Journal articles on the topic 'Unfair value allocation'

The Shapley value is one of the most important normative division scheme in cooperative game theory, satisfying basic axioms. However, some allocation according to the Shapley value may seem unfair to humans. In this paper, we develop an automatic method that generates intuitive explanations for a Shapley-based payoff allocation, which utilizes the basic axioms. Given a coalitional game, our method decomposes it to sub-games, for which it is easy to generate verbal explanations, and shows that the given game is composed of the sub-games. Since the payoff allocation for each sub-game is perceived as fair, the Shapley-based payoff allocation for the given game should seem fair as well. We run an experiment with 210 human participants and show that when applying our method, humans perceive Shapley-based payoff allocation as significantly more fair than when using a general standard explanation.

Purpose Resource allocation has always been a critical problem with significant economic relevance. Many industries allocate the resources based on classical methods such as overall equipment effectiveness (OEE) and data envelopment analysis (DEA). The lack of OEE factors’ weight, how it is defined, analyzed, interpreted and compared in OEE and selection of unrealistic weights, self-appraisal and disability of complete ranking in DEA are challenges that are possible to occur. These defects may result in unfair allocation of the resources. This study aims to overcome the mentioned weaknesses. Design/methodology/approach In this paper, an approach using a set of various DEA models and Nash bargaining solution (NBS) is designed to solve the resource allocation problem based on OEE, among a set of comparable and uniform DMUs (decision-making units) in a fair way. Findings The results show that a unique Pareto optimal allocation solution is obtained by the proposed DEA–NBS model among the DMUs. This allocation is more acceptable for players, because the allocation results are commonly determined by all DMUs rather than a specific one. Furthermore, the rankings achieved by the utilized methods and TOPSIS (technique for order preference by similarity to ideal solution) are compared by Spearman’s rank correlation coefficient to validate the resource allocation plan. The findings indicate that the DEA–NBS method has the best correlation with the TOPSIS approach. Originality/value To the best of authors’ knowledge, no research has considered the use of DEA and NBS with OEE.

With the gradual popularization of carbon trading, individual carbon emission behavior will come with carbon costs, which will have a significant impact on the network freight platform carrier drivers. Therefore, in order to improve the stability within the network freight platform, this paper considers the fairness of benefit distribution among network freight carriers and aims to offset the impact of carbon cost to a greater extent by reducing the relative deprivation of the network freight platform carrier group, so as to finally realize the benign operation of network freight. This paper introduces a number of indicators such as contribution value, expectation realization degree, and relative deprivation feeling, and establishes a dynamic benefit distribution optimization model oriented by relative deprivation feeling. Based on the basic characteristics of the problem, the ant colony labor division model is extended, and the corresponding algorithm is designed to solve the problem. By introducing the contribution value, contribution rate and expected return to reset the stimulus value of the environment and the response threshold of agent, the relative deprivation sense is used to quantify the degree of unfair benefit distribution, which is used as a benchmark to dynamically coordinate the benefit distribution of the carrier group and optimize the benefit distribution scheme. The experimental results show that the extended model and algorithm designed in this paper can significantly reduce the relative deprivation perception of the carrier group in the online freight platform at a low cost.

Drought poses significant risks to society, in particular irrigated-crop production, which accounts for a large share of global freshwater use. Given its key role in the production of food, feed and fiber crops, there exists a need for policy measures to prevent and mitigate the impacts of drought on irrigated agriculture. This paper proposes that the design of drought policy should take into account actual farmer behavior in response to water scarcity. To this end, we offer a detailed analysis of land allocation and crop-choice decisions over time in an irrigation district located in the dry plains of Northern Mexico. We find that farmers systematically change their crop mix in response to water availability. In particular, in times of drought, irrigation water flows to higher-yield and higher-price crops (which also require more intense irrigation) to the detriment of less water-demanding (but lower value) crops. Farmers use water with the goal of earning a living—economizing on water per se has no relevance in that context. Policies that do not explicitly recognize this may result in ineffective, inefficient and/or unfair outcomes.

Much decision-making requires balancing benefits to the self with benefits to the group. There are marked individual differences in this balance such that individualists tend to favor themselves whereas prosocials tend to favor the group. Understanding the mechanisms underlying this difference has important implications for society and its institutions. Using behavioral and fMRI data collected during the performance of the ultimatum game, we show that individual differences in social preferences for resource allocation, so-called “social value orientation,” is linked with activity in the nucleus accumbens and amygdala elicited by inequity, rather than activity in insula, ACC, and dorsolateral pFC. Importantly, the presence of cognitive load made prosocials behave more prosocially and individualists more individualistically, suggesting that social value orientation is driven more by intuition than reflection. In parallel, activity in the nucleus accumbens and amygdala, in response to inequity, tracked this behavioral pattern of prosocials and individualists. In addition, we conducted an impunity game experiment with different participants where they could not punish unfair behavior and found that the inequity-correlated activity seen in prosocials during the ultimatum game disappeared. This result suggests that the accumbens and amygdala activity of prosocials encodes “outcome-oriented emotion” designed to change situations (i.e., achieve equity or punish). Together, our results suggest a pivotal contribution of the nucleus accumbens and amygdala to individual differences in sociality.

IntroductionWe explore how the scope of analysis is defined in health technology assessment (HTA) and economic evaluation and consider the potential implications of these decisions.MethodsThe scope of analysis, including decisions about which methods and domains of HTA to include in the assessment, which costs, and health outcomes are most meaningful, and which comparators are the most relevant are typically informed by the needs of the decision-maker. We undertook two systematic scoping reviews to assess: (i) to what extent systems thinking is considered in literature-based technology assessments; and (ii) how the scope of the analysis is defined in economic evaluation using Clostridioides difficile infection as an exemplar. We synthesized the findings from these reviews and offer three key observations for future research and exploration in the field of HTA.ResultsOur scoping reviews found that the scope of analysis in economic evaluations typically focus on single interventions, often ignoring upstream and downstream interventions. Similarly, published technology assessments have narrowly defined and inconsistent scopes of analysis, with limited consideration of indirect health and non-health impacts. Three key observations for the field of HTA include: (i) economic evaluations focus on the value of single heath interventions. A focus on a single health intervention may simplify the analysis; however, will this siloed decision-making lead to optimal health resource allocation? (ii) published assessments have inconsistently defined scopes of analysis. A decision problem that focuses on the needs of the decision-maker is practical; however, will inconsistencies in perspectives across assessments create unfair conceptualizations of value? (iii) HTA is technology-focused, not patient-focused. A technology-focused HTA system aligns with the technology diffusion process; however, does this move us away from the patient-centered mandate of HTA?ConclusionsThe dynamic nature of HTA leads to many conceptualizations of value. Considering the potential implications of narrowly defined, inconsistent, and technology-focused scopes of analyses may have consequences on achieving a patient-centered high-quality health system.

Purpose The aim of this paper is to understand the antecedents and effects of performance attribution challenges arising in the provision of business-to-business (B2B) services in supply chains. Design/methodology/approach The study draws on three in-depth case studies of logistics service providers (LSPs) offering supply chain solutions to their clients in Sweden. The analysis of performance attribution challenges and their antecedents and effects is based on 38 semi-structured interviews and review of 43 documents, including contracts and performance monitoring records. Findings Three key antecedents of performance attribution challenges are stressed. Two of these, the inseparability and contestability of service inputs, are closely related to the notion of service co-production. The third antecedent is the limited provider capability in performance data collection and analysis. Performance attribution challenges may result in provider aversion to performance-related risk and have a harmful effect on client relationships, for example, in terms of provider perceptions of opportunism and unfair allocation of gains. These effects can be mitigated through contracting, interventions in performance measurement system design and deployment of relational mechanisms. Research limitations/implications The paper extends the service management literature that emphasises on service co-production by suggesting that inputs of the client firm and its supply chain partners may not only vary in quality but also can be inseparable from provider inputs and highly contestable. It also empirically demonstrates how performance attribution challenges and their antecedents and effects manifest themselves in B2B service provision, as opposed to supply chain settings where the main user of logistics services is the consumer. Practical implications LSP managers should contract for performance based on high-quality and incontestable external inputs they rely upon. Contractual specifications (performance indicators and related incentives) should explicate and consider the inputs required by clients and their supply chain partners to minimise their contestability. Originality/value The study proposes an empirically based framework of the antecedents and effects of performance attribution challenges, an issue that has received scant attention in logistics outsourcing research and the business services literature more broadly.

Abstract Social value orientation (SVO) characterizes stable individual differences by an inherent sense of fairness in outcome allocations. Using the event-related potential (ERP), this study investigated differences in fairness decision-making behavior and neural bases between individuals with prosocial and proself orientations using the Ultimatum Game (UG). Behavioral results indicated that prosocials were more prone to rejecting unfair offers with stronger negative emotional reactions compared with proselfs. ERP results revealed that prosocials showed a larger P2 when receiving fair offers than unfair ones in a very early processing stage, whereas such effect was absent in proselfs. In later processing stages, although both groups were sensitive to fairness as reflected by an enhanced medial frontal negativity (MFN) for unfair offers and a larger P3 for fair offers, prosocials exhibited a stronger fairness effect on these ERP components relative to proselfs. Furthermore, the fairness effect on the MFN mediated the SVO effect on rejecting unfair offers. Findings regarding emotional experiences, behavioral patterns and ERPs provide compelling evidence that SVO modulates fairness processing in social decision-making, whereas differences in neural responses to unfair vs fair offers as evidenced by the MFN appear to play important roles in the SVO effect on behavioral responses to unfairness.

