Allocating Care Without Abandonment
Two people with very different life stories end up in the same hospital, on the same day, with heart disease. In the first case (Case 1), one works remotely and orders takeout every night. In the second case (Case 2), the other lives in a food desert, where he cannot find a single piece of fruit for under five dollars.
Taken together, Cases 1 and 2 preview the core claim of this paper: that background injustice and genuine choice operate very differently across patients, and that any plausible theory of justice in healthcare must account for this contrast.
By juxtaposing Case 1 and Case 2, we can see in concrete terms why a pluralist thesis that separates allocation from financing appears more plausible than a simple, responsibility-based allocation rule.
A fundamental tension between structural fairness and personal accountability defines the ethical debate surrounding healthcare resource allocation. On the one hand, there is the empirical reality that health is produced not just by access to medical prevention and treatment but, to a measurably greater extent, by the cumulative experience of social conditions (Daniels, 2008; Segall, 2010; Frieden, 2010). Given this argument, a socioeconomic gradient in health emerges (Daniels, Kennedy, & Kawachi, 2004). Case 1 vividly illustrates the bottom of this gradient, while Case 2 exemplifies how, even at the top, choice still interacts with structural background conditions.
For instance, people in deprived neighborhoods of Glasgow can have a life expectancy 12 years shorter than their affluent counterparts, disparities that universal access to care alone cannot eliminate (Segall, 2010). Consequently, these structural forces entrench health inequities across generations and perpetuate avoidable gaps in health and survival.
On the other hand, theories like Luck Egalitarianism (LE) emphasize that egalitarian justice aims to compensate for disadvantages only if they result from uncontrollable “brute luck,” and explicitly deny compensation for disadvantages arising from voluntary choices or “option luck” (Segall, 2010). This reliance on individual responsibility becomes problematic in an unequal society because structural factors severely compromise the voluntariness of health choices, rendering the choice and the circumstances “epistemically opaque” for the disadvantaged (Voigt, 2013). Using responsibility to allocate resources risks “trivializing the structural constraints” that individuals face and contributes to unjust feelings of “guilt, shame, or frustration” (Voigt, 2013). Thus, the moral outcome of strict LE is the famous “abandonment of the imprudent” objection, which critics find “harsh and wrong,” as it may require denying medical treatment to those deemed responsible for their condition (Anderson, 1999; Segall, 2010; Voigt, 2013). Case 2 brings this objection into sharp focus: even if we accept that the affluent patient is responsible, abandoning him at the bedside still appears morally unacceptable.
To navigate this dilemma, a framework is needed that honors the commitment to basic care while acknowledging the moral relevance of truly voluntary choices made by the privileged. I will argue that, together, Cases 1 and 2 make it more plausible that responsibility should be expressed in financial terms rather than through exclusion from care.
While strict Luck Egalitarianism offers a compelling moral intuition regarding responsibility, it fails as a criterion for allocating scarce medical resources because the influence of Social Determinants of Health renders the distinction between “choice” and “circumstance” epistemically opaque for the disadvantaged. Therefore, we must adopt a pluralist framework: medical access should be governed by a sufficientarian guarantee of care based on need (Frankfurt, 1987; Segall, 2010), and, given this argument, “individual responsibility” should be relegated strictly to the domain of financial contribution (Le Grand, 1987) for the affluent, thereby satisfying the Rawlsian demand for fairness without succumbing to the “abandonment of the imprudent” (Anderson, 1999; Segall, 2010; Voigt, 2013).
As briefly mentioned, I will begin by introducing two cases:
Case 1: The socioeconomically “Disadvantaged Patient,” a low-income individual, develops a condition such as heart disease, where the root cause is linked to a lack of access to affordable, healthy food options. In this case, the patient’s choices are tightly constrained by structural injustice.
Case 2: An “Affluent Patient,” living in a neighborhood like the West Village of New York City, develops the same condition (e.g., heart disease). In this second case, by contrast, the person’s illness may be attributed to long-term consumption of unhealthy foods (e.g., ice cream and junk food), despite easy access to healthier options and preventive care.
