Health of the nation: a philosophical approach to health insurance and the welfare state

In this blog, Rob introduces the ideas of one of his favourite philosophers, Joseph Heath, and shows how they can be applied to contemporary debates about health care and the welfare state.

Introduction: Joseph Heath, market failures and the welfare state

Joseph Heath is a Canadian philosopher who has written about a variety of philosophical topics. One of his major contributions is to apply economic ideas to moral and political philosophy. He has argued that the concept of market failure should be central to how businesses and governments make decisions.


Specifically, Heath argues that, to act ethically, businesses should refrain from taking advantage of market failures, while governments should focus on resolving them. This might sound anodyne, especially to economists, but it is actually an original and distinct philosophical view.


Market failures come in many shapes and sizes. I have identified some of the main ones below. (For an accessible introduction, I would recommend this free online course).

They have in common that they prevent buyers and sellers from carrying out trades which they would otherwise voluntarily make. In economic language, they prevent Pareto improvements from taking place – trades where at least one individual is made better off without making another worse off – and result in inefficient outcomes.

Type of Market FailureDescriptionExampleSolution
ExternalityWhen the individual reaping the benefits from an economic activity does not pay the full costs associated with itA factory polluting the local environment but not paying to clean it upTax the individual or business so they do pay the full costs for their activity
Collective Action Problem
When a group of individuals would collectively be better-off if they cooperated, but they fail to do so because they reason that they will be individually better-off if they defect 
Depletion of shared natural resourcesPrivatise the shared resource or regulate its use
MonopolyWhen are too few sellers in a market or inadequate competition between them, enabling them to price gougeUtilities like electricity, sewage, or water Regulate prices, break up large companies into smaller ones (competition policy), or take them into public ownership
Asymmetric InformationWhen one party in a trade has more information about a good or service than another, enabling them to take advantage of the otherMarket in second hand goodsThird-party accreditation of product quality

Heath takes these concepts and applies them to business ethics and political philosophy.


In business ethics, he disagrees with the two most popular views: that the primary responsibility of corporations is to maximise profits for their shareholders or, alternatively, to balance the interests of their stakeholders. Instead, he argues that the chief responsibility of business is to ensure there is an efficient allocation and use of resources in society1. They should do this by refraining from exploiting market failures. For example, a business should not pollute the local environment without sufficiently compensating those who will be affected (not necessarily something that should be taken for granted!).

1Heath’s “market failures approach” to business ethics builds on the empirical claim that capitalism and free markets have, overall, served us well for the last two hundred years and are demonstrably the most effective way of allocating resources in society to their best (most efficient) use.


In political philosophy, Heath argues that the strongest normative justification for the welfare state – the public provision of health care, pensions, unemployment benefits and so on – is that it solves market failures and provides public goods, which are valuable for everyone in society but would be underprovided if left to market forces alone.


This is distinct from rival views which claim the normative basis for the welfare state is either that it ensures everyone in society’s basic needs are met or, alternatively, that it increases fairness by redistributing wealth and income from rich to poor. To be clear, Heath is not saying these are not legitimate goals, just that they are not the strongest justifications.


I am not going to rehearse Heath’s arguments in this blog (but I have noted his key essays at the bottom). Instead, I aim to show their power and relevance by applying them to a live debate: the public provision of health care.


Specifically, I will respond to the case made by Alex Voorhoeve (another moral and political philosopher with economic inclinations) that it is permissible for a government to mandate individual citizens to purchase more comprehensive health insurance than they themselves want.


Inspired by Heath, I will attempt to show that the two arguments Voorhoeve makes for this position are unconvincing. I will conclude by suggesting that concerns that motivate Voorhoeve’s argument are not as troubling as they initially appear. We can support the public provision of health insurance – and be confident it can function effectively – without being overly worried about some citizens opting out.

What does public provision of health care mean?

It will be useful to clarify what I mean by public provision of health care before getting into the debate. The meaning of public here is probably obvious: the government rather than the market.

The meaning of provision, however, is more subtle2. It refers both to the demand and the supply side of health care, though these are distinct. The demand side essentially means the funding. The options are a single payer public system (where everyone pays the same for insurance), a fully competitive market (where individuals take out private insurance policies), or something in between.

2Or, at least, its meaning is lost on certain commentators on both sides of the political spectrum, who alternatively invoke the privatisation or socialisation of the health system without being clear on what they believe is being either privatised or socialised.

The supply side means the health care professionals (along with the equipment and facilities they use) who deliver health care services. The options are salaried employees of the state, private practitioners and companies, or something in between.

The demand and the supply side can be joined in different combinations. For example, funding of the health system could be via a single payer public system but care itself could be delivered by private practitioners and companies who are contracted by the government.

In this blog, I am focusing the question of how the demand rather than the supply side of the health system should operate. Specifically, this relates to the extent to which governments should be involved in the design and provision of health insurance.

May a government mandate more comprehensive health insurance than (some) citizens want for themselves?

Voorhoeve frames his argument in the context of the Affordable Care Act in the US. This landmark act – more commonly known as Obamacare – provided affordable health insurance for millions of Americans who were not previously covered.

