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Scientific articleTheories of justice and their implications for priority setting in health careAbstractThe paper aims to show how three theories of distributive justice; utilitarianism, egalitarianism and maximin, can provide a clearer understanding of the normative basis of different priority setting regimes in the health service. The paper starts with a brief presentation of the theories, followed by their prescriptions for distribution, as illustrated with their respective preferred points on a utility possibility frontier. After this general discussion, attention is shifted from utils to health. The paper discusses how the recent Norwegian guidelines for priority setting can be understood in the light of the theories. Cited by (0)Copyright © 1997 Published by Elsevier B.V. Distributive justice concerns the fair allocation of resources among diverse members of a community. The principle says that every person should have or have access to approximately the same level of material goods and services. In contrast to the principle of due process, which is concerned with the equal administration of procedural and substantive law, distributive justice focuses on equal social and economic outcomes. The principle of distributive justice is most commonly justified on the grounds that people are morally equal and that equality in material goods and services is the best way to realize this moral ideal. It might be easier to think of distributive justice as “just distribution.” Key Takeaways: Distributive Justice
Theories of Distributive JusticeAs the subject of extensive study in philosophy and the social sciences, several theories of distributive justice have inevitably evolved. While the three theories presented here—fairness, utilitarianism, and egalitarianism—are far from all of these, they are considered to be the most prominent. FairnessIn his book A Theory of Justice, American morality and political philosopher John Rawls outlines his classic theory of justice as fairness. Rawls’ theory consists of three core components:
In formulating a modern view on the social contract theory as first put forth by English philosopher Thomas Hobbes in 1651, Rawls proposes that justice is based on a “basic structure” forming the foundational rules of society, which shape the social and economic institutions, as well as the manner of governance. According to Rawls, the basic structure determines the peoples’ range of life opportunities—what they can reasonably expect to accumulate or achieve. The basic structure, as envisioned by Rawls, is built on the principles of basic rights and duties that all self-aware, rational members of a community accept to benefit their interests in a context of social cooperation needed to realize the common good. Rawls’ fairness theory of distributive justice assumes that designated groups of responsible people will establish “a fair procedure” for determining what constitutes a just distribution of primary goods, including freedoms, opportunities, and control over resources. While it is assumed that while these people will naturally be influenced to an extent by self-interest, they will also share a basic idea of morality and justice. In this manner, Rawls argues that it will be possible for them, via a “nullification of temptations,” to avoid the temptation to exploit circumstances in ways to favor their own positions in society. UtilitarianismThe doctrine of utilitarianism holds that actions are right and justified if they are useful or for the benefit of a majority of the people. Such actions are right because they promote happiness, and the greatest happiness of the greatest number of people should be the guiding principle of social conduct and policy. Actions which increase the overall welfare in society are good, and actions that decrease overall welfare are bad. In his 1789 book An Introduction to the Principles of Morals and Legislation, English philosopher, jurist, and social reformer, Jeremy Bentham argues that the utilitarianism theory of distributive justice is focused on the outcomes of social actions while remaining unconcerned with how these outcomes are achieved. While the basic premise of the utilitarianism theory seems simple, great debate centers on how “welfare” is conceptualized and measured. Bentham originally conceptualized welfare according to the hedonistic calculus—an algorithm for calculating the degree or amount of pleasure that a specific action is likely to induce. As a moralist, Bentham believed it was possible to add up units of pleasure and the units of pain for everyone likely to be affected by a given action and use the balance to determine the overall potential for good or evil of that action. EgalitarianismEgalitarianism is a philosophy based on equality, namely that all people are equal and deserve equal treatment in all things. The egalitarianism theory of distributive justice emphasizes equality and equal treatment across gender, race, religion, economic status, and political beliefs. Egalitarianism may focus on income inequality and the distribution of wealth in the development of various economic and political systems and policies. In the United States, for example, the Equal Pay Act requires that men and women in the same workplace be given equal pay for equal work. The jobs need not be identical, but they must be substantially equal. In this manner, the egalitarianism theory is more concerned with the processes and policies through which equal distribution takes place than with the outcome of those processes and policies. As American philosopher, Elizabeth Anderson defines it, “the positive aim of egalitarian justice is ... to create a community in which people stand in relation of equality to others.” Means of DistributionEgalitarianism is a philosophy based on equality, namely that all people are equal and deserve equal treatment in all things. The egalitarianism theory of distributive justice emphasizes equality and equal treatment across gender, race, religion, economic status, and political beliefs. Egalitarianism may focus on income inequality and the distribution of wealth in the development of various economic and political systems and policies. In the United States, for example, the Equal Pay Act requires that men and women in the same workplace be given equal pay for equal work. The jobs need not be identical, but they must be substantially equal. In this manner, the egalitarianism theory is more concerned with the processes and policies through which equal distribution takes place than with the outcome of those processes and policies. As American philosopher, Elizabeth Anderson defines it, “the positive aim of egalitarian justice is ... to create a community in which people stand in relation of equality to others.” Perhaps the most critical factor in the theory of distributive justice is determining what constitutes “fair” distribution of wealth and resources throughout society. Equality affects two areas of distributive justice—opportunities and outcomes. Equality of opportunity is found when all members of a society are allowed to participate in acquiring goods. No one is blocked from acquiring more goods. Acquiring more goods would be a sole function of will, not because of any social or political reason. Similarly, equality of outcomes results when all people receive approximately the same level of benefit from distributive justice policy. According to the theory of relative deprivation, a sense of injustice of outcomes may arise among individuals who believe that their outcome is not equal to the outcomes received by people like them in similar situations. People who feel they have not received their "fair share” of goods or resources may challenge might object to the system responsible. This is especially likely to happen if a groups' fundamental needs are not