What is Enough?

Sufficiency, Justice, and Health 1st Edition

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1
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Library of Congress Cataloging-​in-​Publication Data

Names: Fourie, Carina, editor. | Rid, Annette, editor.
Title: What is enough? : sufficiency, justice, and health / edited by Carina Fourie
and Annette Rid.
Description: Oxford ; New York : Oxford University Press, [2016] | Includes
bibliographical references and index.
Identifiers: LCCN 2016006945 | ISBN 9780199385263 (hardcover : alk. paper) |
ISBN 9780199385287 (ebook (updf)) | ISBN 9780199385294 (ebook (epub)) |
ISBN 9780199385270 (online content)
Subjects: | MESH: Health Care Rationing—ethics | Health Care
Rationing—economics | Health Services Needs and Demand | Social Justice | Health Policy
Classification: LCC RA418 | NLM WA 525 | DDC 362.1—dc23 LC record available
at http://lccn.loc.gov/2016006945

9 8 7 6 5 4 3 2 1

Printed by Sheridan Books, Inc., United States of America

v

Contents

Acknowledgments vii

Contributors ix

Introduction—Carina Fourie and annette rid 1

PART I: Groundwork

1. The Sufficiency View: A Primer—Carina Fourie 11

2. Sufficiency, Health, and Health Care Justice: The State of
the Debate—Annette Rid 30

PART II: The Sufficiency View

3. Axiological Sufficientarianism—Iwao Hirose 51

4. Sufficiency, Priority, and Aggregation—Robert Huseby 69
5. Some Questions (and Answers) for Sufficientarians—Liam Shields 85
6. Essentially Enough: Elements of a Plausible Account
of Sufficientarianism—David V. Axelsen and lasse nielsen 101

PART III: Sufficiency, Health, and Health Care Justice

7. Intergenerational Justice, Sufficiency, and Health—Axel Gosseries 121

8. Basic Human Functional Capabilities as the Currency
of Sufficientarian Distribution in Health Care—Efrat Ram-​Tiktin 144
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vi Contents

9. Disability, Disease, and Health Sufficiency—Sean Aas

and david wasserman 164
10. Sufficiency of Capabilities, Social Equality, and Two-​Tiered Health Care
Systems—Carina Fourie 185
11. Determining a Basic Minimum of Accessible Health Care:
A Comparative Assessment of the Well-​Being Sufficiency
Approach—Paul T. Menzel 205
12. Just Caring: The Insufficiency of the Sufficiency Principle
in Health Care—Leonard M. Fleck 223

PART IV: Implementing Sufficiency in Health Care Policy and Economics

13. Defining Health Care Benefit Packages: How Sufficientarian

Is Current Practice?—Dimitra Panteli
and ewout van ginneken 247
14. Sufficiency, Comprehensiveness of Health Care Coverage,
and Cost-​Sharing Arrangements in the Realpolitik of Health
Policy—Govind Persad and harald schmidt 267
15. Applying the Capability Approach in Health Economic
Evaluations: A Sufficient Solution—Paul Mark Mitchell ,
tracy e. roberts, pelham m. barton, and joanna coast 281

Bibliography 303

Index 329
vii

Acknowledgments

knowledge and insight are typically the result of collaborative, rather

than individual, effort, and they require dedication and tenacity from everyone
engaged. Both observations have particular salience for this book. It started with
the idea for a workshop on “The Relevance of Sufficiency for Just Health Care” in
the spring of 2010, when we first met at the University of Zurich. The workshop
was eventually held in the summer of 2012 and now, around 6 years after every-
thing started, we are the pleased editors of this volume. Along the way, we have
also become friends.
We have many people to thank. First and foremost, we express our gratitude
to the contributors for their excellent work and patience in engaging with our
comments and suggestions. We have bombarded them with ideas and requests
for clarification, and we can only hope they appreciate that we were motivated by
trying to make this the best volume we could.
The workshop on sufficientarianism at the Ethics Centre, University of Zurich,
showed us that an edited volume on the subject would help fill significant gaps in
the philosophical and bioethical literature. We thank all workshop participants for
their contributions; Anton Leist for co-​organizing the workshop; and Lisa Brun,
who mastered the event’s logistics for us.
Throughout the years, we have had the good fortune of developing the book
while being surrounded by many wonderful colleagues. We worked for 2 years
together at the Institute of Biomedical Ethics (IBME), University of Zurich, and
particularly thank Jan-​Christoph Heilinger, Agomoni Ganguli Mitra, and Verina
Wild for providing us with a stimulating and fun environment in which to work.
Thanks are also due to Nikola Biller-​Andorno, the director of the IBME, for her
support.
Carina is especially grateful to all her colleagues at the Ethics Centre of the
University of Zurich and, later, at the Department of Philosophy at the University
of Washington for their support and for the marvelous working environments in
which this volume was edited. Although it is difficult to single people out because
viii