It was also extremely controversial and much maligned. One particular criticism was that the Act increased the insurance premiums for some US citizens against their will, because their coverage was judged to be insufficiently comprehensive – not providing them with enough protection against the risk of ill health3.

3Or, at least, its meaning is lost on certain commentators on both sides of the political spectrum, who alternatively invoke the privatisation or socialisation of the health system without being clear on what they believe is being either privatised or socialised.

Voorhoeve illustrates the moral quandary with the words of one US Representative:


“What do you say to Mark and Lucinda in my district who had a plan, they liked it, it was affordable, but it is being terminated [because it is not sufficiently comprehensive to meet the requirements of the Affordable Care Act]? It was what they wanted and I will remind you: some people like to drive a Ford, not a Ferrari. Some people like to drink out of a Red Solo cup, not out of crystal. You are taking away their choice.”
Representative Marsha Blackburn, 2013

This feature of the Act seems objectionable because it is an intrusion into an individual’s choice or, in other words, is paternalistic4. It requires an individual to buy more protection against risk than they may themselves be willing to.

4There is a presumption in political philosophy that paternalism is bad and that it is only permissible for governments to behave in paternalistic ways in extreme cases. For more on arguments for and against paternalism, see this free article.

Voorhoeve attempts to show why this feature is justifiable despite its seemingly paternalistic nature. He provides two arguments for this position: (a) the adverse selection argument; and (b) the social egalitarian argument.

(a) The adverse selection argument

Voorhoeve first argues that a mandatory minimum package of health insurance is justified because otherwise the health insurance market could collapse due to an adverse selection mechanism.


Adverse selection is a type of market failure that results from asymmetrical information. Consider a competitive insurance market, where an individual wants to protect themselves against the risk of some significant harm. They therefore pay a sum of money to an insurer, who promises to pay out should this harm befall them.


The insurer will want to know the probability that this harm will occur and, in the event that it does, the amount that they will need to pay out. This will enable them to offer as good a deal as possible to the individual (while still making a profit) and win their business in a competitive market.


This means that the insurer is incentivised to find out as much relevant information as they can about the individual, so they (or, more likely, the actuary working on their behalf) can calculate the risk of harm as precisely as possible. If the individual does not face a significant risk of harm, this does not necessarily pose a problem to them. They can share information about themselves freely with the insurer, without being too concerned about having to pay high insurance premiums as a result.


If they do have a specific risk factor, however, which leads them to face a risk of harm that is statistically higher than the average, this may not be the case. They could want to conceal their risk factor from the insurer so that they do not have to pay high premiums. (Importantly, we are assuming that an individual is likely to have much better information about their own health – and hence their risk of harm – than a third party).


The scene is now set for an adverse selection mechanism to emerge. Imagine a stylised insurance market where two people, Bob and Jill, want to insure themselves against the risk of ill health. The most likely scenario is that one of them will become very ill, in which case their care will cost $10,000, while one will not be ill at all, in which case their care will not cost anything.


As a result, the insurer charges Bob and Jill $5,000 each in premiums, because this is the average they will have to pay out for the two of them. Significantly, however, Bob is already an extremely unhealthy person, while Jill is extremely healthy. The insurer, on the other hand, has no idea about this. While Bob may be very happy to pay the $5,000 premium, Jill is likely to be far less eager. She therefore decides to take her business elsewhere, leaving Bob to pay the elevated $10,000 costs alone.


This is the essence of adverse selection. If we were to add more people to the insurance market, the same mechanism would lead the (relatively) healthy to drop out of market given the high costs they face, while the (relatively) unhealthy face steadily increasing premiums. A death spiral sets in and the insurance market collapses.

To avoid this situation, Voorhoeve argues, there is a strong case for a government to mandate all citizens to buy health insurance that will provide them with a standard of care that is above a certain threshold. In effect, this prevents the healthy from dropping out of market and a death spiral from setting in. Importantly, this mandate can be justified to the healthy as in their own interests. Everyone – even the healthiest – face some risk of serious ill health at some point and therefore would not want all health insurance markets to collapse.

(b) The social egalitarian argument

Voorhoeve’s second argument is that, without a required minimum level of health insurance, social egalitarian public goods, which everyone has reason to value, would be underprovided.


Social egalitarian public goods can be roughly defined as an enabler of trust: the glue that holds the fabric of society together. They are social egalitarian because they allow everyone, regardless of their rank or station, to engage with each other on a basis of equality. This is an important pre-condition for a liberal society.


They are public goods because, in keeping with classic public goods like security or clean air, they are non-excludable and non-rivalrous. This means that for anyone to be able to consume them, everyone must be able to consume them, and their consumption by one person does not affect their accessibility to others.


Public goods are liable to be underprovided by market forces alone. Since everyone can access them without restriction, individuals will be tempted not to contribute to their provision and free ride on the contributions of others. (In other words, collective action problems often emerge around the provision of public goods).


Voorhoeve lays out four distinct social egalitarian public goods related to health, which I have summarised in the table below.

