Distributive Justice and Disability: Utilitarianism against Egalitarianismby Mark S. Stein
Theories of distributive justice are most severely tested in the area of disability. In this book, Mark Stein argues that utilitarianism performs better than egalitarian theories in this area: whereas egalitarian theories help the disabled either too little or too much, utilitarianism achieves the proper balance by placing resources where they will do the most good.
Stein offers what may be the broadest critique of egalitarian theory from a utilitarian perspective. He addresses the work of egalitarian theorists John Rawls, Ronald Dworkin, Amartya Sen, Bruce Ackerman, Martha Nussbaum, Norman Daniels, Philippe Van Parijs, and others. Stein claims that egalitarians are often driven to borrow elements of utilitarianism in order to make their theories at all plausible.
The book concludes with an acknowledgment that both utilitarians and egalitarians face problems in the distribution of life-saving medical resources. Stein advocates a version of utilitarianism that would distribute life-saving resources based on life expectancy, not quality of life. Egalitarian theories, he argues, ignore life expectancy and so are again found wanting.
Distributive Justice and Disability is a powerful and engaging book that helps to reframe the debate between egalitarian and utilitarian thinkers.
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Distributive Justice and DisabilityUtilitarianism against Egalitarianism
By MARK S. STEIN
Yale University PressCopyright © 2006 Yale University
All right reserved.
This book is about the contest between utilitarianism and egalitarianism. Utilitarianism, as a theory of distributive justice, tells us to help those who can most benefit, those who can gain the greatest increase in welfare. Egalitarian theories of distributive justice tell us to help those who are in some way worse off. I advocate utilitarianism.
There is sometimes a convergence between utilitarianism and egalitarian theories; sometimes, those who can most benefit are those who are worse off in various ways. At other times, the theories diverge. One area in which utilitarianism often diverges from egalitarian theories is the area of disability.
I argue in this book that utilitarianism handles distributive issues involving disability better than do egalitarian theories. Egalitarianism would provide either too little help to the disabled or too much, depending on what is sought to be equalized.
An egalitarianism that seeks to equalize material resources would in general make no special provision for the disabled. Resource egalitarianism would not, in general, subsidize the medical expenses of poorpeople or pay for disability aids such as wheelchairs or guide dogs. Under resource egalitarianism, the disabled poor would be entitled only to the minimum income guaranteed to everyone in society; after spending that income on disability-related expenses, they would end up with a lot less than the nondisabled poor, and in some cases they would needlessly die.
On the other hand, an egalitarianism that seeks to equalize welfare would massively redistribute social resources to those severely disabled people who are considered to have the least welfare, such as, for example, young people with terminal cancer. Welfare egalitarianism would continue to lavish resources on the least-welfare disabled long after they ceased to derive much benefit from additional resources. In a welfare-egalitarian system, the nondisabled poor would be viewed purely as a means to increase the welfare of those with least welfare. The nondisabled poor would receive little, if any, help from the government, and they might even be subject to high taxes.
The common defect of egalitarian theories is that they are insensitive to relative benefit. Resource egalitarianism would distribute too little to disabled people who could benefit greatly from additional resources; welfare egalitarianism would distribute too much to disabled people who could benefit hardly at all from additional resources. By contrast, utilitarianism is completely sensitive to relative benefit. Utilitarianism seeks to place resources where they will do the most good. Only utilitarianism, or a theory with a large element of utilitarianism, can avoid both inadequate provision for the disabled and excessive redistribution to the disabled. Utilitarianism is the golden mean of distributive justice.
Because egalitarianism is insensitive to relative benefit, egalitarian theorists are driven to incorporate an element of utilitarianism into their theories: they are driven to distribute resources to those who are better off, by the lights of their own egalitarian theories, in cases where the better-off would benefit more. Sometimes this incorporation of utilitarian elements is done relatively openly, as by Amartya Sen; sometimes it is done in an obscure manner, as by Ronald Dworkin.
The foregoing assertions about egalitarianism and egalitarian theorists need to be backed up, of course. I hope to back them up, to the reader's satisfaction, through the course of this book.
I begin, in Chapter 2, by discussing some preliminary but important matters of method. Like many normative theorists, I test theories against each other through the use of examples. Many of these examples involve interpersonal comparisons of welfare. I argue in Chapter 2 that moral intuition can be confounded if the examples used to test moral intuition contain interpersonal comparisons that are merely stipulated rather than interpersonal comparisons based convincingly on the facts of the example. Thus, Robert Nozick's famous "utility monster" example evokes utilitarian intuitions and turns them, deceptively, against utilitarianism.
Though it is possible to employ such deceptive examples on behalf of utilitarianism rather than against it, I forbear to do so. When I adduce examples in which one person supposedly has more welfare than another person, or in which one person would supposedly benefit more from a scarce resource, I never stipulate that these interpersonal comparisons must be assumed by the reader as true; I always leave it to the reader to determine whether she agrees with my interpersonal comparisons, just as I leave it to the reader to determine whether she agrees with my intuitive judgment that certain distributive results are right or wrong.