Throughout this paper, I will first analyze the “Disadvantaged Patient” (Case 1) to argue that the Social Determinants of Health render strict Luck Egalitarian allocation unjust because meaningful choice collapses under structural pressure. Before I explain what is wrong with responsibility-based allocation in this context, I will show how structural injustice shapes this patient's health outcomes. Second, I will examine the “Affluent Patient” (Case 2) to discuss the “abandonment of the imprudent” objection and explain why denying care to the imprudent is “harsh and wrong.” In doing so, I will use both cases as concrete illustrations that make the pluralist thesis more plausible than its rivals. Third, I will propose a synthesis that separates allocation from payment; thus, responsibility should determine who pays (via taxes or premiums) rather than who lives and dies. Finally, I will defend this pluralist view against the objection that it creates a “pay-to-play” system and, in light of these objections, offer a modest revision of my thesis.
Section I: The Illusion of Choice and the Disadvantaged Patient
Strict Luck Egalitarianism is a theory of distributive justice that holds that an individual being worse off than another due to factors beyond their control, categorized as brute luck, is unfair and mandates social compensation (Segall, 2010; Voigt, 2013). Conversely, inequalities are deemed fair if they result from option luck, which includes voluntary choices for which the agent can reasonably be held responsible (Voigt, 2013). LE requires compensation unless the disadvantage resulted from factors that it would have been reasonable to expect the agent to avoid (Segall, 2010). Given this argument, critics of LE contend that, in an unequal world, the distinction between these two types of luck dissolves; thus, the application of LE principles becomes fundamentally unjust. These passages suggest that, for many patients like the Disadvantaged Patient in Case 1, what appears to be “option luck” may in fact be brute luck in disguise, thereby directly supporting my thesis that responsibility cannot serve as a bedside allocation rule for such patients.
Consider a low-income patient suffering from heart disease, the origins of which can be traced directly to chronic lack of access to nutritious food and persistent exposure to neighborhood blight. This is the Disadvantaged Patient in Case 1, whose weekly food choices are effectively forced to cheap, calorie-dense options. Before I explain why holding this patient responsible is wrong, I want to show how thoroughly the Social Determinants of Health—social factors like income, housing, and social conditions—shape their options. In low-income and minority neighborhoods, studies show a structural environment characterized by more fast-food restaurants and fewer supermarkets selling healthy foods (Larson, Story, & Nelson, 2009). This is precisely Case 1, where the patient’s choice is between different unhealthy foods, not between healthy and unhealthy diets. For Black individuals, systemic inequalities mean that race often predetermines access to health resources, leading to poorer health even when adjusted for income level (Ray, 2023). This detailed description of Case 1 thus serves as a central example that renders the first half of my thesis, that responsibility-based allocation is unjust for the disadvantaged, more plausible.
For this patient, the concept of “option luck” is rendered morally incoherent because the prerequisite of genuine voluntariness is fundamentally unmet. The resultant poor health is overwhelmingly determined by structural injustice rather than deliberate defiance of medical advice (Daniels, Kennedy, & Kawachi, 2004). In Case 1, the patient does not reject medical guidance; they simply inhabit an enviroment where following that guidance (buying healthy fresh foods) is practically impossible. If an individual's choices are made under highly unequal circumstances, then those choices are insufficient to ground personal responsibility (Voigt, 2013). Further support for this claim comes from the finding that low socioeconomic status is linked to reduced agential capacities, severely diminishing a person’s ability to act prudently for their health (Levy, 2019). Insofar as Case 1 exemplifies these conditions, it strengthens the plausibility of my claim that disadvantaged patients should be protected from responsibility-based triage rules.
From the perspective of Rawlsian justice, an individual is only responsible for the choices they made under conditions of social justice (Kniess, 2019). Since the existence of profound social inequality proves that society is unjust, disadvantaged individuals are therefore “let off the hook, so to speak, no matter what they do or do not do to look after their health” (Kniess, 2019). What appears to be personal failure is, in fact, a predictable outcome of unjust background conditions. Furthermore, the most effective public health efforts target socioeconomic factors at the base of the health impact pyramid because they require less individual effort and fundamentally alter the environment (Frieden, 2010). Interventions requiring individual behavioral change, such as expecting the poor patient in Case 1 to source and prepare healthier food, are situated at the least effective tier of the pyramid (Frieden, 2010). The failure to achieve health in this case is, therefore, primarily a failure of the surrounding social structures, not a failure of individual will.