Social egalitarian public goodDescription
Absence of domination and exploitation in private lifeThe less well-off are not highly dependent for their wellbeing on the powerful
Absence of domination in political lifeThe interests of the less well-off are effectively represented
Social bases of self-respectEveryone is able to participate in public life with dignity
Attitudes required for social cooperationEveryone is willing to work with others for mutual benefit, enter reasoned discussions and abide by fair arrangements

His claim is that, if adequate health care is not guaranteed to everyone in society, these social egalitarian public goods will be underprovided. This generates a prudential reason (a reason motivated purely by self-interest) as to why a healthy person should desire other people to be healthy too. On a societal level, this benefits the healthy, enabling them to live in a trusting, well-functioning community.


Importantly, if each healthy individual were left to choose whether to contribute extra resources to provide these social egalitarian public goods, they may decide not to do so. They would be tempted to free ride on the contributions of others, leading to a breakdown of trust and a collective failure to produce the social egalitarian public goods.


In turn, this justifies an external enforcement agency – such as a government – obliging everyone to contribute a minimum amount to the collective scheme. One way of achieving this would be through a mandatory minimum level of health insurance.

Why I think Voorhoeve’s arguments are unpersuasive

I have doubts about the success of both of Voorhoeve’s arguments. First, the adverse selection mechanism is a theoretical risk to the effective functioning of the health insurance market, but in practice less of a concern. Second, even if we accept Voorhoeve’s claim that adequate health care for everyone in society is necessary to the provision of social egalitarian public goods, it is not clear that the best way to provide these is through health insurance. Ideas from Heath provide the basis for both responses.

Adverse selection is more a theoretical than a practical problem

Insurance is a way for an individual to reduce the risks of harm they face in an uncertain world. I do not purchase insurance as an altruistic act. I do it because, by pooling the risk that I face with others, I make it more statistically stable and therefore predictable. This helps me to calculate how much I should spend on protecting myself against risk relative to other things.


Nevertheless, insurance does not have to be perfect, just good enough that it is worth me buying it rather than bearing the risk on my own. Heath presents this distinction in a more technical way in a paper about the insurance industry. Drawing on game theory, he distinguishes two types of equilibrium that could be reached in a cooperative arrangement such as an insurance market:

  1. The feasible set: “the set of possible cooperative arrangements that offer individuals expected payoffs higher than those that could be obtained through the non-cooperative strategy of self-insurance”
  2. The core of the game: “an arrangement from which no individual or coalition of individuals has an incentive to defect”

The feasible set compares a sufficiently good outcome to a bad outcome – the difference between having a decent package of insurance versus none at all. The core of the game compares an optimal outcome to all other outcomes – the difference between having the perfect package of insurance, tailored to the specific risks that an individual faces, versus any other package (or none at all).

The reason why adverse selection is more a theoretical than a practical problem is because, in the real world, we are more interested in ensuring we are in the feasible set than in the core of the game.

If an individual does not have the perfect insurance package, that does not necessarily mean they will drop out of the market. They will only do so if the costs involved in finding a better alternative – such as gathering information about different options and coordinating with others – are sufficiently low and the benefits are sufficiently high that it will be worth their time and effort. This provides an in-built brake on the emergence of adverse selection mechanisms.

(b) The best way to provide social egalitarian public goods may not be through health insurance

Why do governments get involved in the provision of health care? As I noted in the introduction, Heath suggests the most powerful argument is that governments are able to provide services like health care more efficiently than market forces (in the economic sense of producing Pareto improvements). This is because governments are able to create – or facilitate the creation of – large risk pools that distribute the costs of health care more evenly among the population than would otherwise be possible.


Perhaps the more common argument for government involvement in the provision of health care, however, is that this promotes equality. Yet, as Heath points out, the best way for a government to promote equality is usually through the tax system, specifically through progressive taxation which can be used to redistribute wealth and income from rich to poor.


Granted, Voorhoeve’s social egalitarian argument is distinct from other egalitarian arguments in its claim that healthy people have a prudential reason for wanting others in society to be healthy too. Promoting health among everyone in society produces social egalitarian public goods which, in turn, are valuable for all. The normative basis for this argument is efficiency, rather than equality.


I think, however, that the link Voorhoeve makes between social egalitarian public goods and efficiency is tenuous. It would be far more natural to see the value of social egalitarian public goods as consisting in the fact that they promote equality. They are desirable more because they make society a fairer place than because they make each individual better-off. If this is the case, then, as Heath suggests, the best way to provide social egalitarian public goods may be through progressive taxation rather than health insurance.


This intuition can be motivated by a simple thought experiment. Recall unhealthy Bob and healthy Jill. Imagine also that Bob is wealthy, while Jill is poor. Mandating a minimum package of health insurance in this case could actually be regressive, with poor Jill subsidising rich Bob. Jill might reasonably object if we tried to justify this using Voorhoeve’s social egalitarian argument.


“You might have increased equality in one way, through the creation of social egalitarian public goods,” she could say. “But you have decreased equality in another way, through a forced transfer from someone poor to someone rich”.


If, instead, the government were to use progressive taxation to provide social egalitarian public goods (topping up individual insurance contributions), this situation would not arise. A greater proportion of the social egalitarian public goods would be paid for by rich Bob than by poor Jill.