being met, or if there are large discrepancies between the “haves” and the “have-nots.” This has recently become evident in the United States where the distribution of wealth continues to become more and more unequal. Expanding on his original position, that the overriding concern is to provide individuals with the good that are the most essential for pursuing their goal, Rawls theorizes two basic principles to be used in developing means of just distribution, the liberty principle, and the difference principle. Liberty PrincipleRawls’ liberty principle demands that all individuals must be provided with equal access to basic statutory and natural rights and liberties. This, according to Rawls, should allow all persons, regardless of their social or economic status, to access the most extensive set of liberties available to other citizens. As the liberty principle plays out, it becomes a question of both the positive individual access of some people and of negative restrictions on the basic rights and liberties of others. Basic liberties can only be restricted if this is done for the sake of protecting liberty either in a manner that strengthens “the total system of liberties shared by all,” or a less than equal liberty is acceptable to those who are subject to this same lesser liberty. Difference PrincipleThe difference principle addresses how the arrangement of social and economic equality and inequality, and thus “just” distribution should look. Rawls asserts that distribution should be based on not only a reasonable expectation of providing an advantage for all but also on ensuring the most benefit to the least advantaged in society. In addition, the policies and processes of this distribution should be open to all. Inequality of opportunity and distribution can only be acceptable if it enhances “the opportunities of those with lesser opportunities” in society and/or excessive saving within the society either balances out or lessens the gravity of hardship experienced by those who would not traditionally benefit. Disappointment-Prevention PrincipleBentham believed that the loss of something typically has a greater impact on a person or group suffering that loss than the happiness brought about by its gain to anyone else. All other factors being equal, for example, the loss of utility to a person caused by theft will have a greater impact on that person’s happiness than the gain in utility to another person from a gambling win of the same monetary value. He realized, however, that this will not hold if the loser is wealthy and the winner is poor. As a result, Bentham gave a higher priority to laws protecting property than to policies intended to produce wealth. Bettmann / Getty Images These beliefs formed the rationale for what Bentham later called the “disappointment-prevention principle,” which demands that the protection of legitimate expectations, such as equal distribution of wealth, should take precedence over other ends, save where the public interest clearly justifies government intervention. In times of war or famine, for example, government intervention, such as raising funds through taxation for vital services or confiscation of property with just compensation paid to the property owners, might be justified. Greatest Happiness PrincipleIn his 1776 essay, A Fragment on Government, Bentham had stated that the “fundamental axiom” of his utilitarianism theory of distributive justice was that “it is the greatest happiness of the greatest number that is the measure of right and wrong.” In this statement, Bentham argued that the moral quality of government action should be judged by its consequences on human happiness. However, he later realized that this principle might wrongly be used to justify inordinate sacrifices by a minority in the interest of increasing the happiness of a majority. “Be the community in question what it may”, he wrote, “divide it into two unequal parts, call one of them the majority, the other the minority, lay out of the account the feelings of the minority, include in the account no feelings but those of the majority, the result you will find is that to the aggregate stock of the happiness of the community, loss, not profit, is the result of the operation.” Thus, the deficiency in aggregate happiness within the society will become more obvious as the numerical difference between the minority and majority populations decreases. Logically then, he argues, the more closely the happiness of all the members of the community—majority and minority—can be approximated, the greater the aggregate of happiness can be achieved. Practical Applications Bettmann / Getty Images The governments of most constitutional democracies protect individual rights to liberty, order, and safety, thus enabling most people to provide for their basic human needs and to satisfy many, if not all, of their desires. However, some persons in every democracy are unable for various reasons to care adequately for themselves. Therefore, the government provides programs to distribute such basic benefits for disadvantaged persons. In the United States, for example, various social insurance programs, such as Social Security and Medicare that provide supplemental income or medical care to all qualified elderly and retired persons, are examples of distributive justice. As the result of human political processes, the structural frameworks of distributive justice constantly change both across societies and within societies over time. The design and implementation of these frameworks are critical to the success of the society because the distributions of benefits and burdens, such as taxation, resulting from them fundamentally affect people’s lives. Debates over which of these distributions are morally preferable are, therefore, the essence of distributive justice. Far beyond simple “goods,” distributive justice takes into account the equitable distribution of many aspects of social life. Additional benefits and burdens that must be considered include potential income and economic wealth, taxation, work obligations, political influence, education, housing, healthcare, military service, and civic engagement. Controversy in the provision of distributive justice typically arises when certain public policies increase the rights of access to benefits for some people while reducing the real or the perceived rights of others. Equality issues then are commonly seen in affirmative action policies, minimum wage laws, and public education opportunities and quality. Among the more highly contended issues of distributive justice in the United States involve public welfare, including Medicaid and food stamps, as well as providing aid to developing foreign nations, and issues of progressive or tiered income taxes. Sources
What are the main theories of distributive justice?Four theories of justice are discussed: Rawlsian egalitarianism, or justice as fairness; Dworkinian egalitarianism, or equality of resources; Steiner-Vallentyne libertarianism, or common ownership; and Nozickian libertarianism, or entitlements.
What are the three theories of justice?We then examine three overarching theories that might serve to unify the different forms of justice: utilitarianism, contractarianism, and egalitarianism.
Which of the three principles of distributive justice is the other two?Equality affects two areas of distributive justice: opportunities and outcomes. Equality of opportunity is found when all members of a society are allowed to participate in acquiring goods.
What are examples of distributive justice?For example, public programs that provide social security or medical care to all elderly and retired persons are examples of distributive justice in a constitutional democracy. Public schools, which all children have an equal opportunity to attend, are another example.
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