In accordance with my belief that interpersonal comparisons should be convincing, I review, in Chapter 3, some empirical work on the relationship between disability and welfare. The common-sense view, reflected in the work of almost all distributive theorists, is that disability tends to reduce a person's welfare, and that the severely disabled have, on average, less welfare than the nondisabled. I generally endorse this view, with the reservation that because people have the capacity for hedonic adaptation, disability often may not reduce welfare by as much as the nondisabled observer might think.
I also briefly consider, in Chapter 3, the issue of what is a disability. There is no universally applied definition. Rather, the definition of disability varies according to the purpose of the inquiry. This book is a work of distributive theory; it is more about distributive justice than it is about disability. I use disability as a testing ground for utilitarian and egalitarian theories. In line with this approach, I take a broad view of what constitutes a disability. In my discussion, for example, cancer as well as blindness is a disability. Although my view of disability is broad, it is not idiosyncratic; I do not consider anything a disability that would not also be considered a disability by many other writers on distributive justice.
In Chapter 4, I discuss the utilitarian approach to disability and distribution. Utilitarianism seeks to maximize welfare. As disability tends to reduce welfare, measures to cure or ameliorate disability can substantially increase welfare. Therefore, utilitarianism will often endorse such measures. However, utilitarianism will not approve of aid to the disabled that would benefit them only slightly and would divert resources from alternative uses that could provide people with greater benefits.
I discuss at length, in Chapter 4, the argument, most identified with Sen, that utilitarianism would often allocate fewer resources to disabled people than to nondisabled people, so that the disabled would end up with fewer resources and also less welfare. This argument, I claim, is based on a fallacious exaggeration of the circumstances in which disabled people would benefit less from resources than would nondisabled people. In those unusual circumstances in which it is truly credible that disabled people would benefit less, I argue, it does not seem unfair to allocate fewer resources to them.
In Chapter 5, I discuss egalitarian approaches to disability and distribution. For the most part, my discussion of egalitarian theories in this chapter is thematic; I defer detailed consideration of specific egalitarian theorists until subsequent chapters.
Egalitarian theories vary along a number of dimensions. As already suggested, the key dividing line, as concerns disability and distribution, is the one between resource egalitarianism and welfare egalitarianism. I take this dichotomy from Dworkin. However, I give a somewhat different and, I believe, more natural meaning to the term "resources" than does Dworkin. Whereas Dworkin sometimes uses the term "resources" to mean material resources and sometimes uses that term to mean something else, in my discussion "resources" refers only to material resources.
Like Dworkin, I use the term "welfare" broadly. In my discussion, a welfare egalitarian is one who is concerned not with resources, but with the benefit that people derive from resources, in the broadest possible sense. Sen says that he wants to equalize not welfare, but "capabilities" to achieve "functionings"; G. A. Cohen says that he wants to equalize not welfare, but "access to advantage." I treat both Sen and Cohen as welfare egalitarians, as both are concerned with the benefits that people get from resources rather than merely with the equal distribution of resources.
As Ian Shapiro has observed, most contemporary theories of distributive justice can be described across two dimensions, according to the metric they use, and the principle or function they apply to the chosen metric. For utilitarianism, the metric is welfare and the function is maximization: utilitarianism seeks to maximize welfare. Welfare egalitarianism uses the same metric as utilitarianism-welfare-but a different function: welfare egalitarianism seeks to equalize welfare. Resource egalitarianism uses the same function as welfare egalitarianism-equalization-but a different metric: resource egalitarianism seeks to equalize resources.
Resource egalitarians and welfare egalitarians often raise issues of disability in their arguments with each other. The resource egalitarian contends that welfare egalitarianism, if taken seriously, could require virtually unlimited redistribution from the nondisabled to the disabled, in order to bring the disabled as close as possible to equality of welfare with the nondisabled. The welfare egalitarian responds that a strict resource egalitarianism would allow disabled people no more resources than the nondisabled poor, even if the disabled would fare horribly without additional help.
I conclude, in Chapter 5, that welfare egalitarians and resource egalitarians are correct in the criticisms they level against each other. Welfare egalitarianism does indeed require too much redistribution to the disabled, and resource egalitarianism does indeed require too little.
I next proceed to a detailed consideration of particular egalitarian theorists. I devote more space to resource egalitarians than to welfare egalitarians, as resource egalitarians make a greater pretense of putting forth distributive principles that rely not at all on considerations of relative benefit. In Chapters 6, 7, and 8, respectively, I discuss three of the most prominent resource egalitarians: John Rawls, Ronald Dworkin, and Bruce Ackerman. I demonstrate that these theorists must contort their theories in order to provide redistribution to the disabled. They must then contort their theories once more in order to halt redistribution to the disabled. Thus, resource-egalitarian theorists oscillate between inadequate redistribution to the disabled and excessive redistribution to the disabled. Only when resource egalitarians surreptitiously incorporate an element of utilitarianism into their theories do they reach an intermediate and satisfying position.