There are, moreover, precedents for governments using progressive taxation in this way. For example, the subsidisation of transport in hard-to-reach areas and public investment in digital connectivity are usually funded in this fashion rather than via public insurance schemes. These are policies, furthermore, which can be justified (at least in part) by an appeal to the fact that they provide social egalitarian public goods.5

5This is related to a broader critique of a tradition in egalitarian political philosophy, which views health as an area where government involvement is especially important. Arguably this tradition pays too much attention to health and not enough to other important issues like transport or communications. Government involvement in these areas can be justified using similar arguments to the ones which this tradition puts forward in relation to health.

Conclusion: public health insurance without mandates?

Voorhoeve gives two arguments as to why it is permissible for the government to mandate more comprehensive health insurance than some citizens want for themselves. I have argued these are both unpersuasive.


Where do we go from here? I see three options.

  1. Try a different route. Find other arguments that show why it is permissible for the government to mandate more comprehensive health insurance than some citizens want for themselves. I will not consider this option further.
  2. Bite the bullet. Accept it is paternalistic for the government to mandate more comprehensive health insurance than some citizens want for themselves but maintain this is the best option anyway.
  3. Reverse course. Hold that the government should refrain from mandating more comprehensive health insurance than some citizens want for themselves.


Biting the bullet is an unattractive option, given it would mean the government adopting a paternalistic policy. Yet there are some things to be said for it. This could build on findings from behavioural economics. The behavioural economics literature identifies a number of cognitive biases which cloud people’s judgements when they make decisions about how to navigate risk. These are not just one-off events, but systematic (and therefore in theory predictable) diversions from rationality.


For example, people tend to discount the value of the future in a hyperbolic way – seeing a positive experience in the present as dramatically more valuable than a positive experience a few years in the future. Moreover, when it comes to assessing small risks of significant harm, people can be innumerate – treating a low probability as zero probability.


Such cognitive biases could justify the government making some decisions on behalf of citizens, particularly in relation to risk, on the grounds that it is in citizens’ own interests. Yet the paternalism objection to this approach remains.


The more appealing option could be to reverse course. On the face of it, this may appear strange. If the government refrained from mandating more comprehensive health insurance than some citizens want for themselves, this could prevent those who opt out from accessing important but expensive health care when they need it and threaten the effective functioning of the health insurance market for those who remain.


For two reasons, however, I think these concerns are less troubling than they initially appear. The first is the argument I gave above suggesting that the risk of an adverse selection mechanism emerging in the health insurance market is quite low. An in-built brake on the emergence of adverse selection mechanisms means we do not need to worry as much about the effective functioning of the health insurance market in the absence of a mandatory minimum package.


The second is that there are ways to encourage citizens to buy a reasonably large package of health insurance without resorting to coercion. Most obviously, we could explain to citizens the power of pooling their risk of ill health with others and emphasise that, as they grow older and their chance of ill health increases, they will benefit from having paid relatively higher insurance premiums when younger.


More interestingly, we could appeal to citizens’ feelings of solidarity with others in society. Health insurance, risk pooling, and the nuts and bolts of the welfare state may sound technical and boring. Yet in large, modern societies, they are one of the most significant ways in which we are connected to others with whom we live and work. The stranger in the crowd, the person we pass in the street – simply by living alongside each other and pooling the risks that we face, we benefit each other. Communicated effectively, this reciprocal advantage may be enough to persuade each person to invest in a sufficient quantity of insurance – to the benefit of all.

Bibliography


Joseph Heath, ‘A Market Failures Approach to Business Ethics’ (2004)
—, ‘Reasonable Restrictions on Underwriting’ (2006)
—, ‘Three Normative Models of the Welfare State’ (2011)
—, The Machinery of Government: Public Administration and the Liberal State (2020)
Alex Voorhoeve, ‘May a Government Mandate more Comprehensive Health Insurance than Citizens Want for Themselves?’ (2018)

Sufficientarianism within Limits

In the second blog in this series, I argued that the currency of sufficientarianism – the metric that can be used to quantify how much is ‘enough’ for each person – should be self-respect. If a person has self-respect, then they have enough.

In this third and final blog post, I explore the implications of this view. Specifically, I explain how it allows the rebuttal of a powerful objection to sufficientarianism: that it is indirectly self-defeating. This provides even stronger grounds to hold that the currency of sufficientarianism should be self-respect. With other currencies, like welfare or resources, the objection cannot be so convincingly answered.

What is an indirectly self-defeating theory?

A self-defeating theory is one which, if sound, would demonstrate itself to be unsound. For example, relativism holds that nothing can be true objectively, for all people at all times. Yet, if true, relativism itself would not be true objectively. Hedonism is a putatively self-defeating normative theory. It holds that people should pursue pleasure above all else. In doing so, however, a hedonist would conceivably receive less pleasure in the long run than if they had pursued another value. Pleasure is not the kind of thing that can be attained through conscious effort.

Derek Parfit made a perceptive distinction between directly and indirectlyself-defeating normative theories. 

