, my


1


" [A]












beneficence


should


left


each


person


decide.


Regarding


this


duty


, he


says:


[The


says


only


that


well-being


should


others


sacrifi


without


:e a part
hope of


requital,


because


this


a duty;


cannot


ass


ign


determinate


These
person


limits


limits


will


true


to the
depend,


needs


extent


in large


consist


of this


part,


sacrifice
on what


view


temp
this


erament


, and


himself


it must


. (DV


left


to each


to decide


: 392


Kant,


then,


there


level


sacrifi


that


voluntary


obligatory.


We must make


sacrifices


: it


is our


duty.


After


some


level


of sacrifice


, each


person


may


decide


whether


to sacrifi


more.


duty


of beneficence


, then


, has


certain


limitations.


These


limitations


include


one


can


only


promote


other'


permit


ssible


ends


are


forbidden


exalt


oursel


ves


over


another


while


discharging


this


duty


: 447


one


cannot


act


immorally


addition


promoting


these


ends


GMM:


and


we are


required


to perform


unreasonable


sacrifices


DV: 453


will


return


(iii)


below.


Importantly,


however,


Kant


duty


beneficence


goes


"beyond benevolence


our wishes


regarding


others


(which


costs


us nothing)


and


make


this


benevolence


practical


that


everyone


who


has


means


should


beneficent


, so












law"


(DV:


451,


emphasis


added)


Since


every


man


who


finds


himself


in need


wishes


to be helped by


other men,


Kant


again


concludes,


every man


s duty


to be beneficent


--that


to promote,


according


of others who are in need,


gaining


anything


his
and


means


happiness


this without hope


452)


"The


maxim


self-interest,


Kant


concludes,


"contradicts


itself


when


is made a


universal


[permissive]


[i.e. ,


public


--that


contrary


duty.


Consequently


" he explains,


" the maxim of


common interest


--0


beneficence toward the needy--is a universal duty of


[persons


[since]


[persons]


are to be considered fellow-[persons] --


that


rational


beings with needs


, united by nature


in one


dwelling


ace


purpose


helping


one


another"


, underline added).


Finally,


out.


helping the needy involves actively seeking them


While it is not our duty to experience sadness or joy in


sympathy


with


others,


according


Kant,


duty


participate


actively in


fate


others.


Thus
shall


our


find


essentials,


duty:


poor
rather


not


avoid


who


lack


to seek


places


most


them out.


where


basic


. For


this


still


one of


impulses


which nature has


implanted
of duty
emphasis


in us so that


alone
added)


would


we may do what


not


accomplish"


thought
r: 457,


-- -. -11-











morally


requiring


action,


second


formulation


categorical


imperative


treat


persons


ends


-in-


themselves)


requires


practice,


seek


out "


and


aid


needy,


without


hope


of gaining


anything


There


, Kant


says


, "less


value


in compliance


than


service"


233


Enforcing


Duty


of Beneficence


duty


beneficence


enforced


through


legislation


(e.g. ,


through


taxation) ?28


Kantian


immediate


reaction


would be


"No "


, and


at least


reasons


am sure


there


are


many


more)


One,


duty


of beneficence


imperfect


"duty


virtue,


Kant


specifically


differentiates


them


from


"duties


justice,


" claiming


former


are


internally


latter


externally


legislated


(MEJ:


-220


Secondly,


what


about


limitation


iii),


one


cannot


act


immorally


while


promoting


some


end?


Nozick


points


out,


use


a person


in this


way


[forcing


him


give


aid]


does


sufficiently


respect


and


take


account


fact


that


is a separate


person,


that


only


life


he has"


Although


do not


intend


to give


this


issue


exhaustive


treatment,


would


like


suggest


a response


these


obj sections


as a way


to suggest


that


Kant


s theory


would












first


read


what


Kant


says


about


taxation.


[T]he
taxes


supreme


commander


them


conservation,


poor,


foundling


[the


possesses
people]


in particular,


hospitals


; in


right


their


relief
other


to levy


own


words


what


institute


are


ons


usually
emphasis


called


charitable


add


Ther


before


require tn
subsistence


most


necessary


wealthy
r those


needs


government i
to provide


who


are


unable


nature


authorized


means


Sto provide
themselves.


money


should


raised


merely


through


voluntary
extractions


contributions,
nir \ 29


M EVlJ


: 320


compulsory


[T] he


funds


care


poor


should


sed from


current


contributions


versus


permanent


funds]


so that


poor


each


. [which]


generation
is compatible


will


support


with


own


rights


which


live


because


number
poverty


poor


will


cannot
using


people


not


abandon
current


increases


become


anyone


contributions


, the


means


when


profession
livelihood


lazy


.and


thus


state


will


required
the people


impose


(MEJ


[juridically]


: 326


, underline


un u


st burden


added)


Kant


says


two


interesting


things


here.


One,


that


state


right


levy


taxes


needs


that


are


usually


charitable


and


two


, that


this


right


certain


limits


, since


it cannot


place


unjust


burdens


on the


people.


These


passages


suggest


that


Kant


would


rely


charity


only


to a point,


after


which,


there


great


need


the


government


may


29Parenthe


tically,


Kant


explains


that


"some


voluntary


- .2 1. 2


state,


_I


.1 .


L. L.


__. _%,L-


-LL


. -.. X -


1.











enforce


beneficence


law.


relevance


of Kant's


position


whether


ought


require


contributions


providing


health


care


citizens


U.S.


today


striking.


With


almost


million


uninsured,


million


whom


are


children,


have


surely


passed


limit


relying


charity,


noble


Neverthel


ess


, if


this


what


Kant


says,


how


can


reconciled


this


with


: that


above


duty


objections


beneficence


first


one


criticism was


"duties


virtue


" which


always


internally


legislated


, not


a "duty


justice


" which


s externally


slated.


Hence,


Kant


could


not


recommend


legi


slating


benefit


cence.


However,


Cummisky


605ff


suggests


that


Kant


could


legi


slate


beneficence


because


possible,


within


Kantian


system,


beneficence


"duty


justice


possibility


arises,


Cummisky


says


, when


realize


that


distinction


(between


duties


justice


and


duties


virtue


"misleading.


The


reason


distinction


misleading


centers


on confusing


"genuine


concern


others


internal


and


cannot


legislated,


"external


action


of providing


assistance


" which


can.


Hence


, the


state


cannot


legislate


benevolence


cannot


force


us to have


kind


thoughts,


or good


motives.


However


, the


duty


of beneficence,