To penalize this low-income patient during the allocation of scarce medical resources based on the claim of “option luck” would constitute a double victimization. The individual is penalized once by the initial structural injustice that caused their illness (poverty, food deserts), and again by the health system that punishes the predictable consequences of that injustice (Daniels, Kennedy, & Kawachi, 2004). This would mean blaming the patient in Case 1 for the very pattern of cheap takeout and convenience store meals that the surrounding neighborhood all but guarantees. Thus, utilizing responsibility criteria risks trivializing the structural constraints that the patient faces, lending weight to language generally understood in “conservative terms” that understates the relevance of social structures (Voigt, 2013). Moreover, allocating resources based on need or choice, rather than strict equality, may “lack plausible equitable distributive purpose” (Culyer & Wagstaff, 1993). Case 1, therefore, functions as a powerful counterexample to strict LE as an allocation rule and directly supports the need-based, sufficientarian component of my thesis.
Strict Luck Egalitarianism fails when applied to the disadvantaged because the necessary prerequisite for moral accountability—a truly voluntary choice—is demonstrably undermined by the Social Determinants of Health; hence, its use as an allocation criterion in such contexts is unjustified. The patient’s poor health is, in effect, a product of brute luck disguised as option luck; it follows that holding this patient fully responsible in allocation decisions would be unjust.
Section II: The Affluent Patient and the “Abandonment” Dilemma
In contrast to the disadvantaged patient, the affluent patient, a West Village resident, presents a clearer philosophical case for individual responsibility. This person develops heart disease mainly because of modifiable risk factors such as overconsumption of unhealthy food. Unlike the poor, the rich (Case 2) enjoy socioeconomic advantages—high income, access to recreational space, and ample access to healthcare—which actively reduce the constraints imposed by the Social Determinants of Health (SDH) (Daniels, Kennedy, & Kawachi, 2004). However, economic development, marked by greater wealth and improved living standards, can paradoxically increase illness due to modifiable risk factors associated with overconsumption of unhealthy food (Frieden, 2010). These passages suggest that the affluent patient’s illness in Case 2 is connected to choices that were, in principle, avoidable, and thus provide a contrasting example that helps explain the second, responsibility-sensitive half of my thesis.
Theoretically, the affluent patient’s resulting health problems fall squarely into the category of “option luck” (Segall, 2010). Because the affluent patient had the resources to choose healthier behaviors, strict LE suggests that the inequality resulting from their deliberate choices should be considered fair (Segall, 2010). The Case 2 patient had ample opportunity to avoid these risks, so the LE framework would require the patient to be held accountable for the consequences of those choices, theoretically granting them a lower claim to scarce medical resources compared to those suffering from pure brute luck (Segall, 2010; Voigt, 2013). This description of LE leads directly to the “abandonment of the imprudent” objection, which Case 2 is designed to dramatize.
However, the problem arises when applying this framework to the allocation of life-saving medical care. The principal philosophical objection to LE is the abandonment of the imprudent critique, which argues that the theory is too narrow because it requires denying medical treatment to individuals culpable for their ill health due to “bad option luck” (Segall, 2010; Voigt, 2013). Critics argue that actually failing to treat the affluent patient simply because they gambled with their health would be “harsh and wrong” (Segall, 2010). To make Case 2 vivid, it would mean refusing a life-saving intervention as they lie in the same ICU as Case 1, solely because their overeating was more voluntary. These passages suggest that, even when responsibility is clear, it cannot straightforwardly determine who receives life-saving care.
Shlomi Segall, a proponent of LE, attempts to mitigate this harshness by arguing that, even if LE “does not find a duty of justice” to treat the imprudent, society may recognize a separate, non-justice-based duty—a sufficientarian safeguard—to meet all individuals' basic needs, including their medical needs (Segall, 2010). This principle, famously articulated as “what is important from the point of view of morality is not that everyone should have the same but that each should have enough,” functions to guarantee a basic level of care, regardless of desert (Frankfurt, 1987). Sufficientarianism thus operates as a moral floor beneath luck-based considerations. This floor would guarantee that both Case 1 and 2 patients receive basic life-saving care, though only the latter clearly bears responsibility for their condition.