  1. Directly self-defeating: where doing what the theory tells you leads to achieve the aims it gives you less successfully than if you did something else (as in the hedonism example).
  1. Indirectly self-defeating: where efforts or attempts to do what the theory tell you leads to achieve the aims it gives you less successfully than if you did something else.

Parfit gives impartial consequentialism as an example of an indirectly self-defeating theory. Impartial consequentialism holds that the morally right action is the one that has the best consequences, impartially considered. An impartial consequentialist might not care much about keeping up with their friends and family. They’d be focused on achieving the best outcomes for people they didn’t necessarily know. Yet if everyone was an impartial consequentialist, then no-one would care about keeping up with their friends and family, and the value of such relationships to society would be lost. 

To achieve the best consequences, impartially considered, it is plausible that it would be best if no-one (or, at least, not everyone) were an impartial consequentialist. Yet this isn’t because of an inconsistency within impartial consequentialism. Rather, it’s because impartial consequentialism neglects important social and psychological facts and so indirectly undermines itself.

How sufficientarianism could be indirectly self-defeating

Directly or indirectly self-defeating theories are unsound. If sufficientarianism were self-defeating, we should reject it and adopt a different principle of distributive justice (such as the difference principle, which I wrote about in the first post in this series).

How could sufficientarianism be self-defeating? Recall that sufficientarianism, roughly put, holds that a just distribution is one in which all members of society have at least enough to live a dignified life. Provided this condition is met, it would be fine, from the standpoint of justice, for individuals to amass as much wealth, power, and influence as they might want.

But now imagine a society where that is taken to extreme limits. A tiny fraction of the population emerges with incredible amounts of wealth, power, and influence, orders of magnitude greater than everyone else. This huge inequality between the 1 and the 99 percent would conceivably be very bad for social and political cohesion. This process could mean that those with the least in society lose out and no longer have enough to live a dignified life. For example, technological progress might drive large-scale automation of people’s jobs, leading to widespread unemployment. However, the increased profits from this automation may be concentrated in the hands of the 1 percent, with the 99 percent left without jobs or compensation.

In such cases, sufficientarianism would be indirectly self-defeating. By focusing only on ensuring that those at the bottom have enough, sufficientarianism neglects the fact that the sustainability of this situation partly depends on how much those at the top have. Too much inequality between the bottom and the top could threaten the integrity of the sufficientarian distribution. Efforts to achieve the aims given to us by sufficientarianism – that everyone has enough to live a dignified life – could therefore lead us to achieve these aims less successfully than if we followed a different principle of distributive justice, which prevented too much inequality from developing.

Why sufficientarianism is not (always) indirectly self-defeating

I think this objection is unsound. It falsely assumes that the currency of sufficientarianism is one that would allow such huge inequalities to emerge in the first place. Specified correctly, with the right currency, sufficientarianism could prevent this from happening. 

What qualities would such a currency need to have? As well as imposing an explicit lower bound on what people should have, it would have to impose an implicit upper bound on what they can have. As I explain below, I think the currency of self-respect does just this. 

My argument here draws on an insightful paper by Yannic Vitz about the relationship between libertarianism and limitarianism. These are two seemingly competing philosophical theories. Libertarianism is a set of views roughly holding that individual freedom should be prized above all other values. Limitarianism, meanwhile, is the claim that there should be a limit on the amount of resources that any one individual has. We might reasonably suppose that your average libertarian would completely reject this claim. Provided everyone is completely free, then there is no problem with having a lot. Yet Vitz shows that a popular interpretation of libertarianism implicitly does accept there should be such limits. 

This interpretation is one that includes a condition regulating how people acquire resources in the first place. This kind of libertarian might hold, for example, that it is necessary to leave ‘enough and as good for others’, in the words of John Locke. A person couldn’t simply come along and grab all the resources before any else has a chance to. If they did, they would have to pay compensation to others. Moreover, the value of this compensation would have to be greater than that of the grabbed resources, to make up for the harm inflicted as well as the value of the resources foregone. 

Vitz points out that, if one adopts this interpretation, then implicitly one is accepting that there is a theoretical limit on the amount of resources that an individual can have. An individual should not take more resources than they can compensate others for. ‘If one would do so’, in Vitz’s words, ‘one would be impermissibly well off’. 

Similarly, sufficientarianism combined with the currency of self-respect would implicitly impose an upper bound on the amount that an individual or group of individuals could have. This is because, like libertarianism, it would implicitly set some practical conditions for how society is organised. As I explained in the last blog post, these would be that: 

(a) society conforms with some basic principles of equality and tolerance; and 

(b) everyone has an opportunity to achieve reasonably-held goals. 

In practice, condition (a) would directly limit the amount of inequality that could permissibly develop. Condition (b) would do so indirectly. As a society became wealthier, so the expectations of people living in it would become more ambitious and they would need more to achieve their reasonably-held goals. Correspondingly, the level of what constitutes enough would rise, acting as a check on the growth of inequality. In combination, these conditions would arguably prevent the kind of dystopian situation I envisaged above from emerging.