Purpose Following the global financial crisis in 2008, the construction sector in UAE has been facing emergent criticisms for growing adversarial culture and rising prevalent claims and disputes between stakeholders. The complex, large size and fast track nature of construction projects in UAE, make project management very challenging under the commonly used traditional procurement routes. This paper aims to examine whether implementing collaborative procurement approaches can facilitate resolving the escalating number of claims and disputes in the UAE construction industry. Design/methodology/approach Considering the nature of the study, a quantitative method was selected to realize the research objectives. The questionnaire was uploaded using an online survey facility and distributed through e-mails and professional networks. The questionnaire was piloted with experts to assess whether the questions are unambiguous, easy to respond and intelligible. The feedback received was mostly positive with few comments and recommendations. The pilot responses were incorporated and the questionnaire was modified before the final sending out. The questionnaire survey consisted of six main sections to fulfill the research objectives. Findings Around three-quarters of the experts believe that the relationship is adversarial, with a lack of trust, win-lose attitude, with dismissive and opportunistic behavior. The survey reveals that the top causes of claims and disputes comprise the following: variations because clients initiated change requests; contractors selection on low bid only rather than including quality and performance considerations; and unfair risk allocation where majority of risks are transferred to contractors. The findings also identify eight collaborative practices, which have crucial positive impacts such as early identification of problems, better communication and enhanced trust and teamwork. Originality/value This research contributes to the enhancement of the management of claims and disputes for construction projects, which encompasses the following: the key characteristics of collaborative arrangements to improve the adversarial construction culture comprise: mutual respect, openness, fairness and non-opportunistic behaviors; the foremost roles of collaborative procurement in reducing claims and disputes embrace: early identification and resolution of problems, enhanced trust and teamwork spirit, improved relationships and better quality communication; the major practical barriers of implementing collaborative approaches incorporate: lack of awareness of their benefits, primitive legal framework of partnering arrangements and lack of transparency in procurement processes.

Aim: The paper discusses cases in which a refusal by an energy enterprise to connect other enterprises to the network is treated as a prohibited abuse of the enterprise's dominant position and, equally, will represent behavior prohibited by art. 12 of the Treaty on the Functioning of the European Union and by art. 9 par. 2 item 2 of the Competition and Consumer Protection Law as well as legal consequences of such refusal. It is important to pinpoint such cases since the EU sectoral regulation does not provide for obligating any undertakings which manage and operate oil pipelines to enter into contracts with other undertakings such as contracts on connecting into their network or contracts on providing crude oil transfer services. Conditions for accessing oil pipelines and selling their transfer capacities are determined by the owners of the networks: private oil companies in the countries across which the pipelines are routed. These conditions are not governed by the EU law. Furthermore, the very obligation of connecting other entities to own network by energy undertakings operating in the oil transfer sector in Poland will only arise from generally applicable provisions of the Polish competition law. Design / Research methods: The purpose of the paper has been reached by conducting a doctrinal analysis of relevant provisions of Polish and EU law and an analysis of guidelines issued by the EU governing bodies. Furthermore, the research included the functional analysis method which analyses how law works in practice. Conclusions / findings: The deliberations show that a refusal to access the network will be a manifestation of a prohibited abuse of a dominant position and will be a prohibited action always when the dominant's action is harmful in terms of the allocation effectiveness. It will be particularly harmful when delivery of goods or services objectively required for effective competition on a lower level market, a discriminatory refusal which leads to elimination of an effective competition on the consequent market, a refusal leading to unfair treatment of consumers and an unjustified refusal. Originality / value of the article: The paper discusses the prerequisites which trigger the obligation to connect entities to own network by energy undertakings operating in the oil transfer sector. The obligation has a material impact on the operations of the oil transmitting undertakings, in particular on those who dominate the market. The regulatory bodies in the competition sector may classify a refusal of access to own network by other enterprises as a prohibited abuse of the dominant position, exposing such undertakings to financial consequences.Implications of the research: The research results presented in the paper may be used in decisions issued by the President of the OCCP and in judgement of Polish civil courts and EU courts. This may cause a significant change in the approach to classifying prohibited practices to prohibited behavior which represent abuse of the dominant position. The deliberations may also prompt the Polish and EU legislator to continue works on the legislation.

Assessing students’ aptitude and educational performance and grading them on a hierarchical scale is a universal feature of the schooling process. In light of grades’ instrumental, motivational, and symbolic saliency in students’ school experience, it is not surprising they are highly ”valued goods,” and the process of their fair or unfair distribution is of great concern, echoed in students’ and teachers’ discourses. In this investigation, we focus on gender differentials in sense of justice about grades, comparing high school students in two educational settings: Israel and Germany. Although the strong norm of equitable distribution of grades would predict no gender differentials in grade allocation, the pattern of results suggest that gender plays a role in both the distribution of this reward and the judgment of fair distribution, therefore affecting students’ sense of (in)justice. Similarities as well as certain differences in the comparison of sense of justice of Israeli and German boys and girls are discussed in light of system-specific features.

LBA4500 Background: Poor-prognosis GCT (IGCCCG, J Clin Oncol 1997) remains a challenge with no improvement in the 50% survival demonstrated in phase III trials for 25 years. Day 21 serum tumor marker decline rate identified a subgroup of patients (pts) with a better outcome (J Clin Oncol 2004, 22: 3868-76). The hypothesis we tested in this study is that treatment allocation based on early tumor marker decline will improve the progression-free survival (PFS). Methods: Pts with IGCCCG poor-prognosis GCT were treated with a first cycle of BEP. AFP and hCG were assessed at day 18–21: 1) Pts with a favorable decline continued BEP for a total of 4 courses (Fav-BEP); 2) Pts with an unfavorable decline were randomized to receive either BEP (Unfav-BEP) or a dose-dense regimen (Unfav-dose-dense), consisting of paclitaxel-BEP plus day-10 oxaliplatin x 2 cycles, followed by 2 cycles of cisplatin, ifosfamide, and continuous infusion bleomycin (depending on lung function) + G-CSF. The primary endpoint was PFS (hypothesis: 20% difference, type 1 error: 5%, power 80%, 196 randomized pts needed). Results: 263 pts were enrolled and 254 were evaluable at day 21 (6 early deaths, 3 withdrawals): 51 pts (20%) had favorable tumor marker decline and 203 had unfavorable decline (randomized: 105 Unfav-dose-dense arm, 98 Unfav-BEP). The prognostic value of early tumor marker decline (Fav-BEP vs Unfav-BEP) was confirmed: 70% vs 48% for 3-year PFS (p=0.01), and 84% vs 65% for overall survival (OS) (p=0.02). The 3-year PFS was 59% in the Unfav-dose-dense arm vs 48% in the Unfav-BEP arm (p=0.05; HR: 0.66 [0.44-1.00]). 3-year OS was 73% and 65%, respectively. More ≥ grade 2 neurotoxicity (21% vs 4%) and more hematotoxicity occurred in the dose-dense arm, with no excess febrile neutropenia (17% each arm) or toxic deaths (1 each arm). Salvage high-dose chemotherapy + stem-cell transplant were required in 6% in the Unfav-dose-dense arm and 16% in the Unfav-BEP arm (p=0.01). Conclusions: An algorithm of individualized treatment intensification determined by the rate of early tumor marker decline reduces the risk of progression or death in men with poor-prognosis GCT. Clinical trial information: NCT00104676.

Following on from categories of theoretical and empirical levels of learning, the revision of the modern economic policy instruments is made for the purpose of their compliance with the directions of the (macro)economic theories, determination of the objectives of its actualization, and also revealing its stabilizing and allocative functions in the process of its acquisition of the international economic policy attributes. It’s established that economic theory, which is per se a dynamic, open, and unstable system of the economic knowledge that is based on corresponding assumptions and presumes simplified modeling of the economic processes because of the limitations of the offered methods, demonstrates low explicative ability in the course of analysis requested when choosing one or another economic policy according to the challenges of times. It’s proved that although different economic theories can be an effective tool in the rivalry for unfair intellectual arguments in favor of one or another political decision in particular cases, the economic policy typically doesn’t look like a way of mechanistic implementation of theoretical generalization. Although the rivalry with the help of the analytical arguments between the followers of the fiscal and monetary instruments of the macroeconomic policy allowed to get the intermediate result within the New macroeconomic consensus (NMC) with regard to recognition of the monetary policy precedence in the realization of the low rate of the price advance, the experience of the global financial crisis in 2008 – 2010 and global recession in 2020 threw into question the ability of the stabilization programs developed on the basis of NMC recommendations to achieve the expected results. The experience of the last decade marked with combination of the instability of both cyclical and structural and systemic nature, formed the demand for recognition of the fiscal policy as the stabilization programs’ component of the full value. In a bid for interpretation of the ways and aftermaths of the realization of the international economic policy the demand is made for the forming of the new scientific consensual evaluations and theoretical generalizations.

