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Just health: replies and further thoughts
  1. N Daniels
  1. Dr N Daniels, Harvard University, Department of Global Health and Population, Harvard School of Public Health, Room 1210D, Bldg 1, 665 Huntington Ave, Boston, MA 02115, USA; ndaniels{at}


This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and James Wilson argues that healthcare is not of special importance if social determinants of health have a major causal impact on population health. Annette Rid is concerned that the relevance condition in accountability for reasonableness is unclear and does little work. Harald Schmidt aims to flesh out where an account of responsibility for health should go since one is under-developed in Just health. Michael Schefczyk and Susanne Brauer challenge aspects of the prudential lifespan account. Samia Hurst asks what impact a population view should have on clinician obligations.

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  • Competing interests: None declared.

  • i In Just health care (p30),9 I grounded my appeal to normal functioning on Boorse’s biostatistical account of biological function and of disease; in Just health (p38–40)1 I follow Boorse10 in saying that normal functioning (and the important concept of pathology) can be grounded in a more eclectic view that admits an etiological account of biological function and some normative component in the characterisation of dysfunction. Specifically, I am neutral between Boorse and Wakefield11 and their overlapping but slightly divergent accounts of departures from normal functioning.

  • ii Note that this view is not, as Schramme asserts, the claim that people should have as “many opportunities as possible” given their talents and skills. The claim is they should have the exercisable opportunities they would have were they functioning normally in that context. Schramme also claims that I equivocate between a comparative and non-comparative sense of disadvantage. Sometimes we do need to make comparisons between individuals (eg, in saying someone has a stronger claim on assistance because their needs are greater) and sometimes the judgment is a comparison of the individual with a standard (eg, in saying that someone’s diminished health state has reduced their opportunity range from their fair share of the NOR). In any event, on my view justice requires promoting normal functioning even if all individuals equally possess a significant form of pathology—so the view is non-comparative in that sense. Also, even where the view is comparative, its focus is as much on the functioning needed for cooperation and not simply competition.

  • iii Schramme2 prefaces this argument with the claim that my notion of normal functioning and its connection to disadvantage is both too strong and too weak. It is too weak: if a normal condition can be disadvantageous (idiopathic shortness), why not treat it? (I reply to this worry at length in chapter 5 and space prevents me from addressing it again here). It is too strong: a pathological condition, such as spotted skin (dyschromic spirochetosis), might be valued by a culture and so not be disadvantageous, yet someone with it might have a claim to be treated. On my view, having a pathological condition provides an eligibility requirement for having claims on medical services, but how important those claims are depends on many factors, including the degree of (negative) impact on opportunity, what can be done for it, what resources there are, and what are the opportunity costs of treating it. In any case Schramme offers no argument, only assertion, for his view that the condition should be treated if someone wants treatment.

  • iv Rid argues that my view of procedural justice is confusingly presented, but I think the discussion of applications of the view in chapters 9–12 should have made the view she arrives at perspicuous.

  • v Since I am not imagining that consensus on relevant reasons will emerge in the fair process, it may be necessary to resolve disputes through a process that involves voting. Whether that involves simple majority votes or super-majorities is a detail of fair process that may depend on the institutional level at which the process is implemented. In Just health and earlier discussions Jim Sabin and I express reservations about relying solely on voting, viewed as a simple aggregation of preferences, and we stress the importance of deliberation as a way of focusing on reasons that even losers in a vote will agree are relevant.

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