The inclusion of the sufficientarian safeguard, however, creates a dilemma when allocating scarce resources (Segall, 2010). In this scenario, there are two options: ignore responsibility or deny care to the affluent individual. If the affluent patient is treated identically to the disadvantaged patient, society ignores the affluent individual’s voluntary assumption of risk, effectively rendering their option luck morally irrelevant. This is considered unfair to the prudent members of society who did not impose preventable burdens on the shared resource pool. If the patient is denied life-saving care due to their responsibility, society avoids the unfairness to the prudent but, in so doing, commits the moral error of “abandonment,“ which is judged as “harsh and wrong” (Segall, 2010).
This tension, therefore, forces recognition that the philosophical relevance of individual responsibility, while compelling in the case of the affluent, must nevertheless be relegated to a secondary concern behind the moral imperative of meeting basic needs, unless the prudent and the imprudent are literally “vying for some scarce treatment” (Segall, 2010). In the next section, I develop a pluralist framework that separates allocation from financing.
Section III: My Synthesis Separating Allocation and Financing
I propose that the tension between individual responsibility and structural constraints can be resolved only by adopting a pluralist model that maintains a clear distinction between the allocation criterion for medical treatment and the financial criterion for sustaining the health system (Le Grand, 1987). This separation allows us to uphold the fundamental moral mandate that health care access should be universal while nevertheless imposing financial accountability where genuinely voluntary choice exists.
I contend that medical treatment must be allocated solely on the basis of medical need and prognosis, and must be wholly divorced from any assessment of a patient’s past conduct. This priority is secured by a sufficientarian safeguard, which requires guaranteeing a basic level of care regardless of desert (Frankfurt, 1987). As proponents of Luck Egalitarianism acknowledge, society must always recognize a non-justice-based duty to meet all individuals’ basic medical needs, thereby mitigating the “harshness” of strictly theoretical applications of justice (Segall, 2010). Bedside decisions should therefore reflect need, not desert. On this view, both Case 1 and Case 2 receive the same priority when equally sick, regardless of the voluntariness of their past behavior.
Further, basing allocation on need supports the Rawlsian goal of safeguarding Fair Equality of Opportunity (Daniels, 2008). Justice in this sense mandates ensuring citizens maintain “normal species functioning” by restoring health deficits as much as medically possible (Buchanan et al., 2000). Thus, this requirement demands that both the disadvantaged patient (Case 1) and the affluent patient (Case 2) receive equal priority when they are equally ill, solely based on their medical need to restore function. By restoring the duty to care to the affluent individual, even the culpable one, this view avoids the “abandonment of the imprudent” objection, a critique levied against those who strictly apply responsibility in clinical reasoning (Anderson, 1999; Segall, 2010). Compassion should govern triage, while responsibility should be located elsewhere in the system.
While allocation must remain neutral toward past conduct, the principle of retributivity mandates that the affluent individual who willingly assumes risk must contribute financially. Before explaining how this contribution should work, it is important to highlight a core inconsistency identified by economists. If health differences resulting from voluntary choices are deemed equitable, then providing free treatment to restore that health is necessarily inequitable to the prudent who do not impose burdens on the system (Culyer & Wagstaff, 1993).
To resolve this tension, I propose applying Le Grand’s financial model, which shifts accountability from the hospital to the system’s finance (Le Grand, 1987). On this proposal, the affluent, responsible agent (Case 2) should acknowledge their option luck not by forfeiting their life, but by forfeiting some of their wealth. By contrast, the disadvantaged patient whose behavior is shaped by brute luck would not face the same financial burden.