Purpose The purpose of this paper is to develop a model to harness occupancy sensing in a commercial hot-desking environment. Hot-desking is a method of office resource management designed to reduce the real estate costs of professional practices. However, the shortcoming is often in the suitability and appropriateness of allocated work environments. The Internet of Things could produce new data sets in the office at a resolution, speed and validity of which that they could be factored into desk-allocation, distributing seats based on appropriate noise levels, stay length, equipment requirements, previous presence and proximity to others working on the same project, among many others. Design/methodology/approach The study utilises primary data from a commercial office environment in Central London (numerical building system data and semi-structured interviews) to feed a discrete events simulator. To test the hypothesis, the authors look at the potential for intelligent hot-desking to use “work type” data to improve the distribution of individuals in the office, increasing productivity through the creation of positive “work type environments” – where those working on specific tasks perform better when grouped with others doing the same task. The simulation runs for a typical work day, and the authors compare the intelligent hot-desking arrangement to a base case. Findings The study shows that sensor data can be used for desk allocation in a hot-desking environment utilising activity-based working, with results that outweigh the costs of occupancy detection. The authors are not only able to optimise desk utilisation based on quality occupancy data but also demonstrate how overall productivity increases as individuals are allocated desks of their preference as much as possible among other enabling optimisations that can be applied. Moreover, the authors explore how an increase in occupancy data collection in the private sector could have key advantages for the business as an organization and the city as a whole. Research limitations/implications The research explores only one possible incarnation of intelligent hot-desking, and the authors presume that all data have already been collected, and while not insurmountable, they do not discuss the technical or cultural difficulties to this end. Furthermore, final examination of the productivity benefit – because of the difficulty in defining and measuring the concept – is exploratory rather than definitive. This research suggests that not only human-centric smart building research should be prioritised over energy or space-based themes but also large-scale private sector collection of occupancy data may be imminent, and its potential should be examined. Practical implications Findings strongly suggest that the hot-desking may cost more in lost productivity than it gains in reduced rental costs and as such many commercial offices should revaluate the transition, particularly with a view to facilitate intelligent hot-desking. Companies should begin to think strategically about the wider benefits of collecting occupancy data across their real estate portfolio, rather than reviewing use cases in silos. Finally, cities should consider scenarios of widespread collection of occupancy data in the private sector, examining the value these data have to city systems such as transport, and how the city might procure it for these ends. Social implications This paper raises positive and negative social concerns. The value in occupancy data suggested herein, bringing with it the implication it should be collected en mass, has a noted concern that this brings privacy concerns. As such, policy and regulation should heed that current standards should be reviewed to ensure they are sufficient to protect those in offices from being unfairly discriminated, spied or exploited through occupancy data. However, the improved use of occupancy data improving workplaces could indeed make them more enjoyable places to work, and have the potential to become a staple in company’s corporate social responsibility policies. Originality/value This paper fulfils an identified need for better understanding the specific uses of occupancy data in the smart building mantra. Several sources suggest the current research focus on energy and rental costs is misguided when the holistic cost of an office is considered, and concepts related to staff – although less understood – may have an order of magnitude bigger impact. This research supports this hypothesis through the example of intelligent hot-desking. The value of this paper lies in redirecting industry and research towards the considering occupancy data in smart building uses cases including – but not limited to– intelligent hot-desking.

Purpose What has been called “the McDonaldization of universities” (another name for top-down and strong corporate managerialism) has gained momentum as a model for governing and managing universities. This trend exacerbates the traditional tension between academic freedom and managerial control – a major challenge for the administration of academic institutions. The ideas of Charles Darwin represent an opportunity for overcoming such a challenge. However, traditional managerial models show inadequate, pre-Darwinian assumptions for devising organizational designs. This paper aims to show not only the opportunities but also the challenges of embracing a Darwinian paradigm for designing social systems. The case of managerialism in universities is an illustrative example. The paper proposes evolutionary guidelines for designing universities capable of maintaining managerial control while warranting academic freedom. Design/methodology/approach The paper proposes to understand the tension between academic freedom and managerial control in universities as the same tension between freedom and control that Karl Popper identified as successfully handled by evolutionary processes. The paper uses Darwinian theory, understood as a broader theory for complex systems, as a heuristic for designing social systems – universities in this case – able to adapt to changing environmental conditions while handling equilibrium between freedom and control. The methodology articulates the Popperian model of knowledge with the Darwinian scheme proposed by David Ellerman known as “parallel experimentation” for suggesting organizational forms in which university administrators and faculty can interact for generating free innovations in pseudo-controlled organizational arrangements. Findings A salient characteristic of strong managerialism is its pre-Darwinian understanding of survival and adaptation; such an approach shows important flaws that can lead universities to unfit designs that changing environments can select for elimination. As an alternative, the philosophy behind the ideas of Charles Darwin provides guidelines for designing innovative and adaptive social systems. Evolutionary principles challenge basic tenets of strong managerialism as Darwinian designs discard the possibility of seeing managers as knowledgeable designers that allegedly can avoid mistakes by allocating resources to “one-best” solutions through ex ante exhaustive, top-down control. Instead, a Darwinian model requires considering survival as a matter of adaptability through continuous experimentation of blind trials controlled by ex post selection. The key is to organize universities as experimenting systems that try new and different things all the time and that learn and improve by making mistakes, as an adaptive system. Research limitations/implications Governing and managing universities require to acknowledge the uniqueness of academic institutions and demand to look for appropriate forms of organization. The proposal of this paper opens possibilities for exploring and implementing action-research initiatives and practical solutions for universities. Studies in management and administration of higher-education institutions must take into account the characteristics of this type of organizations and should consider wider spectrums of possibilities beyond the core ideas of managerialism. Practical implications University managers face a special challenge for achieving equilibrium between managerial control and academic freedom. Darwinian models of management invite to reconsider several management creeds, for instance, that “errors are bad things” – instead of innovation triggers and learning opportunities or that “one solution must fit all” – instead of considering bottom-up, different and adaptive solutions triggered by local academic units, each facing different environments. Originality/value Currently, there is no clear picture for governing universities. This paper introduces principles and guidelines for facing the current challenge that strong managerialism represents if universities are expected to maintain academic freedom and also survive in volatile environments.

Problem definition: Tasks sequentially arrive, and their values to the workers who are going to perform them are independent random variables. The common way to allocate tasks to workers is according to the first-in, first-out order. But this method both is inefficient and seems unfair to those who receive a low-valued task after a long wait. We are looking for a better allocation method. Academic/practical relevance: Finding a fair and efficient task allocation method is an aspiration of manpower firms that employ a pool of workers, such as salespersons, technicians, emergency medical stuff, nurses, or taxi drivers. We present many more implementations, such as turn taking and load management. Methodology: We propose a self-selected task allocation method and discuss its importance and implementations. The proposed method is defined as a cyclic queueing game with a fixed number of players. Every unit of time a prize with a random value is offered to the players according to their order in the queue, and a player who accepts a prize moves to the end of the queue. The process of choosing which prizes to accept in each position is presented as a noncooperative multiplayer game. We analyze strategies and symmetric equilibria for three variations. Results: We provide closed-form solutions and suggest a novel intuitive interpretation to find equilibria via calculating maximum-profit strategies. We complement the theoretical results by conducting a numerical study. Managerial implications: The proposed method is natural and easy to implement, its outcome is better than the common allocation by seniority, and the ratio of the expected value obtained under the two methods is unbounded.

AbstractTime has become a valuable asset within capitalism. “Time is money” is a well known and usually shared principle. As in regard to many other type of assets, the distribution of time is pretty unfair, as well as it is the value consideration of the time allocated for different people to different activities. The distribution of time, as well as what people can or cannot do with their time, is a key issue among feminist debates. The main argument is that time allocation to paid and unpaid work is very different and unfair between genders. Women allocate much more time to unpaid work, and men, on the contrary allocate much more time to paid work. This has a reasonable and direct consequence in terms of income generation. This unequal distribution of time (and work) represents the main obstacle to women’s economic autonomy and to overcome gender income gaps.

AbstractThe increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it helps to maximize patients’ benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources.

Platform enterprises operate in the platform business model, which is very different from traditional enterprises. Therefore, the legal regulation of mutual monopoly of Internet platform enterprises has become more complex. Facing the monopoly phenomenon in the platform economy market, we must have appropriate policies to deal with it and alleviate the problem of unfair resource allocation under incomplete market competition. This essay briefly analyses the corresponding policy of platform monopoly in different jurisdictions. From the antitrust experience of the United States and China, it can be concluded that preventing market monopoly is the primary goal to deal with platform monopoly. From the EU's antitrust experience, it can be supposed that preventing data monopoly is a vital goal to deal with platform monopoly. Through the combination of Anti-market monopoly and Anti-data Monopoly policies, we can appropriately deal with the platform's market monopoly, stimulate the platform's economic vitality, and create more economic value for the market.

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine and life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance.

Purpose Current covid-19 pandemic challenges health-care ethics. Ones of the most important challenges are medical resources allocation and a duty to treat, often addressed to medical personnel. This paper suggests that there are good reasons to rethink our health-care ethics for future global catastrophic risks. Current pandemic shows how challenging can be an issue of resources allocation even in a relatively small kind of catastrophic event such as covid-19 pandemic. In this paper, the authors show that any future existential bigger catastrophe may require new guidelines for the allocation of medical resources. The idea of assisted dying is considered as a hypothetical scenario. Design/methodology/approach This is a conceptual work based on conceptual analysis at the intersection of risk studies, health-care ethics and future studies. This study builds the argument on the assumption that the covid-19 pandemic should be treated as a sort of global catastrophic risk. Findings show that there are no such attempts in currently published peer-reviewed academic literature. This is crucial concept for the meta-analysis. This study shows why and how current pandemic can be interpreted in terms of global catastrophic risk even if, literally, covid-19 does not meet all criteria required in the risk studies to be called a global catastrophe. Findings We can expect an emergence of discriminatory selection policy which will require some actions taken by future patients like, for example, genetic engineering. But even then it is inevitable that there will still be a large number of survivors who require medical assistance, which they have no chance of receiving. This is why this study has considered the concept of assisted dying understood as an official protocol for health-care ethics and resources allocation policy in the case of emergency situations. Possibly more controversial idea discussed in this paper is an idea of assisted dying for those who cannot receive required medical help. Such procedure could be applied in a mass-scale during a global catastrophic event. Research limitations/implications Philosophers and ethicists should identify and study all possible pros and cons of this discrimination rule. As this study’s findings suggested above, a reliable point of reference is the concept of substantial human enhancement. Human enhancement as such, widely debated, should be studied in that specific context of discrimination of patients in an access to limited medical resources. Last but not least, scientific community should study the concept of assisted dying which could be applied for those survivors who have no chance of obtaining medical care. Such criteria and concepts as cost-benefit analysis, the ethics of quality of life, autonomy of patients and duty of medical personnel should be considered. Practical implications Politicians and policymakers should prepare protocols for global catastrophes where these discrimination criteria would have to be applied. The same applies to the development of medical robotics aimed at replacing human health-care personnel. We assume that this is important implication for practical policy in healthcare. Our prediction, however plausible, is not a good scenario for humanity. But given this realistic development trajectory, we should do everything possible to prevent the need for the discriminatory rules in medical care described above. Originality/value This study offers the idea of assisted dying as a health-care policy in emergency situations. The authors expect that next future global catastrophes – looking at the current pandemic only as a mild prelude – will force a radical change in moral values and medical standards. New criteria of selection and discrimination will be perceived as much more exclusivist and unfair than criteria applied today.