One might object that, even taken together, these conditions would only be a weak check against the growth of inequality. First, even if people’s expectations did rise a society became wealthier, this could be at a much slower rate than increases in levels of inequality. Second, it is possible that people’s expectations would not rise at all (or not very much) as a society became wealthier. For example, there could be a widespread belief that individuals take full responsibility for wherever they end up, because success depends simply on how hard one tries. The fact that some people become wealthier or more powerful may have no bearing on what others reasonably expect. 

In response, I’d note that both objections are empirical in nature. They need to be backed up with evidence before we can judge whether they are persuasive. Moreover, there may be good grounds for dismissing the second objection even if it is empirically valid. This is because it is morally objectionable to hold that individuals in a society must take full responsibility for wherever they end up, regardless of whether a majority believe this is right. This belief is mistaken. It neglects the fact that some people are privileged by the circumstances of their birth; that people have basic needs which others arguably have a duty to meet; and that gross inequalities may be objectionable even if they fully reflect people’s conscious choices.1

 1 There is a parallel here with the problem of ‘adaptive preferences’ explored by Amartya Sen and Martha Nussbaum. The problem relates to situations where people living in deprivation or under oppression lower their expectations of life and need less to satisfy their preferences. This counts against preference-based theories of wellbeing, which hold that wellbeing consists in preference satisfaction. Preferences themselves are not necessarily innocent or value neutral. 

A further defence of the currency of self-respect

If I am right, then sufficientarianism can escape the objection that it is indirectly self-defeating. Yet observe that this is only the case when the currency of sufficientarianism imposes an implicit upper bound on what people can have, in addition to an explicit lower bound on what they should have. How do currencies of sufficientarianism other than the self-respect currency fare in this regard?

First, consider the resources currency. This is clearly vulnerable to the objection. It would require only that everyone has at least a base level of resources, saying nothing against the emergence of extreme inequality in the amounts of resources different individuals have.

Second, consider the welfare currency. This would prevent the emergence of large inequality in the amounts of resources different individuals have, insofar as such inequality would push the group at the bottom of the distribution under the minimum acceptable level of welfare. Yet the size of such an effect may not be large and could therefore be a weak safeguard against the emergence of extreme inequality. More dramatically, we could imagine the wealthy and powerful deliberately maintaining the poor and weak in a state of ignorant bliss in order to keep them pliant, as in Brave New World by Aldous Huxley or The Matrix films. Such a situation may be permissible under sufficientarianism combined with the welfare currency.

Finally, consider the capabilities currency. Depending on the specific capabilities included, this might prevent the emergence of extreme inequality. For instance, capabilities related to political freedoms or economic opportunities might indirectly limit the amount of inequality that could develop. This would be true to the extent that inequality could prevent everyone from having such capabilities. Yet this would not be the case with respect to other, perhaps more characteristic capabilities, such as access to healthcare, housing and education. 

With the possible exception of the capabilities currency, the currency of self-respect emerges as one of the only plausible currencies that can enable sufficientarianism to escape the objection that it is indirectly self-defeating. This provides further grounds to believe that the currency of sufficientarianism should be self-respect.

Conclusion

In this series of blog posts, I have motivated and fleshed out an interpretation of sufficientarianism inspired by the ideas of Rawls. This interpretation may not persuade critics of sufficientarianism that it is the best justified principle of distributive justice. There are counter-arguments that I haven’t addressed. Nevertheless, I hope that my arguments have shown that, starting from a similar position to Rawls (one that is popular with many philosophers), it is possible to arrive at a different destination. If you take Rawls’ arguments seriously, then you should take sufficientarianism seriously too.

With thanks (again) to Yannic Vitz, Cedar Green and Karl Reimer for helpful comments.

Refer to the introductory post in the series here, the first blog here, and the second blog here.

Have some (self) respect- the currency of sufficientarianism

In the first blog in this series, I explained how Rawls’ arguments for the difference principle, his preferred theory of distributive justice, also support sufficientarianism, a rival theory. 

In this blog, I consider a related question: what should the currency of sufficientarianism be? By currency, I mean the metric that is used to quantify what or how much individuals should receive under a sufficientarian distribution. Drawing on the ideas of Rawls, I argue the currency should be self-respect. In other words, provided everyone has self-respect, then they have enough.

Importantly, the debate here is about what currency is of fundamental moral importance, not simply what is an adequate proxy for this currency. We’re trying to work out what, from the perspective of justice, should be distributed fairly between people, even if, practically speaking, we need to allocate something more tangible (e.g. money) to turn the vision into reality. 

What currencies are there?

Currencies of distributive justice fall into three broad categories: welfare, resources, and capabilities.

Welfare

Making welfare our currency would mean trying to identify and then distribute units of wellbeing. This is motivated by the broadly utilitarian view that wellbeing – rather than, say, rights or virtues – is of ultimate moral importance and that we can accurately quantify it. Accurately measuring welfare might seem impossible, but there are credible ways of doing so. For instance, we could use surveys to measure how happy people are in different situations (or, in more technical language, their hedonic states). 

The advantage to making welfare our currency is that it would enable us to account for the fact that some people might legitimately need more than others. For instance, disabled people might need more than non-disabled people so they could, say, buy a wheelchair or guide dog and attain the same quality of life. By using welfare as our currency, this reality would be reflected in our distributive choices.