viii Acknowledgments

so many have been helpful, particular mention must go to Peter Schaber and
Sebastian Muders at the University of Zurich. Carina is also very grateful to Sabine
Hohl of the University of Graz and Fabian Schuppert of Queen’s University Belfast
for consistently providing constructive feedback and comments.
Annette thanks her colleagues at the Department of Global Health & Social
Medicine at King’s College London, and the Department of Bioethics, National
Institutes of Health (NIH) Clinical Center, for their fantastic support through-
out the years. Special thanks are due to Franklin Miller, Joseph Millum, Seema
Shah, David Wendler, and the late Alan Wertheimer at NIH, as well as Danielle
Bromwich (now at the University of Massachusetts, Boston) and Silvia Camporesi,
Barbara Prainsack and Sridhar Venkatapuram at King’s College London. In ad-
dition, Katharina Kieslich, Peter Littlejohns, Catherine Max, Benedict Rumbold,
Albert Weale, and James Wilson have been providing a wonderful forum for dis-
cussion as part of the Social Values and Health Priority Setting Group that runs
between King’s College London and University College London. Annette is also
deeply grateful to Thomas Rid for his unfailing encouragement and support.
When our ideas for the book started to take shape, we received many helpful
comments on our initial book proposal from Robert Goodin, Australian National
University, with whom Annette spent a terrific year at the NIH, and from two
anonymous reviewers for Oxford University Press. Our final plan for the book
looked very different, and indeed significantly better, than the prior drafts. Our
thanks also go to Lucy Randall and Peter Ohlin at Oxford University Press for their
capable and steady editorial support; to Rose Mortimer, then an inspiring student
in the Postgraduate Programme in Bioethics & Society at King’s College London
for last-​minute help with editing and formatting manuscripts; to Elin Simonson
for compiling the book’s index; and to Daniel Hays for his diligent copyediting;
and to Joseph Lurdu Antoine for his attention to detail in seeing the book through
to production. An anonymous reviewer for Oxford University Press also provided
excellent feedback to help us make final revisions to the volume.
Finally, this project would not have been possible without our funders. The ini-
tial workshop was supported by the Swiss National Science Foundation (10CO15_​
136125), the Corti Foundation, and the IBME at the University of Zurich. Grants
from the University Research Priority Program for Ethics (URPP for Ethics),
also at the University of Zurich, and the Department of Global Health & Social
Medicine, King’s College London, allowed us to delegate the manuscript format-
ting and indexing. Carina’s research has been financially supported for many
years by the Swiss National Science Foundation (100012-​120200 and 100017_​
146668). Funding from the People Programme (Marie Curie Actions) of the
European Union’s Seventh Framework Programme (FP7/​2007-​2013) under REA
grant agreement No. 301816 gave Annette more time to focus on her writing.
ix

Contributors

Sean Aas, MA, PhD, has been a postdoctoral fellow in the Department of Bioethics
at the US National Institutes of Health since 2013. Previously, he was a fellow
at the Center for Advanced Studies Justititia Amplificata in Frankfurt, Germany.
He works at the intersection of bioethics and political philosophy, with particular
focus on global justice and the ethics and politics of disability.

David V. Axelsen, PhD, is a postdoctoral fellow at the Department of Political

Science, Aarhus University and the Department of Government, London School
of Economics and Social Science. He works on global justice, national identity, po-
litical philosophical methodology, and, as in the case of the current contribution,
distributive justice. He has recently published two articles in the Journal of Political
Philosophy (one of which is coauthored with Lasse Nielsen). When not engaged in
academia, he enjoys competing in the Danish sport, flaghelmet.