PurposeThe purpose of this paper is to discuss whether fair value accounting fits for long-term equity investments, which are considered key to retool economies according to sustainability criteria. In doing so, the paper focuses on the European Union and addresses the European Commission’s (2018a) concern that current accounting rules are unfit for achieving the United Nations Sustainable Development goals and the targets of the Paris Agreement on climate change.Design/methodology/approachThe paper grounds in a wide literature review on the effects of fair value accounting on investors’ asset allocation strategies. By critically integrating literature on the notion of long-term investment with theories and possible accounting approaches, the paper provides implications for a revision of the current measurement system for long-term equity investments.FindingsThe literature review supports the view that fair value accounting has played a role in discouraging equity investments over time, thus leaving economies with poorer risk-sharing and weaker long-term investments. The paper contributes to the debate on alternative measurement systems by suggesting possible solutions in relation to controversies arising from empirical evidence.Originality/valueReorienting economies according to sustainability criteria represents an urgent issue which requires prompt and policy-oriented responses. Accordingly, this paper offers insights and guidelines that can help policymakers revise current accounting rules for long-term equity investments in line with sustainable development objectives.

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. [4] Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. “What is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. [5] Bedinger, M. 2020 Apr 22. “After Uproar, Mass. Revises Guidelines on Who Gets an ICU Bed or Ventilator Amid COVID-19 Surge.” Wbur. https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus; Wigglesworth, A. 2020 May 11. “Institutional Racism, Inequity Fuel High Minority Death Toll from Coronavirus, L.A. Officials Say.” Los Angeles Times. https://www.latimes.com/california/story/2020-05-11/institutional-racism-inequity-high-minority-death-toll-coronavirus. [6] Executive Office of Health and Human Services Department of Public Health. 2020 Oct 20. “Crises Standards of Care Planning and Guidance for the COVID-19 Pandemic.” Commonwealth of Massachusetts. https://www.mass.gov/doc/crisis-standards-of-care-planning-guidance-for-the-covid-19-pandemic. [7] Emanuel, E. J., G. Persad, R. Upshur, et al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 382: 2049-55. https://doi.org/10.1056/NEJMsb2005114. [8] Salway, S., G. Mir, D. Turner, G. T. Ellison, L. Carter, and K. Gerrish. 2016. “Obstacles to "Race Equality" in the English National Health Service: Insights from the Healthcare Commissioning Arena.” Social Science and Medicine 152: 102-110. https://doi.org/10.1016/j.socscimed.2016.01.031. [9] Rawls, J. A Theory of Justice (Revised Edition) (Cambridge, MA: Belknap Press of Harvard University Press, 1999). [10] Zack, N. Applicative Justice: A Pragmatic Empirical Approach to Racial Injustice (New York: The Rowman & Littlefield Publishing Group, 2016). [11] Charatz-Litt, C. 1992. “A Chronicle of Racism: The Effects of the White Medical Community on Black Health.” Journal of the National Medical Association 84 (8): 717-25. http://hdl.handle.net/10822/857182. [12] Washington, H. A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday, 2006). [13] d'Oliveira, A. F., S. G. Diniz, and L. B. Schraiber. 2002. “Violence Against Women in Health-care Institutions: An Emerging Problem.” Lancet. 359 (9318): 1681-5. https://doi.org/10.1016/S0140-6736(02)08592-6. [14] Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 9 (4): e1184. https://doi.org/10.7759/cureus.1184; Drescher, J., A. Schwartz, F. Casoy, et al. 2016. “The Growing Regulation of Conversion Therapy.” Journal of Medical Regulation 102 (2): 7-12. https://doi.org/10.30770/2572-1852-102.2.7; Stroumsa, D. 2014. “The State of Transgender Health Care: Policy, Law, and Medical Frameworks.” American Journal of Public Health. 104 (3): e31-8. https://doi.org/10.2105/AJPH.2013.301789. [15] Stepanikova, I., and G. R. Oates. 2017. “Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.” American Journal of Preventative Medicine. 52 (1s1): S86-s94. https://doi.org/10.1016/j.amepre.2016.09.024; Swartz, K. “Health Care for the Poor: For Whom, What Care, and Whose Responsibility?” In Cancian, M., and S. Danziger (Eds.). Changing Poverty, Changing Policies (New York: Russell Sage Foundation Press, 2009), 69-74. [16] Meghani, S. H., E. Byun, and R. M. Gallagher. 2012. “Time to Take Stock: A Meta-analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States.” Pain Medicine 13 (2): 150-74. https://doi.org/10.1111/j.1526-4637.2011.01310.x; Williams, D. R., and T. D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. https://scholar.harvard.edu/davidrwilliams/dwilliam/publications/understanding-and-addressing-racial-disparities-health. [17] Hoffman, K. M., S. Trawalter, J. R. Axt, and M. N. Oliver. 2016. “Racial Bias in Pain assessment and treatment recommendations, and false beliefs about biological Differences Between Blacks and Whites.” PNAS 113 (16): 4296-4301. https://doi.org/10.1073/pnas.1516047113. [18] Pacheco, C. M., S. M. Daley, T. Brown, M. Filipp, K. A. Greiner, and C. M. Daley. 2013. “Moving Forward: Breaking the Cycle of Mistrust Between American Indians and Researchers.” American Journal of Public Health. 103 (12): 2152-9. https://doi.org/10.2105/AJPH.2013.301480. [19] Velasco-Mondragon, E., A. Jimenez, A. G. Palladino-Davis, D. Davis, and J. A. Escamilla-Cejudo. 2016. “Hispanic Health in the USA: A Scoping Review of the Literature.” Public Health Reviews 37:31. https://doi.org/10.1186/s40985-016-0043-2. [20] Cameron, K. A., J. Song, L. M. Manheim, and D. D. Dunlop. 2010. “Gender Disparities in Health and Healthcare Use Among Older Adults.” Journal of Women’s Health (Larchmt) 19 (9): 1643-50. https://doi.org/10.1089/jwh.2009.1701. [21] Bierman, A. S. 2007. “Sex Matters: Gender Disparities in Quality and Outcomes of Care. Canadian Medical Association Journal 177 (12): 1520-1. https://doi.org/10.1503/cmaj.071541; Fowler, R. A., S. Sabur, P. Li, et al. 2007. “Sex-and Age-based Differences in the Delivery and Outcomes of Critical Care. Canadian Medical Association Journal 177 (12): 1513-9. https://doi.org/10.1503/cmaj.071112. [22] McLaughlin, D. K., and C. S. Stokes. 2002. “Income Inequality and Mortality in US Counties: Does Minority Racial Concentration Matter?” American Journal of Public Health 92 (1): 99-104. https://doi.org/.10.2105/ajph.92.1.99; Shea, S., J. Lima, A. Diez-Roux, N. W. Jorgensen, and R. L. McClelland. 2016. “Socioeconomic Status and Poor Health Outcome at 10 years of Follow-up in the Multi-ethnic Study of Atherosclerosis.” PLoS One 11 (11): e0165651. https://doi.org/10.1371/journal.pone.0165651. [23] Han, X., K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon. 2015. “Reports of Insurance-based Discrimination in Health care and its Association with Access to Care.” American Journal of Public Health 105 Suppl 3 (Suppl 3): S517-25. https://doi.org/10.2105/AJPH.2015.302668. [24] Aldridge, R. W., D. Menezes, D. Lewer, et al. 2019. “Causes of Death Among Homeless People: A Population-based Cross-sectional Study of Linked Hospitalization and Mortality Data in England.” Wellcome Open Research 4:49. https://doi.org/10.12688/wellcomeopenres.15151.1. [25] Richardson, E. T., M. M. Malik, W. A. Darity Jr., et al. 2021. “Reparations for Black American Descendants of Persons Enslaved in the U.S. and their Potential Impact on SARS-CoV-2 Transmission.” Social Science and Medicine 276: 113741. https://doi.org/10.1016/j.socscimed.2021.113741. [26] Wispelwey, B., and M. Morse. 2021. “An Antiracist Agenda for Medicine.” Boston Review. http://bostonreview.net/science-nature-race/bram-wispelwey-michelle-morse-antiracist-agenda-medicine. [27] Johnson, S. F., A. Ojo, and H. J. Warraich. 2021. “Academic Health Centers’ Antiracism Strategies Must Extend to their Business Practices.” Annals of Internal Medicine 174 (2): 254-5. https://doi.org/10.7326/M20-6203; Golub, M., N. Calman, C. Ruddock, et al. 2011. “A Community Mobilizes to End Medical Apartheid.” Progress in Community Health Partnerships: Research, Education, and Action 5 (3): 317-25. https://doi.org/10.1353/cpr.2011.0041. [28] New York State Bar Association. 2020. “New York State Bar Association House of Delegates: Revised COVID-19 Resolutions.” https://nysba.org/app/uploads/2020/10/Final-Health-Law-Section-COVID-19-Resolutions_10-8-20-1-1.pdf. [29] Egede, L. E. 2006. “Race, Ethnicity, Culture, and Disparities in Health Care.” Journal of General Internal Medicine 21 (6): 667-669. https://doi.org/10.1111%2Fj.1525-1497.2006.0512.x