However, with welfare as our currency we would not necessarily be able to distinguish legitimate and illegitimate reasons for differential resource allocation. An example of a potentially illegitimate reason is expensive tastes. It does not seem justifiable to give one person more because they need caviar to reach the same level of wellbeing as someone who is happy with a cheese sandwich.

Resources

Making resources our currency would mean distributing a good or service that is taken to be valuable for everyone. An obvious example is money. More sophisticated examples could be baskets of different goods and services that plausibly everyone would value, regardless of who they are.

The advantage to making resources our currency is that it would satisfy the intuition that we should be aiming for equality of opportunity rather than outcome. It would give individuals the ability to make choices for themselves about how to use their resources and, in this way, would protect and promote their autonomy.

On the other hand, using resources as our currency conflicts with the fact that different people plausibly need different amounts of resources to achieve equal levels of welfare or standing in society. (This is the same point made above in relation to the welfare currency). 

Capabilities

Capabilities can be understood as freedoms or opportunities to do the things we want to do. G.A. Cohen distinguishes capabilities from welfare and resources using the example of nutrition. The capability to be well nourished would mean having access to nutritious food, which allows one to carry out the activities and accomplish the objectives one wants to. By contrast, the welfare currency would focus on ‘the utility [a person] gets out of eating food’, while the resources currency would be concerned simply by a person’s ‘food supply’.

Having capabilities as our currency would involve trying to identify what they should be and then either distributing them fairly or ensuring everyone had access to them. There are a range of plausible contenders for capabilities, such as access to healthcare, housing, education, and employment. The UN Development Programme’s Human Development Index, inspired by the capabilities idea, is an example of what they could look like when operationalised. This index measures countries’ development based on their life expectancy, levels of education, and per capita income indicators.

Making capabilities our currency would arguably combine the best of the welfare and resources currencies. Like welfare, capabilities emphasise what people can actually do with various goods and services, rather than their mere supply. Like resources, they protect and promote individuals’ autonomy because they enable people to make choices for themselves about what to do with their opportunities.

Yet as well as having the advantages of the welfare and resources currencies, the capabilities currency may have some of their downsides. Under the welfare currency, it may be difficult to distinguish legitimate and illegitimate reasons for differential resource allocation. Similarly, under the capabilities currency, it may be hard to specify which capabilities are normatively valid. The resources currency struggles with the fact that different people may legitimately need different quantities of resources. Likewise, the capabilities currency faces the challenge that different people may need different amounts or compositions of capabilities to achieve the same ends.

CurrencyRationaleObjectionAssociated with
WelfareEnables us to account for the fact that some people may legitimately need more than others.Fails to distinguish legitimate and illegitimate reasons for differential resource allocation.Utilitarianism
ResourcesProtects and promotes individuals’ autonomy by enabling them to choose how to use their resources.Doesn’t capture the fact that some people may need more resources to achieve the same welfare level or standing in society as others.Gerald Dworkin
CapabilitiesEmphasises what individuals can actually do with resources, while protecting and promoting their autonomy.May be difficult to specify which capabilities are normatively valid; people may need different amounts or compositions of capabilities to achieve the same ends.Amartya Sen

What should the currency of sufficientarianism be?

In theory, sufficientarianism (along with all other distributive principles) could be combined with any of these three currencies. Welfare sufficientarianism would ensure that everyone in society had a base level of welfare; resources sufficientarianism that they had access to a minimum quantity of goods and services; and capabilities sufficientarianism that they at least those capabilities deemed essential for all. 

Nevertheless, it may be that certain distributive principles are conceptually better suited to one currency or another. For instance, utilitarianism seems clearly suited to the welfare currency.1 Unlike the resources and capabilities currencies, utilitarianism isn’t motivated by appeals to individual autonomy. Instead, like the welfare currency, it is motivated by the idea that we can assess what is good for people from an impartial perspective and make comparisons between how well-off different individuals are.

Similarly, I think sufficientarianism is best suited to a particular currency: self-respect. I won’t comment in detail on how to categorise this currency using the framework above, but I’d suggest it falls somewhere between resources and capabilities.

 1 Utilitarianism is not commonly thought of as a principle of distributive justice, but it can be interpreted in this way. It holds that a just distribution is one that maximises either the average or total amount of a given currency within society. For more on the wide variety of ideas associated with utilitarianism, see this interesting website.

What do I mean by self-respect?

Rawls argued that self-respect comprises two conditions:

  1. ‘A person’s sense of his own value, his secure conviction […] that his plan of life is worth carrying out’

and

  1. ‘A confidence in one’s ability, so far as it is within one’s power, to fulfil one’s intentions’

I call (1) the psychological and (2) the material condition. While Rawls doesn’t say this explicitly, I think we can take him to mean the conditions are individually necessary but only collectively sufficient for self-respect.