Pelham M. Barton, PhD, is a reader in Mathematical Modeling in the Health

Economics Unit and director of the MSc program in Health Economics and Health
Policy at the University of Birmingham, UK. He has more than 70 publications, of
which approximately 50 are academic papers published in peer-​reviewed journals,
including The BMJ, Health Economics, Health Technology Assessment, and Journal
of Health Services Research & Policy. He is an internationally recognized expert in
modeling applied to health care provision, both preventative and curative. His
methodological work includes adoption of ideas from outside health economics
to resolve the tension between adequacy, efficiency, and transparency of models.

Joanna Coast, PhD, is Professor in the Economics of Health & Care in the School of
Social and Community Medicine, University of Bristol, UK. Her research interests
lie in the theory underlying economic evaluation (including capability), develop-
ing broader measures of outcome for use in economic evaluation (including mea-
sures of capability), health care decision-​making, the economics of antimicrobial
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x Contributors

resistance, and the organization of care. She also has a methodological interest in
the use of qualitative methods in health economics. She has published extensively
in all of these areas. Work on capability has included methodological work in rela-
tion to health economics as well as empirical applications in health and end-​of-​life
care. She has led the development of the ICECAP capability instruments. She
has received major grants from the Medical Research Council and the European
Research Council. She is Senior Editor (Health Economics) for Social Science and
Medicine.

Leonard M. Fleck, PhD, is Professor of Philosophy and Medical Ethics in the

Center for Ethics, College of Human Medicine, Michigan State University. He is
author of Just Caring: Health Care Rationing and Democratic Deliberation (Oxford
University Press, 2009) and is coeditor with Marion Danis, Samia Hurst, Reidun
Forde, and Ann Slowther of Fair Resource Allocation and Rationing at the Bedside
(Oxford University Press (OUP), 2014). His published essays address a wide range
of topics related to health care justice, rational democratic deliberation, health care
rationing, and ethical issues related to precision medicine and emerging genetic
technologies.

Carina Fourie, PhD, is the Benjamin Rabinowitz Assistant Professor of Medical

Ethics at the Department of Philosophy, University of Washington, and a member
of the Department’s Program on Values in Society. She works on a variety of topics
in medical ethics and also in social and political philosophy, with particular interest
in social justice and equality and their application to public health and health care
policy. Her recent publications include “Moral Distress and Moral Conflict in Clinical
Ethics” (Bioethics, 2015) and the collected volume Social Equality: On What It Means to
Be Equals (coedited with Fabian Schuppert and Ivo Wallimann-​Helmer; OUP, 2015).

Ewout van Ginneken, PhD, is Coordinator of the Berlin hub of the European
Observatory on Health Systems and Policies, at the Berlin University of
Technology. His topics of interest include international health systems, health in-
surance, health financing, cross-​border health care, pharmaceutical policy, and
the impact of European Union law. He is the author of “Implementing Insurance
Exchanges—​ Lessons from Europe” (with Kathy Swartz; New England Journal
of Medicine, 2013) and “Coverage for Undocumented Migrants Becomes More
Urgent” (with Bradford Gray, Annals of Internal Medicine, 2013).

Axel Gosseries, PhD, is Senior Research Fellow at the Fonds de la Recherche

Scientifique (FNRS, Brussels) and Professor at the University of Louvain (Hoover
xi

Contributors xi

Chair in Economic and Social Ethics, UCL, Belgium). As a political philosopher,

his research focuses on theories of intergenerational justice and on democracy
within organizations. He has authored more than 50 papers in philosophy, law,
and economics, as well as one book on intergenerational justice (Flammarion,
2004). He has edited three books, including Intergenerational Justice (with
L. Meyer; Oxford University Press, 2009) and Intellectual Property and Theories of
Justice (with A. Marciano and A. Strowel; Palgrave, 2008).

Iwao Hirose, PhD, is Associate Professor at the Philosophy Department and

the School of Environment, McGill University in Canada. He works on a wide
range of topics in normative ethics, including projects on egalitarianism, jus-
tice in health and health care, and climate justice, as well as in the philosophy
of economics. He is author of Moral Aggregation (OUP, 2015), Egalitarianism
(Routledge, 2015), and The Ethics of Health Care Rationing (with Greg Bognar;
Routledge, 2014), as well as the editor of The Oxford Handbook of Value Theory
(with Jonas Olson; OUP, 2015) and Weighing and Reasoning (with Andrew
Reisner; OUP, 2015).

Robert Huseby, PhD, is Professor of Political Science at the University of Oslo.