My mechanism would rely on higher insurance premiums or specific taxes on luxury, unhealthy behaviors for those above a certain socioeconomic threshold. In practice, Case 2, who enjoys ample income and alternatives, falls squarely within this class, as Case 1 does not. This approach internalizes the costs associated with controllable risk factors, such as those related to overconsumption of unhealthy food (Frieden, 2010). For example, Le Grand specifically suggested that those who engage in risky behavior pay an annual premium to cover the expected costs of treatment associated with their behavior (Le Grand, 1987). The system respects the affluent patient’s agency and freedom to make lifestyle choices, but holds them accountable by requiring them to pay “their own way” (Wikler, 1978).
This pluralist synthesis achieves a moral victory by securing two competing ideals: universal care and accountability. While maintaining the sufficientarian floor, ensuring that the individual receives the same entitlement to healthcare as the disadvantaged patient, it also satisfies the egalitarian intuition that cost imbalances due to individual choice should be addressed.
Section IV: Addressing Objections to the Pluralist Model
There are two objections which I will now address: the Fairness/Asymmetry Objection and the Commodification Objection.
The first objection claims that applying financial accountability only to the affluent is discriminatory and overlooks the profound asymmetry between the Social Determinants of Health, which shape capacity for choice across socioeconomic classes. Critics who insist on strict equality in billing ignore the reality that SDH render the distinction between “choice” and “circumstance” epistemically opaque for the disadvantaged (Voigt, 2013). For low-income individuals, unhealthy choices are often a predictable consequence of structural constraints, such as neighborhood disparities involving more fast-food restaurants and fewer supermarkets, making poor health a product of initial injustice rather than mere imprudence (Larson, Story, & Nelson, 2009; Daniels, Kennedy, & Kawachi, 2004). That is the situation of Case 1. Conversely, the choices made by the affluent resident (Case 2), who possesses wealth, ample opportunity, and greater agential capacity to avoid risk, are substantially less constrained by SDH, making their financial responsibility “epistemically clear” (Voigt, 2013). Because justice requires society to compensate for disadvantages that result in outcomes that could not have been avoided, the proposed system is equitable precisely because it tracks the actual capacity for genuine, unconstrained responsibility, focusing on accountability where option luck truly exists.
The second objection holds that allowing the affluent to pay for their health choices commodifies justice, effectively letting them buy out of moral responsibility. This misinterprets the goal of the financial mechanism. Healthcare justice is not concerned with moralism or forcing people to suffer penance for bad habits, which is consistent with the Rawlsian view that individuals should maintain the freedom to make lifestyle choices without the “fear of social sanction” (Daniels, 2011). Instead, the objective is cost internalization as a matter of financial fairness, a concept supported by economists who argue that, if health differences due to choice are considered equitable, then society treating and restoring health for free is, consequently, “inequitable” to the prudent (Culyer & Wagstaff, 1993). Under Le Grand’s model, requiring the affluent to pay an “annual premium” reflecting the expected costs of their risk-taking satisfies the duty of reciprocity to fellow system members by ensuring they do not impose unreasonable costs on the community (Le Grand, 1987; Davies & Savulescu, 2019). For Case 2, this means paying more into the system while still fully entitled to care; for Case 1, it means protection from being priced out or blamed for the structurally induced risk. Since the allocation of care is guaranteed by the sufficientarian floor, this financial contribution satisfies justice's demand for fairness without requiring the barbaric step of denying the patient life-saving treatment (Segall, 2010).
While these objections highlight the inherent difficulties of constructing a split system, one that allocates care neutrally but apportions costs based on complex judgments of fault, the pluralist framework remains the only logical approach that respects the reality of profound social inequality. We can hold people financially accountable for genuine choices while upholding the sufficientarian duty to treat everyone based on medical need; thus, the framework avoids the profound injustice of punishing the vulnerable for their circumstances (Segall, 2010; Culyer & Wagstaff, 1993).
Section V: Conclusion
The paper’s core argument rests on finding that strict adherence to Luck Egalitarianism as a medical allocation criterion is untenable in an unequal society. For these individuals in Cases 1 and 2, choices were made under unequal circumstances. Personal health outcomes result from structural injustice rather than genuinely voluntary choice (Voigt, 2013). These passages suggest that the distinction between brute luck (circumstance) and option luck (choice) is morally unstable, and thus unsuitable as a reliable allocation criterion. Consequently, penalizing the disadvantaged patient in triage would inflict a “double victimization (Daniels, Kennedy, & Kawachi, 2004), punishing them for the predictable health consequences of a system that has already failed to provide social justice.