The psychological condition refers to an individual’s belief that their life is important and meaningful. I’d suggest that whether one can coherently hold this belief depends on whether one’s society conforms with some basic principles of equality and tolerance. A society is made of up of individuals pursuing different goals. Nevertheless, if everyone agrees that no-one is automatically more important than anyone else and that there are many legitimate goals one can have, then everyone can appreciate they are important and able to live a meaningful life, regardless of who they are or what goals they have. 

The material condition relates to an individual’s ability to translate their goals into reality. My interpretation is that this does not require that everyone does achieve their goals. People’s goals may be unreasonable; for instance, not everyone is going to be a famous singer or football player. Instead, it requires that have everyone has an opportunity to achieve goals it is reasonable for them to have, such as success in a career. This is essential because a person who doesn’t have such an opportunity cannot genuinely feel their lives are as important or meaningful as others who do. 

One might object that condition (2) is psychological, not material. Logically, a person could be ‘confident in one’s ability […] to fulfil one’s intentions’ even while living in extremely poor material circumstances. Such a person would arguably be delusional though; they would need at least some material resources to achieve their reasonably-held goals. Correspondingly, material resources would still be necessary, even if indirectly, for them to have self-respect.

Why the currency of self-respect?

Sufficientarianism with the currency of self-respect would ensure that everyone in society had enough to secure their self-respect. In line with the interpretation of self-respect I set out above, in practice this would require that: (a) society conforms with some basic principles of equality and tolerance; and (b) everyone has an opportunity to achieve reasonably-held goals.

So why self-respect? I noted above that certain distributive principles seem conceptually better suited to one currency or another. I think this is the case for self-respect in relation to sufficientarianism.

Rawls’ argument that parties in the original position would select a distributive principle that secures the social bases of self-respect gives one reason. (See the blog post before this for an explanation of this argument). What better way to ensure that the ultimate distribution secures self-respect for all than by making this the very currency of the distributive principle?

Yet there are also grounds to support self-respect as the currency of sufficientarianism even if you do not buy Rawls’ reasoning. The concept of sufficiency depends, at least partly, on a social context. Once a person’s basic needs have been met, whether they have ‘enough’ is a function of what others around them have. It plausibly means having access to a quantity and quality of goods and services that a person could reasonably expect depending on the society in which they live.

The currency of self-respect, unlike welfare, resources, and capabilities, is sensitive to social context. It would have different implications depending on the society to which it was applied. For example, in a wealthier society, meeting the material condition may be more demanding than in a poorer society; a person might need more to have to achieve their reasonably-held goals. Accordingly, a sufficientarian distribution with the currency of self-respect would set different levels of ‘enough’ in different societies (varying across both time and place). 

Objections

One objection is that the currency of self-respect appears to have regressive implications. We can easily imagine a society in which the quantity and quality of goods and services a person can reasonably expect is very low. The currency of self-respect could legitimise the existence of poverty in such a society, even though we might strongly believe that this poverty is morally bad.

My initial response would be that the currency of self-respect would plausibly imply a high minimum threshold regardless of the society in which it applied. For the material condition to be met, a person would need access to a reasonably high quantity and quality of goods and services. This means the objection has less bite. 

A more profound response is that, in this situation, we could agree that the poverty was morally bad, but not for reasons of justice. Instead, the existence of poverty could be morally bad because it showed that well-off people had not acted upon their obligations to help people in need if it came at insignificant cost to them. We might maintain, though, that the poverty was not unjust. Justice relates to the background rules and principles that should govern society, rather than obligations incumbent on individuals.

A second objection is that the currency of self-respect is insufficiently distinct from another currency of distributive justice: Rawls’ primary goods. Primary of goods are things, divided into the categories ‘natural’ and ‘social’, that Rawls claims it would be rational for everyone to want (see a list in the table below). The specific objection is that Rawls already includes self-respect (referring to it as ‘the social bases of self-respect) within his list of primary goods. So what makes the currency of self-respect different?

Type of primary goodIncluding
NaturalHealth Intelligence
SocialRights and freedoms
Income and wealth
Social bases of self-respect

In answering, I would highlight that other primary goods Rawls identifies are implied by the currency of self-respect. Specifically, the psychological condition would guarantee some basic rights and freedoms, while the material condition would ensure everyone had access to a base level of income and wealth. The currency of self-respect should be preferred to primary goods on the grounds that it is a simpler theory.

A third and final objection is that self-respect is not a workable currency of distributive justice, because accurately measuring whether someone has self-respect is impossible. 

In response, I would emphasise that we’re trying to identity a currency that is of fundamental moral importance and that this may not be easily measurable. Nevertheless, I do think that the psychological and material conditions give us some practical steps to securing self-respect for every individual. Moreover, other currencies, such as the welfare currency, might have appeared impossible to measure, but psychologists and economists have now devised credible methods to do so. This makes it seem more plausible that accurate ways to measure self-respect could be created.

In the third and final blog in this series, I’ll explain how sufficientarianism with the currency of self-respect has some surprising and advantageous features. Specifically, it enables a satisfactory response to the claim that sufficientarianism is indirectly self-defeating. This provides further grounds for holding that the currency of sufficientarianism should be self-respect.

With thanks to Yannic Vitz and Cedar Green for helpful comments.

Refer to the introductory post in the series here and the first blog here.