Background Morocco launched an appeal in 2002 with the view of developing a fundamental law on Basic Medical Coverage. Two systems have been put in place: Compulsory Health Insurance (AMO) based on the principles of solidarity and social security contributions; and a Medical Assistance Scheme based on the principle of social protection. The objective of these systems is to achieve Universal Health Coverage (UHC) to attain equity and equality in access to health care. In the international trend, access to economic and social rights has become a major concern in public policies. This concept based on the value of "equity" is now essential in the evaluation of equal opportunities in social systems and health systems. More importantly, there is a need to clarify the difference between the terms equality and equity in health. In most cases, reference is made to the definition used in Anglo-Saxon literature (equity, equality, fairness). Therefore, not all inequalities are inequities. The difference between equality and equity lies in the fact that the first term gives the result of a comparison without value judgment, while the second makes a judgment that qualifies the result as fair or unfair. The purpose of our study is to analyze the specific problems related to the healthcare policy focused on allocating the supply of care, and efforts to improve financial accessibility specifically by developing medical coverage. We will present results that reflect the availability and quality of care in Morocco and shed light on the problem of not seeking healthcare for financial, geographical, and other reasons. In addition, we will discuss the difficulties related to the use of care by Moroccan citizens. The findings of this paper can potentially inform national healthcare policy and add to the small but growing literature on this subject in Morocco. Methodology The methodology is based on research & data taken from official institutional publications from Morocco & United Nations organizations (gray literature), along with data derived from articles published in scientific journals. Results Morocco continues to suffer from disparities in the distribution of health practitioners due to an imbalanced distribution of health infrastructure and human resources between rural and urban areas. The Health Map developed by the Ministry of Health and Social Protection in 2016 is a very good tool to monitor the distribution of public health needs in each region, plan the delivery of care, regulate spending, and consolidate regionalization policy for ensuring equity in supply and access to health care. At the end of 2021, the national average ratios were 7.3 physicians and 10 beds per 10000 inhabitants. In 2018, more than 60% of the Moroccan population enjoyed basic medical coverage and the Moroccan Government is committed to reaching 100% of Universal Health Coverage (UHC) by 2030. Conclusion The health map will make it possible to control health expenditure, by allocating human and financial resources according to needs and will determine the future location of health facilities to establish equity in the offer and access to health care.