The alternative, seen through the lens of the affluent patient, handles accountability without falling into the moral trap of “abandonment of the imprudent” (Anderson, 1999; Segall, 2010). Case 2 shows that genuine option luck can and should matter, but not in the ways that cost people their lives. While the affluent patient's poor health often stems from choices less constrained by structural factors, representing genuine “option luck” (Segall, 2010), the moral imperative to meet basic needs requires a sufficientarian degree of medical care regardless of fault. This pluralist synthesis maintains accountability not at the bedside but in healthcare finance (Le Grand, 1987). By implementing financial models, such as charging an annual premium to cover the expected costs of the treatment associated with voluntary behavior, the responsible affluent individual shoulders their financial burden and therefore ensures they receive the same healthcare entitlements as others, based on medical need. This division of moral labor supports a just health system.
This careful separation of the resource allocation domain from the finance domain provides the conceptual scaffolding necessary for a just public health policy. By universalizing medical access based on need, the framework satisfies the Rawlsian requirement to protect “normal species functioning” and uphold Fair Equality of Opportunity (Buchanan et al., 2000; Daniels, 2008). Simultaneously, by limiting financial accountability to genuinely free choices, it respects the individual's liberty to pursue their life plans. Ultimately, this solution acknowledges that justice demands sensitivity to the distinct ethical demands presented by an unequal society and offers a framework capable of resolving “conflicting moral beliefs” within institutions (Daniels, 2004). With this framework, we do not have to choose between compassion and accountability; we simply need to assign them to their proper domains: compassion for the bedside, accountability for the tax bill.
Refrences
Anderson, E. S. (1999). What is the point of equality? Ethics, 109(2), 287–337.
Buchanan, A., Brock, D. W., Daniels, N., & Wikler, D. (2000). From chance to choice: Genetics and Justice. Cambridge University Press.
Culyer, A. J., & Wagstaff, A. (1993). Equity and equality in health and health care. Journal of Health Economics, 12(4), 431–457.
Daniels, N. (2008). Just health: Meeting health needs fairly. Cambridge University Press.
Daniels, N. (2011). Individual and social responsibility for health. In C. Knight & Z. Stemplowska (Eds.), Responsibility and distributive justice (pp. 266–286). Oxford University Press.
Daniels, N., Kennedy, B. P., & Kawachi, I. (2004). Justice is good for our health. Beacon Press.
Davies, B., & Savulescu, J. (2019). Obligations to fellow members of the system to protect their health and not impose unreasonable costs. Bioethics, 33(2), 135–141.
Frankfurt, H. (1987). Equality as a moral ideal. Ethics, 98(1), 21–43.
Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(3), 590–595.
Kniess, C. (2019). Where there is no justice, there is no (substantive) responsibility. Journal of Applied Philosophy, 36(1), 115–116.
Larson, N. I., Story, M. T., & Nelson, M. C. (2009). Neighborhood environments: Disparities in access to healthy foods. American Journal of Preventive Medicine, 36(1), 74–81.
Le Grand, J. (1987). Equity, health, and health care. Social Justice Research, 1(3), 257–274.
Levy, N. (2019). The greater prevalence of harmful health behaviors among people with low socioeconomic status. Bioethics, 33(1), 106–107.
Ray, K. (2023). Introduction. In Black health. Oxford University Press.
Segall, S. (2010). Is Health (Really) Special? Health Policy between Rawlsian and Luck Egalitarian Justice. Journal of Applied Philosophy, 27(4), 344–358.
Voigt, K. (2013). Appeals to individual responsibility for health: Reconsidering the luck egalitarian perspective. Cambridge Quarterly of Healthcare Ethics, 22(2), 146–158.
Wikler, D. I. (1978). Persuasion and coercion for health: Ethical issues in government efforts to change lifestyles. The Milbank Memorial Fund Quarterly. Health and Society, 56(3), 303–338.