I devote greatest attention to Dworkin's theory. Dworkin's system of hypothetical insurance is a challenge to my contention that a pure egalitarian theory cannot achieve a position intermediate between inadequate redistribution to the disabled and excessive redistribution to the disabled. I contend that Dworkin's hypothetical insurance is actually a form of utilitarianism, akin to hypothetical-choice variants of utilitarianism offered many years ago by utilitarian economists John Harsanyi and William Vickrey. Hypothetical insurance is a rough and not entirely satisfactory way of distributing resources to the people who would most benefit from them.
In Chapter 9, I turn to the contest between utilitarianism and welfare egalitarianism. I engage with a number of theorists who adhere at least partially to welfare egalitarianism, including Sen, Cohen, Norman Daniels, and Martha Nussbaum.
No theorist even pretends to be a pure welfare egalitarian; all of the welfare-egalitarian theorists acknowledge, some more explicitly than others, that one criterion in the distribution of resources to disabled people must be the extent to which the disabled would benefit from those resources. The real contest, therefore, is between utilitarianism and a hybrid theory, often called prioritarianism, that combines elements of utilitarianism and welfare egalitarianism. As considerations of relative benefit will often be determinative in prioritarianism, as they are in utilitarianism, it is difficult to pose the choice between the two theories in a manner perspicuous to moral intuition. I offer some considerations on behalf of utilitarianism and against prioritarianism, but I cannot completely rule out prioritarianism as an appealing theory; I can only conclude that a plausible version of prioritarianism must be very close to utilitarianism.
In Chapter 10, I consider the problem of aggregation. If many small benefits sum to more than a few large benefits, is it right to help the many rather than the few? I argue that utilitarianism rarely produces wrong-seeming results in cases involving aggregation; we are rarely convinced both that the many small benefits really do sum to more than the few large benefits and that it is wrong to help the many rather than the few. I also explain, in Chapter 10, why the utilitarian commitment to aggregation allows utilitarianism to be more respectful of liberty than a pure egalitarian theory can hope to be.
In Chapter 11, I discuss the distribution of life. Utilitarianism is able to advocate substantial aid to the disabled based on the assumption that disability substantially reduces welfare: in view of this substantial reduction, some measures to cure or aid the disabled hold the promise of substantially increasing welfare. However, the assumption that disability substantially reduces welfare also suggests the possibly counterintuitive conclusion that disabled lives are less worth saving, on utilitarian grounds, than are nondisabled lives. So although utilitarianism seems to give the right answers in most distributive contexts, it may apparently produce counterintuitive results in addressing the distribution of scarce life-saving medical resources.
Peter Singer and other utilitarian bioethicists have accepted the conclusion that disabled lives are in general less worth saving than nondisabled lives. Singer et al. have proposed that disabled people should receive less consideration, in the allocation of life-saving treatment, than people who are not disabled (other than in their need for such treatment). So, for example, a life-saving organ transplant should be given to an ambulatory person in preference to a paraplegic who would have the same post-transplant life expectancy, in order to maximize quality-adjusted life years.
I am troubled by the conclusion that disabled lives are less worth saving than nondisabled lives. I am not sure that utilitarianism requires us to discriminate against the disabled in the distribution of life; I offer an argument in Chapter 11 that utilitarianism does not so require. If utilitarianism does require discrimination against the disabled in the distribution of life, I am not sure that utilitarianism gives the right answer in all matters concerning the distribution of life. My advocacy of utilitarianism, then, is less confident in this area.
If the distribution of life poses problems for utilitarians, it poses even bigger problems for egalitarians. Any plausible theory in this area must take into account at least one form of relative benefit: life expectancy. In many cases, it seems right to give preference, in the distribution of life, to those who would gain the most life years. Egalitarian theories cannot do so. In addition, many versions of egalitarianism would appear to require that we discriminate in favor of disabled people in the allocation of life-saving medical treatment; to me, this policy would if anything be more counterintuitive than discriminating against the disabled.
While most of this book is an argument against egalitarianism, I should make it clear that I support the value of equality, in matters of distributive justice, in two ways. First, I believe that society should treat (at least) all its members with equal respect. This does not distinguish me from other distributive theorists; as Sen has demonstrated, every contemporary theory of distributive justice can claim to be based on some notion of equal respect.
Excerpted from Distributive Justice and Disability by MARK S. STEIN Copyright © 2006 by Yale University. Excerpted by permission.
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Meet the Author
Mark S. Stein is academic fellow at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School.
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