Photo by Evgeni Tcherkasski on Unsplash ABSTRACT Public health ethics has been contingent on a political landscape leading to several operational hurdles, especially during global health emergencies. Several scholars have pointed out that liberal decision-making has prevented public health institutions from achieving their goals. Thus, the need for a substantive outlook on public health has never been stronger. First, this article highlights the ethical tension and limitations of a presumptive approach to public health that a vaccination policy might produce in a liberal political landscape. Second, influenced by the works of Angus Dawson, this article emphasizes the importance of a substantive approach to public health, especially in a post-COVID era. Last, it looks at how TM Scanlon’s theory of contractualism aids in framing a substantive approach to health policy design and the added advantages of the theory. INTRODUCTION A public health intervention like a vaccination program for COVID-19, let alone a mandatory one, faces difficulties in implementation as it presents a clash between the role of the government and liberty of its citizens.[1] The clash stems from public health operating in a liberal political landscape that accords great regard for individual liberty. The government, in good conscience, is right in feeling morally obligated to act in ways that serve to prevent the pandemic from escalating. To represent the citizens, governments and policymakers prioritize achieving and maintaining herd immunity. The tension of the state versus individual liberty questions the extent to which governments can go to implement a vaccination policy. In trying to balance the considerations of individual liberty and the scope of the state to impose an intervention, the Nuffield Council on Bioethics came up with a design known as the ‘intervention ladder.’[2] The takeaway from the intervention ladder is that the state has the burden of proof in justifying reasons for implementing a particular policy.[3] Such justified trade-offs envisioned from the intervention ladder have guided policymakers in their attempt to design and shape interventions. However, public health ethics and even the intervention ladder view public health through a presumptive or a moderate liberal lens.[4] In a presumptive approach or a moderate-liberal approach to public health, policymakers regard values like liberty or autonomy as more prominent when weighed against values like creation of public goods and their maintenance.[5] A libertarian approach favors liberty and autonomy even more strongly. The substantive view of public health holds that values, such as liberty and autonomy, do not automatically hold precedence over community-oriented values such as public goods creation.[6] Some have critiqued the intervention ladder endorsed by the Nuffield Council of Bioethics. Angus Dawson remarks that the intervention ladder as a metaphor prevents the act of climbing. He claims the ladder assumes that liberty is the only guiding principle in policymaking. Such a view neglects any responsibility the citizens have in achieving public goods and maintaining them.[7] The emphasis on the drawbacks of a presumptive approach, especially in a situation like the COVID-19 pandemic, leads us to question should public health undergo a redefinition? The approach in public health focusing on non-interference stems from traditional clinical bioethics.[8] However, I argue that public health ethics in a pandemic should accord less emphasis to individual liberty and evaluate every ethical value on a level playing field. Individual liberty provides less platform for action in situations where the community has not established herd immunity. Accountability for the harm principle and maintenance of public goods override concerns surrounding liberty.[9] Angus Dawson argues that with more participation in a vaccination program, protection of public goods from disease can be created faster.[10] Characterizing public health as an antagonist to individual liberty undermines the confidence in public health institutions and interventions for which public trust is vital. Although the government may propose a mandatory vaccination policy when voluntary measures fail to meet public health requirements, clear scientific evidence and accountability for public welfare should be the guiding principle. Thus, resetting the parameters gauging a public health intervention is the starting point to prepare for future pandemics. In Resetting the Parameters, Angus Dawson suggests that utilitarianism or contractualism could serve as philosophical frameworks that may aid in framing a substantive approach to public health.[11] Evaluating utilitarianism and contractualism according to the COVID-19 facts would help clarify which is better suited to framing a substantive public health approach. l. Is Utilitarianism Substantive? Under utilitarianism, the morbid circumstances of the COVID-19 pandemic urge us to act in ways that translate to maximizing the overall good. Utilitarianism is a philosophical theory that prides itself on maximizing the best of outcomes for the maximum number of people. In an ideal utilitarian framework, a morally right act does good for all. Utilitarians consider utility the single determining variable that should guide actions.[12] The actionable aspect of a utilitarian framework is its ability to quantify thresholds or markers that mostly dwell in the abstract. In Utilitarianism and the Pandemic, Savulescu et al. outline certain determinants as aids in applying utilitarianism.[13] Looking at the aids in the context of a mandatory vaccination policy in light of COVID-19, shows some pitfalls of utilitarianism. The first utilitarian aid is to save the maximum number of lives.[14] Rightly so, an intuitive starting point in a pandemic with striking mortality rates is attempting to save the most lives. However, implementing and justifying a policy with the aim of saving the highest number of lives is complex. While a high number of deaths is a concern, it is reductionist to concentrate only on the end goal and not the means through which such a goal is attained. The second utilitarian aid is the length of life.[15] The length of benefit gained from an outcome is crucial for utilitarians. The duration of a benefit determines the quantity of good produced. As an extension, younger people should then, theoretically, count for more than older individuals in prioritizing benefits. Such prioritization has been a matter of concern during the COVID-19 pandemic. While it is true that younger people might tend to benefit more, the pathology of COVID-19 goes against such logic. Elderly populations have experienced disproportionately more severe cases. Therefore, prioritizing youth when the elderly are suffering more of the harm would be ethically contentious.[16] The third utilitarian aid is the quality-of-life post-intervention.[17] Through measures such as QALYs and DALYs,[18] utilitarians have attempted to quantify each individual's quality after an intervention. This quantification can result in connecting an individual’s quality of life to their social worth. From a utilitarian viewpoint, a person's ability to produce relevance in society becomes a key determinant in shaping public policy. By extension, people born with disabilities such as mental illness or late-stage dementia can be overlooked merely because they lack "social value.”[19] And yet, “taboo trade-offs occur when we are forced to put a finite monetary value on these sacred values [life, health, ability], when we acknowledge that there is a maximum ‘price’ that we want to pay to uphold values that should be of ‘infinite’ value.” [20]. As such, it is unethical to place a value on someone's life based on the duration or quality of life they may have after an intervention. Besides creating difficulty in assessing the quality of life, measures such as QALYs do not address the nuances in providing healthcare. In Economic Evaluation of Mental Health Interventions, Luyten et al. discuss several operational changes that account for these nuances.[21] Utilitarians believe in a moral indifference between actions and omissions as the fourth aid.[22] It does not matter how a result is achieved as long as it benefits the common good. Putting forward a bad policy is the same as not putting forward a policy. In the ever-changing and unpredictable dynamics of the COVID-19 pandemic, actions and omissions have different moral implications. Equating them often places an unfair burden on lawmakers, leaving them emotionally and morally exhausted as they weigh the advantages and risks of various outcomes. Actively avoiding social biases, feelings, intuitions, and heuristics is the fifth aid.[23] The pandemic elicits strong feelings and aggressively tests beliefs. During the pandemic, some profoundly troubling ethical dilemmas stemmed from bias. In a utilitarian system, a mandatory vaccination policy aimed at crossing the threshold for herd immunity may overlook groups of people who are vulnerable due to a lack of access to the social determinants of health. Attempting to avoid feelings and intuitions all the time does not always result in the creation of a fair policy. Anti-vaccination activists use emotion to further their cause, hence it is critical that politicians consider the feelings at stake for the general public when enacting a mandatory vaccination policy. While utilitarianism has benefits such as developing simple operationalizable concepts, providing a quantitative check, and a balance sheet of risks and benefits, it is based on an ethical dystopia. Utilitarian policies can treat people as a means to an end by focusing solely on outcomes. Utilitarianism rests on a presumptive outlook toward public health by replacing liberty with utility. It ignores fair and just distribution and allocation of resources. Utilitarianism is not the most ethical approach to pandemic vaccination policy. ll. Is Contractualism Substantive? The libertarian and utilitarian frameworks assume positive and negative connotations to different actions. They hold that certain acts are right and certain acts are wrong. A libertarian might hold that unnecessary infringement of individual liberty is not acceptable, while a utilitarian might be of the opinion that actions that contribute to disutility are unfavorable for the promotion of the greatest happiness principle.[24] Contractualism is a philosophy that values the social contract. A contractualist approach begins its discourse by arguing that actions have inherent neutrality.[25] By saying that, “being valuable is not always a matter of being ‘to be promoted’”[26], Scanlon does not neglect the value of certain actions but urges us to respond to value through other means, as well as to find value in plurality. In What We Owe to Each Other, Scanlon finds morality through the ability to reason while attributing inherent neutrality to our actions. A discourse in contractualism does not begin by presuming that values such as liberty or autonomy hold precedence among other ethical values, i.e., it is not presumptive in its approach. Instead, he locates morality in the ability to reason and find justifications for certain actions. Thus, compared to utilitarianism, contractualism allows for a substantive approach by holding all the relevant ethical values in a level playing field. Liberty would gain precedence when justifications for safeguarding it are strong and cannot be reasonably rejected. The same goes for other values, such as promoting public goods. In short, an action is termed wrong when “the principle that allows for it, can be reasonably rejected.”[27] For Scanlon, justifiability to others is the normative determinant of right or wrong.[28] He proceeds to say that the value of justifiability is the underlying premise of our duties. Additionally, Verweij argues that treating people rationally occurs by treating them in “ways they cannot reasonably reject.”[29] By disregarding any a priori assumptions about the importance of different values, people can find and construct values that cannot be reasonably rejected as they would be justified. Scanlon believes that this can be attained if we reflect on what we owe to each other. lll. The Inherent Moral Neutrality Allows for a Substantive Approach A contractualist approach has implications for framing a substantive approach to public health. These values have been adapted from Scanlon and Verweij, and the elaboration has been framed in the context of COVID-19. The inherent neutrality of principles that contractualism holds becomes crucial while devising a public health intervention. The COVID-19 pandemic presents a situation where otherwise acceptable ethical principles require scrutiny. A blank state where there are no a priori principles that suggest which acts are morally justified and which are not helps us navigate the operational principles involved in a vaccination policy. Thus, values such as liberty, utility, and autonomy are viewed on the same level as the creation of public goods, fairness in contribution, and avoiding collective harm. a. Arriving at Principles Starting with the inherent neutrality, the state, policymakers, and the public can identify ethical principles that would form a part of the vaccination policy smorgasbord. In a public health framework where negotiation is a crucial aspect in its implementation, it is important that all the stakeholders aim to find principles that are acceptable for everyone. This would culminate with principles of action that would produce the least number of complaints by all the parties involved. If an individual has very strong reservations against a principle, these cannot be outweighed by weaker reservations held by others.