His research interests include distributive justice and climate ethics. Among
his recent publications are “Should the Beneficiaries Pay?” Politics, Philosophy &
Economics, 2015, and “John Rawls and Climate Justice—An Amendment to The
Law of Peoples,” Environmental Ethics, 2013.

Paul T. Menzel, PhD, is Professor of Philosophy emeritus at Pacific Lutheran

University. He has written widely on moral questions in health economics and
health policy. Publications include “A Cultural Moral Right to a Basic Minimum
of Accessible Health Care,” Kennedy Institute of Ethics Journal (2011); Prevention
vs. Treatment: What’s the Right Balance? (coedited with H. S. Faust; OUP, 2012);
and “Advance Directives, Dementia, and Withholding Food and Water by Mouth”
(coauthored with M. C. Chandler-​Cramer), Hastings Center Report (2014).

Paul Mark Mitchell, PhD, is Senior Research Associate at the School of Social
and Community Medicine, University of Bristol. His research interests are in
measuring capabilities and the theory and methods for conducting health eco-
nomic evaluations. First author publications by Paul include “Assessing suf-
ficient capability: a new approach to economic evaluation”, Social Science &
Medicine (2015); “The Relative Impacts of Disease on Health Status and Capability
Wellbeing: A Multi-​Country Study”, PLoS ONE (2015).
xii

xii Contributors

Lasse Nielsen, PhD, is a postdoctoral fellow at the Department of Political Science

and Government, Aarhus University in Denmark. He works on topics in political
philosophy, such as the value of equality and sufficiency in distributive justice and
the applicability of the capability approach to health and health care ethics. He is
coauthor of the article, “Sufficiency as Freedom from Duress” in Journal of Political
Philosophy (2015). He is author of the article, “Why Health Matters to Justice: A
Capability Theory Perspective,” in Ethical Theory and Moral Practice (2014). He is a
keen participant in the Danish sport, flaghelmet.

Dimitra Panteli, MD, DrPH, is a research fellow at the Department of Health

Care Management, Berlin University of Technology. Her research topics include
evidence-​based decision-​making in health care with a focus on health technology
assessment (HTA) and clinical guidelines, health systems research, pharmaceuti-
cal policy, and cross-​border care. She coordinates the department’s teaching on
HTA and health systems and is a member of the editorial team of the European
Observatory on Health Systems and Policies.

Govind Persad, JD, PhD, is Assistant Professor in the Berman Institute of Bioethics
and Department of Health Policy and Management at Johns Hopkins University.
His research bridges applied ethics, political philosophy, and health law. Recent
projects focus on the normative implications of socioeconomic mobility as well as
the ethical dimensions of health care financing and health insurance. His publica-
tions include “Priority-​Setting, Cost-​Effectiveness, and the Affordable Care Act”
(American Journal of Law and Medicine, 2015) and “The Ethics of Expanding Access
to Cheaper, Less-​Effective Treatments” (with Ezekiel Emanuel; Lancet, 2016).

Efrat Ram-​Tiktin, PhD, is a lecturer at the Department of Philosophy, Bar-​Ilan

University. Her research topics include political philosophy and various issues
in medical ethics, such as triage of patients under extreme scarcity of resources.
She has also developed a theory of sufficiency of basic human functional capabili-
ties that she applies to questions surrounding justice in health and health care.
Among her publications are “The Right to Healthcare as a Right to Basic Human
Functional Capabilities” in Ethical Theory and Moral Practice (2012) and “Possible
Effects of Moral Bioenhancement on Political Privileges and Fair Equality of
Opportunity” (2014) in the American Journal of Bioethics.

Annette Rid, MD, is a Senior Lecturer in Bioethics and Society in at the Department
of Global Health & Social Medicine at King’s College London and an Elected
Fellow of the Hastings Center. She works in a variety of areas in bioethics, includ-
ing research ethics, clinical ethics, justice in health and health care, and ethics in
xiii

Contributors xiii

transplantation medicine. Her publications on justice in health and health care

include “Justice and Procedure: How Does ‘Accountability for Reasonableness’
Result in Fair Limit-​Setting Decisions?” (Journal of Medical Ethics, 2009) and
“The Importance of Being NICE” (with Peter Littlejohns, James Wilson, Benedict
Rumbold, Katharina Kieslich, and Albert Weale; Journal of the Royal Society of
Medicine, 2015).