[30] b. Reasonable Rejection as a Marker of Deliberation A mandatory vaccination policy in a contractualist framework would then have to incorporate reasonable rejection. A framework based on reasonable rejection includes a variety of moral considerations that shape well-being and provide a basis for fairness, choice, and responsibility. Scanlon makes an important remark in the thesis of What We Owe to Each Other: the acceptability of a principle depends on a one-by-one assessment of the strength of individuals' reasons for rejecting the principles compared to any existing alternatives. In other words, for Scanlon, what is foundational for contractualism is not minimizing what is undesirable but constructing principles no one can reasonably reject. In the context of COVID-19, a person should be able to justify the level of precaution he takes to anyone who would bear the risk of exposure. Each individual would then have strong reasons for contributing to herd immunity with regard to their duty to protect the vulnerable. The justification to forego vaccination would need to be strong.[31] The difference in a contractualist approach is that it provides a platform for valid concerns from the public. This allows more room for dialogue and for individual liberty, which seems to form a significant part of the critique. A plan of action that allows for individual concerns such as safety, efficacy, and strong medical reasons to forego vaccination encourages inclusivity in policymaking. Another public concern is that public health institutions have alienated themselves from society in general.[32]A dialogue between the stakeholders would remedy such a notion and help redefine public health according to how Dawson and Verweij view “public”– as a social entity/target as well as a mode of intervention (requiring collective action).[33] Contractualism, like the rest of the ethical frameworks, has its own set of critiques. In Obligatory Precautions Against Infection, Marcel Verweij argues that a contractualist theory inadvertently ends up asking for excessive precautions. The first claim that contractualism asks for excessive precautions arises from the fact that a contractualist approach does not consider the consequences of individual actions.[34] He believes that since consequences are not weighted, one individual’s wish to forego precautionary measures does not justify another’s non-compliance towards precaution, culminating in the other having to take excessive precautions. He also criticizes the contractualist deliberation for its failure to focus on the consequences of individual acts but on creating universalizable principles.[35] While this may seem true, such a conclusion rests on the fact that the consequences of individual acts are not weighted. However, an excerpt from Verweij’s paper offers evidence that contractualism does weigh individual acts: Suppose that we both aim to find moral principles that regulate our interaction and that can be accepted by both of us. If you then propose a principle that imposes many risks on me but none for you, then it would be reasonable if I were to reject it (especially if there are alternative principles that would yield much lower risks).[36] Both a consequentialist approach and a contractualist approach share the language of risks and burdens. For the utilitarian, risks and burdens are consequences of an action, whereas, for the contractualist, they are consequences of accepting or rejecting a principle. In the excerpt above, when an individual assesses the risks imposed, a consequentialist way of thinking is incorporated in contractualism and consequences to individuals do matter and are weighed. Verweij’s contention that a contractualist approach does not focus on individual consequences is not supported, and, as a logical extension, the argument of excessive precautions begins to fade. Being vaccinated would absolve us of having to take excessive precautions. Upon crossing the threshold of herd immunity, excessive precautions such as masks, social distancing, rigorous testing pre- as well as post-travel, and obsessively checking our phones for exposure can be done away with. The COVID-19 pandemic has immersed us in routines of excessive precautionary measures that it has become normalized for most of us. Thus, being vaccinated and covering society with a blanket of herd immunity removes the need for excessive precautions. lV. Bridging What “Is” and What “Ought” To Be Although contractualism presents a perspective that best suits a substantive approach to public health, it appears desirable only in theory. There exists a distinct reality outside of academia – politics, societal engagement, and governance reflect a different picture. This can be thought of as the gap between the is and the ought. We could envision and claim that a mandatory vaccination policy ought to be implemented in a certain manner, however, it might not be. In her paper, Realizing Bioethics’ Goals in Practice: Ten Ways “Is” Can Help “Ought,” Mildred Z. Solomon provides several reasons for this disconnect.[37] The general theme is the importance of empirical research – the need to find a balance between normative assumptions and empirical evidence – and how policymakers can, in turn, use such evidence to fine-tune the policy design process. Contractualism can prove especially useful to bridge the divide between is and ought. Theories of libertarian philosophy and utilitarianism rest on a design based on a normative approach that values liberty and utility and should guide the policymaking process. However, contractualism separates itself from these theories since constructing principles justifiable for all, and the idea of reasonable rejection must rely on empirical evidence. Engagement between various stakeholders and recognizing the plurality in values helps bridge the disconnect between the is and the ought. This is more important in the context of a mandatory vaccination policy since its requirement arises only if voluntary vaccination policies fail. Knowing why vaccination rates are low and how better to reach herd immunity will be important empirical evidence that can fine-tune the policy. In Re-enchanting Democracy as a Mode of Governance, Patsy Healey acknowledges that a struggle for political change often focuses on installing new policy designs.[38] Healey provides a list of qualities to keep in mind when designing a more people-centered policy initiative. The first quality is recognizing a shared, diverse, and conflictual political community where distributive justice is vital. The second is to foster is respect for different arguments, positions, and feelings— considering groups with conflicting values as adversaries but not enemies. The third quality is that of an ‘intelligent’ and multi-sided discussion of issues and reasoning ‘in public.’ The fourth is the fostering of respect for the role of the government while simultaneously recognizing the complexities of interactions. The fifth, and a key value in the context of the COVID-19 pandemic, is fostering respect for people who perform public services. Liberalism and utilitarianism create combative ethical discourse around those qualities, while contractualism could elevate shared public values. While liberal democracies arguably have the makings of those qualities, public engagement must be fostered at an intellectual level to promote cohesion. Another important aspect to consider is the question of what a framework should aim to answer. In Building an Ethical Framework for COVID-19 Resource Allocation: The How and Why, Angus Dawson addresses the goal of a framework, especially at the time of a pandemic.[39] He stresses the importance of context in constructing a framework and urges to engage with a diverse group of people. Value-laden normative approaches such as the libertarian and utilitarian frameworks provide less opportunity for different stakeholder claims. Dawson then argues that explicit discussions provide more clarity and help policy makers better understand the role of context in shaping a framework. Dawson asserts that a frame chosen sympathetically can help the public better appreciate the moral content involved in deliberation, whereas aiming for goals such as liberty and utility is a distraction from the workings of reality. In evaluating stakeholders, those with lower incomes often are unable to work remotely. They face a greater risk of COVID-19 due to workplace exposure as well as commutes and living conditions.[40] Although a mandatory vaccination policy has the clearly defined goal of achieving herd immunity, ensuring distributive and procedural justice should not be viewed as being mutually exclusive. CONCLUSION Societal change relies on justifiable goals, policies, and a multitude of viewpoints. As such, a contractualist approach best accommodates a multitude of views of what we owe each other. Moving forward, if pandemic-type circumstances do disseminate within the constructs of our society, public policy should further consider contractualist approaches as a healthy, inclusive means. - [1] Luyten, Jeroen. "Mutual Moral Obligations in the Prevention of Infectious Diseases." In Justice, Luck & Responsibility in Health Care, pp. 85-100. Springer, Dordrecht, 2013. [2] Council, Nuffield Bioethics. "Public Health: Ethical Issues." Nuffield Council on Bioethics (2007) [3] Dawson, Angus J. "Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy." Journal of Medical Ethics 42, no. 8 (2016): 510-513. [4] Dawson, Angus, ed. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press, 2011. [5] Dawson, Angus. "Resetting the Parameters." Public Health Ethics (2011): 1-19. [6] Dawson, Angus, ed. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press, 2011. [7] Dawson, Angus J. "Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy." Journal Of Medical Ethics 42, no. 8 (2016): 510-513. [8] Dawson, Angus, ed. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press, 2011. [9] Savulescu, Julian. "Good Reasons to Vaccinate: Mandatory or Payment for Risk?." Journal of Medical Ethics 47, no. 2 (2021): 78-85. [10] Dawson, Angus, ed. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press, 2011. [11] Dawson, Angus. "Resetting the Parameters." Public Health Ethics (2011): 1-19. [12] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [13] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [14] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [15] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [16] Luyten, Jeroen, and Yvonne Denier. "Explicit Cost-Effectiveness Thresholds in Health Care: A Kaleidoscope." Social Justice Research 32, no. 2 (2019): 155-171. [17] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [18] Luyten, Jeroen, Huseyin Naci, and Martin Knapp. "Economic Evaluation of Mental Health Interventions: An Introduction to Cost-Utility Analysis." Evidence-Based Mental Health 19, no. 2 (2016): 49-53. [19] Luyten, Jeroen, and Yvonne Denier. "Explicit Cost-Effectiveness Thresholds in Health Care: A Kaleidoscope." Social Justice Research 32, no. 2 (2019): 155-171. [20] (Luyten and Denier, 2019, p.10) [21] Luyten, Jeroen, Huseyin Naci, and Martin Knapp. "Economic Evaluation of Mental Health Interventions: An Introduction to Cost-Utility Analysis." Evidence-Based Mental Health 19, no. 2 (2016): 49-53. [22] Savulescu, Julian, Ingmar Persson, and Dominic Wilkinson. "Utilitarianism and the Pandemic." Bioethics 34, no. 6 (2020): 620-632. [23] Savulescu, et al. [24] Mill, John Stuart. "Utilitarianism, ed. George Sher." (2001). [25] Scanlon, Thomas M. "Précis of" What We Owe to Each Other"." (2003): 159-161. [26] Scanlon 2003 p.159) [27] Verweij, Marcel. "Obligatory precautions against infection." Bioethics 19, no. 4 (2005): 323-335. [28] Scanlon, Thomas M. "Précis of" What We Owe to Each Other"." (2003): 159-161. [29] Verweij, Marcel. "Obligatory precautions against infection." Bioethics 19, no. 4 (2005): 323-335. [30] Verweij, Marcel. "Obligatory precautions against infection." Bioethics 19, no. 4 (2005): 323-335. [31] Verweij, Marcel. "Obligatory precautions against infection." Bioethics 19, no. 4 (2005): 323-335. [32] Financial Times, 2021, “Covid is the Enemy, Not the Government” Sunil Jain April 26 Accessed 14 May 2021 https://www.financialexpress.com/opinion/covid-is-the-enemy-not-the-government/2240340/ [33] Dawson, Angus, ed. Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge University Press, 2011. [34] Verweij, Marcel. "Obligatory Precautions Against Infection." Bioethics 19, no. 4 (2005): 323-335. [35] Verweij, Marcel. "Obligatory Precautions Against Infection." Bioethics 19, no. 4 (2005): 323-335. [36] Verweij, Marcel. "Obligatory Precautions Against Infection." Bioethics 19, no. 4 (2005): 323-335. [37] Solomon, Mildred Z. "Realizing Bioethics' Goals in Practice: Ten Ways “Is” Can Help “Ought”." Hastings Center Report 35, no. 4 (2005): 40-47. [38] Healey, Patsy. "Re-enchanting Democracy as a Mode of Governance." In Connections, pp. 61-78. Routledge, 2017. [39] Dawson, Angus. "Building an Ethics Framework for COVID-19 Resource Allocation: The How and the Why." Journal of Bioethical Inquiry 17, no. 4 (2020): 757-760. [40] Schmidt, Harald, Lawrence O. Gostin, and Michelle A. Williams. "Is it Lawful and Ethical to Prioritize Racial Minorities for COVID-19 Vaccines?." Jama 324, no. 20 (2020): 2023-2024.