Tracy E. Roberts, PhD, is Professor of Health Economics and head of the Health
Economics Unit at the University of Birmingham, UK. She has specific research
interests in the area of economic evaluation and in particular of testing and screen-
ing programs, especially in the areas of sexual health, obstetrics, and gynecology,
and has published widely. She has also developed interest in pursuing outcome
valuation for use in economic evaluation in these clinical specialties. She leads two
applied research themes within the unit: women’s health and infection. She also
works within the two main methodological themes of modeling and capabilities.

Harald Schmidt, PhD, is Assistant Professor at the Department of Medical Ethics

and Health Policy and Research Associate at the Center for Health Incentives and
Behavioral Economics, both at the University of Pennsylvania’s Perelman School
of Medicine. His work centers around fairness in resource allocation, public health
ethics, and personal responsibility for health. Publications include “Public Health,
Universal Health Coverage, and Sustainable Development Goals: Can They
Coexist?” (with Lawrence Gostin and Ezekiel Emanuel; Lancet, 2015) and “Equity
and Non-​communicable Disease Reduction Under the Sustainable Development
Goals” (with Anne Barnhill; PloS Medicine, 2015).

Liam Shields, PhD, is a lecturer in political theory at the University of Manchester.

He has previously held research positions at the McCoy Family Center for Ethics,
Stanford University and the Institute of Advanced Study, University of Warwick.
His main areas of research interest are distributive justice, especially sufficientari-
anism, equality of opportunity, justice in education, and justice in childrearing.
He has published in journals such as Utilitas, Canadian Journal of Philosophy and
Politics, Philosophy and Economics and has a monograph forthcoming titled Just
Enough: Sufficiency as a Demand of Justice (Edinburgh University Press, 2016).

David Wasserman, JD, MA (psychology) has been a visiting scholar at the

Department of Bioethics at the US National Institutes of Health since January
2013. Previously, he was Director of Research at the Center for Ethics, Yeshiva
University. He has written extensively on ethical and policy issues in disability,
reproduction, genetics, health care, biotechnology, and neuroscience. He has
xiv

xiv Contributors

coauthored Disability, Difference, Discrimination (with Anita Silvers and Mary

Mahowald, 1998) and Debating Procreation (with David Benatar, 2015). He has co-
edited Genetics and Criminal Behavior (2001); Quality of Life and Human Difference:
Genetic Testing, Health-​Care, and Disability (2005); and Harming Future Persons:
Ethics, Genetics, and the Nonidentity Problem (2009). He has also coedited special
journal issues on bioethics and risk and on the ethics of enhancement. He is on
the editorial boards of Ethics and the Journal of Applied Ethics, and he is a fellow of
the Center.
xv

What Is Enough?
xvi
1

Introduction
Carina Fourie and Annette Rid

w h at d o w e owe future generations in terms of their health? How much

should we invest today in technologies to eradicate diseases in the future? An
intuitively appealing claim is that we should invest enough that future genera-
tions have sufficient health. What about our obligations here and now? What do
we owe our fellow citizens today in terms of health care? It seems prima facie
reasonable to claim that everyone should be provided with “enough” health care
for maintaining a good quality of life. These answers seem to point to the idea that
sufficiency of health or health care could be an important aim of social justice and
public policy.
The notion of sufficient health or health care can be contrasted, for example,
to conceptions of justice that promote equal health, provide the worst off with
the best possible health, or maximize the total health of the population. Helping
individuals to achieve sufficient life spans seems to be an intuitively more appeal-
ing aim of health policy than, for instance, helping them achieve equal life spans.
Also, although giving priority to the worst off may be a fair strategy below cer-
tain thresholds of health, its appeal might wane if the worst off are actually quite
healthy—​or what might be called “sufficiently” healthy.
Yet despite the intuitive attraction of the sufficiency view, what sufficiency is,
why we need it, and how it applies to practical challenges—​such as the distri-
bution of health care and the social determinants of health—​still require much
analysis. This is true of the broad philosophical discussion as well as debates
within applied fields. With regard to the ethics of distribution, for example, the
conflict between favoring equality or giving priority to the worst off is usually the
central focus. A handful of authors explicitly defend a sufficientarian approach
to health or health care justice, although—​on closer examination—​a number of
scholars, who one might not initially associate with sufficientarianism, seem to be