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33.

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33.

Introduction Greater resilience is associated with the ability to self-organise, and with social learning as part of a process of adaptation and transformation (Goldstein 341). This article deals with responses to a crisis in a Norwegian community in the late 1880s, and with some of the many internal conflicts it caused. The crisis and the subsequent conflicts in this particular community, Volda, were caused by a number of processes, driven mostly by external forces and closely linked to the expansion of the capitalist mode of production in rural Norway. But the crisis also reflects a growing nationalism in Norway. In the late 1880s, all these causes seemed to come together in Volda, a small community consisting mostly of independent small farmers and of fishers. The article employs the concept of ‘resilience’ and the theory of resilience in order better to understand how individuals and the community reacted to crisis and conflict in Volda in late 1880, experiences which will cast light on the history of the late 1880s in Volda, and on individuals and communities elsewhere which have also experienced such crises. Theoretical Perspectives Some understandings of social resilience inspired by systems theory and ecology focus on a society’s ability to maintain existing structures. Reducing conflict to promote greater collaboration and resilience, however, may become a reactionary strategy, perpetuating inequalities (Arthur, Friend and Marschke). Instead, the understanding of resilience could be enriched by drawing on ecological perspectives that see conflict as an integral aspect of a diverse ecology in continuous development. In the same vein, Grove has argued that some approaches to anticipatory politics fashion subjects to withstand ‘shocks and responding to adversity through modern institutions such as human rights and the social contract, rather than mobilising against the sources of insecurity’. As an alternative, radical politics of resilience ought to explore political alternatives to the existing order of things. Methodology According to Hall and Lamont, understanding “how individuals, communities, and societies secured their well-being” in the face of the challenges imposed by neoliberalism is a “problem of understanding the bases for social resilience”. This article takes a similarly broad approach to understanding resilience, focusing on a small group of people within a relatively small community to understand how they attempted to secure their well-being in the face of the challenges posed by capitalism and growing nationalism. The main interest, however, is not resilience understood as something that exists or is being produced within this small group, but, rather, how this group produced social imaginaries of the past and the future in cooperation and conflict with other groups in the same community. The research proceeds to analyse the contributions mainly of six members of this small group. It draws on existing literature on the history of the community in the late 1800s and, in particular, biographies of Synnøve Riste (Øyehaug) and Rasmus Steinsvik (Gausemel). In addition, the research builds on original empirical research of approximately 500 articles written by the members of the group in the period from 1887 to 1895 and published in the newspapers Vestmannen, Fedraheimen and 17de Mai; and will try to re-tell a history of key events, referring to a selection of these articles. A Story about Being a Woman in Volda in the Late 1880s This history begins with a letter from Synnøve Riste, a young peasant woman and daughter of a local member of parliament, to Anders Hovden, a friend and theology student. In the letter, Synnøve Riste told her friend about something she just had experienced and had found disturbing (more details in Øyehaug). She first sets her story in the context of an evangelical awakening that was gaining momentum in the community. There was one preacher in particular who seemed to have become very popular among the young women. He had few problems when it comes to women, she wrote, ironically. Curious about the whole thing, Synnøve decided to attend a meeting to see for herself what was going on. The preacher noticed her among the group of young women. He turned his attention towards her and scolded her for her apparent lack of religious fervour. In the letter she explained the feeling of shame that came over her when the preacher singled her out for public criticism. But the feeling of shame soon gave way to anger, she wrote, before adding that the worst part of it was ‘not being able to speak back’; as a woman at a religious meeting she had to hold her tongue. Synnøve Riste was worried about the consequences of the religious awakening. She asked her friend to do something. Could he perhaps write a poem for the weekly newspaper the group had begun to publish only a few months earlier? Anders Hovden duly complied. The poem was published, anonymously, on Wednesday 17 March 1888. Previously, the poem says, women enjoyed the freedom to roam the mountains and valleys. Now, however, a dark mood had come over the young women. ‘Use your mind! Let the madness end! Throw off the blood sucker! And let the world see that you are a woman!’ The puritans appreciated neither the poem nor the newspaper. The newspaper was published by the same group of young men and women who had already organised a private language school for those who wanted to learn to read and write New Norwegian, a ‘new’ language based on the old dialects stemming from the time before Norway lost its independence and became a part of Denmark and then, after 1814, Sweden. At the language school the students read and discussed translations of Karl Marx and the anarchist Peter Kropotkin. The newspaper quickly grew radical. It reported on the riots following the hanging of the Haymarket Anarchists in Chicago in 1886. It advocated women’s suffrage, agitated against capitalism, argued that peasants and small farmers must learn solidarity from the industrial workers defended a young woman in Oslo who was convicted of killing her newborn baby and published articles from international socialist and anarchist newspapers and magazines. Social Causes for Individual Resilience and Collaborative Resilience Recent literature on developmental psychology link resilience to ‘the availability of close attachments or a supportive and disciplined environment’ (Hall and Lamont 13). Some psychologists have studied how individuals feel empowered or constrained by their environment. Synnøve Riste clearly felt constrained by developments in her social world, but was also resourceful enough to find ways to resist and engage in transformational social action on many levels. According to contemporary testimonies, Synnøve Riste must have been an extraordinary woman (Steinsvik "Synnøve Riste"). She was born Synnøve Aarflot, but later married Per Riste and took his family name. The Aarflot family was relatively well-off and locally influential, although the farms were quite small by European standards. Both her father and her uncle served as members of parliament for the (‘left’) Liberal Party. From a young age she took responsibility for her younger siblings and for the family farm, as her father spent much time in the capital. Her grandfather had been granted the privilege of printing books and newspapers, which meant that she grew up with easy access to current news and debates. She married a man of her own choosing; a man substantially older than herself, but with a reputation for liberal ideas on language, education and social issues. Psychological approaches to resilience consider the influence of cognitive ability, self-perception and emotional regulation, in addition to social networks and community support, as important sources of resilience (Lamont, Welburn and Fleming). Synnøve Riste’s friend and lover, Rasmus Steinsvik, later described her as ‘a mainspring’ of social activity. She did not only rely on family, social networks and community support to resist stigmatisation from the puritans, but she was herself a driving force behind social activities that produced new knowledge and generated communities of support for others. Lamont, Welburn and Fleming underline the importance for social resilience of cultural repertoires and the availability of ‘alternative ways of understanding social reality’ (Lamont, Welburn and Fleming). Many of the social activities Synnøve Riste instigated served as arenas for debate and collaborative activity to develop alternative understandings of the social reality of the community. In 1887, Synnøve Riste had relied on support from her extended family to found the newspaper Vestmannen, but as the group around the language school and newspaper gradually produced more radical alternative understandings of the social reality they came increasingly into conflict with less radical members of the Liberal Party. Her uncle owned the printing press where Vestmannen was printed. He was also a member of parliament seeking re-election. And he was certainly not amused when Rasmus Steinsvik, editor of Vestmannen, published an article reprimanding him for his lacklustre performance in general and his unprincipled voting in support of a budget allocating the Swedish king a substantial amount of money. Steinsvik advised the readers to vote instead for Per Riste, Synnøve Riste’s liberal husband and director of the language school. The uncle stopped printing the newspaper. Social Resilience in Volda The growing social conflicts in Volda might be taken to indicate a lack of resilience. This, however, would be a mistake. Social connectedness is an important source of social resilience (Barnes and Hall 226). Strong ties to family and friends matter, as does membership in associations. Dense networks of social connectedness are related to well-being and social resilience. Inversely, high levels of inequality seem to be linked to low levels of resilience. Participation in democratic processes has also been found to be an important source of resilience (Barnes and Hall 229). Volda was a small community with relatively low levels of inequality and local cultural traditions underlining the importance of cooperation and the obligations of everyone to participate in various forms of communal work. Similarly, even though a couple of families dominated local politics, there was no significant socioeconomic division between the average and the more prosperous farmers. Traditionally, women on the small, independent farms participated actively in most aspects of social life. Volda would thus score high on most indicators predicting social resilience. Reading the local newspapers confirms this impression of high levels of social resilience. In fact, this small community of only a few hundred families produced two competing newspapers at the time. Vestmannen dedicated ample space to issues related to education and schools, including adult education, reflecting the fact that Volda was emerging as a local educational centre; local youths attending schools outside the community regularly wrote articles in the newspaper to share the new knowledge they had attained with other members of the community. The topics were in large part related to farming, earth sciences, meteorology and fisheries. Vestmannen also reported on other local associations and activities. The local newspapers reported on numerous political meetings and public debates. The Liberal Party was traditionally the strongest political party in Volda and pushed for greater independence from Sweden, but was divided between moderates and radicals. The radicals joined workers and socialists in demanding universal suffrage, including, as we have seen, women’s right to vote. The left libertarians in Volda organised a ‘radical left’ faction of the Liberal Party and in the run-up to the elections in 1888 numerous rallies were arranged. In some parts of the municipality the youth set up independent and often quite radical youth organisations, while others established a ‘book discussion’. The language issue developed into a particularly powerful source for social resilience. All members of the community shared the experience of having to write and speak a foreign language when communicating with authorities or during higher education. It was a shared experience of discrimination that contributed to producing a common identity. Hing has shown that those who value their in-group ‘can draw on this positive identity to provide a sense of self-worth that offers resilience’. The struggle for recognition stimulated locals to arrange independent activities, and it was in fact through the burgeoning movement for a New Norwegian language that the local radicals in Volda first encountered radical literature that helped them reframe the problems and issues of their social world. In his biography of Ivar Mortensson Egnund, editor of the newspaper Fedraheimen and a lifelong collaborator of Rasmus Steinsvik, Klaus Langen has argued that Mortensson Egnund saw the ideal type of community imagined by the anarchist Leo Tolstoy in the small Norwegian communities of independent small farmers, a potential model for cooperation, participation and freedom. It was not an uncritical perspective, however. The left libertarians were constantly involved in clashes with what they saw as repressive forces within the communities. It is probably more correct to say that they believed that the potential existed, within these communities, for freedom to flourish. Most importantly, however, reading Fedraheimen, and particularly the journalist, editor and novelist Arne Garborg, infused this group of local radicals with anti-capitalist perspectives to be used to make sense of the processes of change that affected the community. One of Garborg’s biographers, claims that no Norwegian has ever been more fundamentally anti-capitalist than Garborg (Thesen). This anti-capitalism helped the radicals in Volda to understand the local conflicts and the evangelical awakening as symptoms of a deeper and more fundamental development driven by capitalism. A series of article in Vestmannen called for solidarity and unity between small farmers and the growing urban class of industrial workers. Science and Modernity The left libertarians put their hope in science and modernity to improve the lives of people. They believed that education was the key to move forward and get rid of the old and bad ways of doing things. The newspaper was reporting the latest advances in natural sciences and life sciences. It reported enthusiastically about the marvels of electricity, and speculated about a future in which Norway could exploit the waterfalls to generate it on a large scale. Vestmannen printed articles in defence of Darwinism (Egnund), new insights from astronomy (Steinsvik "Kva Den Nye Astronomien"), health sciences, agronomy, new methods of fishing and farming – and much more. This was a time when such matters mattered. Reports on new advances in meteorology in the newspaper appeared next to harrowing reports about the devastating effects of a storm that surprised local fishermen at sea where many men regularly paid with their lives. Hunger was still a constant threat in the harsh winter months, so new knowledge that could improve the harvest was most welcome. Leprosy and other diseases continued to be serious problems in this region of Norway. Health could not be taken lightly, and the left libertarians believed that science and knowledge was the only way forward. ‘Knowledge is a sweet fruit,’ Vestmannen wrote. Reporting on Darwinism and astronomy again pitted Vestmannen against the puritans. On several occasions the newspaper reported on confrontations between those who promoted science and those who defended a fundamentalist view of the Bible. In November 1888 the signature ‘-t’ published an article on a meeting that had taken place a few days earlier in a small village not far from Volda (Unknown). The article described how local teachers and other participants were scolded for holding liberal views on science and religion. Anyone who expressed the view that the Bible should not be interpreted literally risked being stigmatised and ostracised. It is tempting to label the group of left libertarians ‘positivists’ or ‘modernists’, but that would be unfair. Arne Garborg, the group’s most important source of inspiration, was indeed inspired by Émile Zola and the French naturalists. Garborg had argued that nothing less than the uncompromising search for truth was acceptable. Nevertheless, he did not believe in objectivity; Garborg and his followers agreed that it was not possible or even desirable to be anything else than subjective. Adaptation or Transformation? PM Giærder, a friend of Rasmus Steinsvik’s, built a new printing press with the help of local blacksmiths, so the newspaper could keep afloat for a few more months. Finally, however, in 1888, the editor and the printer took the printing press with them and moved to Tynset, another small community to the east. There they joined forces with another dwindling left libertarian publication, Fedraheimen. Generations later, more details emerged about the hurried exit from Volda. Synnøve Riste had become pregnant, but not by her husband Per. She was pregnant by Rasmus Steinsvik, the editor of Vestmannen and co-founder of the language school. And then, after giving birth to a baby daughter she fell ill and died. The former friends Per and Rasmus were now enemies and the group of left libertarians in Volda fell apart. It would be too easy to conclude that the left libertarians failed to transform the community and a closer look would reveal a more nuanced picture. Key members of the radical group went on to play important roles on the local and national political scene. Locally, the remaining members of the group formed new alliances with former opponents to continue the language struggle. The local church gradually began to sympathise with those who agitated for a new language based on the Norwegian dialects. The radical faction of the Liberal Party grew in importance as the conflict with Sweden over the hated union intensified. The anarchists Garborg and Steinsvik became successful editors of a radical national newspaper, 17de Mai, while two other members of the small group of radicals went on to become mayors of Volda. One was later elected member of parliament for the Liberal Party. Many of the more radical anarchist and communist ideas failed to make an impact on society. However, on issues such as women’s rights, voting and science, the left libertarians left a lasting impression on the community. It is fair to say that they contributed to transforming their society in many and lasting ways. Conclusion This study of crisis and conflict in Volda indicate that conflict can play an important role in social learning and collective creativity in resilient communities. There is a tendency, in parts of resilience literature, to view resilient communities as harmonious wholes without rifts or clashes of interests (see for instance Goldstein; Arthur, Friend and Marschke). Instead, conflicts should rather be understood as a natural aspect of any society adapting and transforming itself to respond to crisis. Future research on social resilience could benefit from an ecological understanding of nature that accepts polarisation and conflict as a natural part of ecology and which helps us to reach deeper understandings of the social world, also fostering learning, creativity and the production of alternative political solutions. This research has indicated the importance of social imaginaries of the past. Collective memories of ‘what everybody knows that everybody else knows’ about ‘what has worked in the past’ form the basis for producing ideas about how to create collective action (Swidler 338, 39). Historical institutions are pivotal in producing schemas which are default options for collective action. In Volda, the left libertarians imagined a potential for freedom in the past of the community; this formed the basis for producing an alternative social imaginary of the future of the community. The social imaginary was not, however, based only on local experience and collective memory of the past. Theories played an important role in the process of trying to understand the past and the present in order to imagine future alternatives. The conflicts themselves stimulated the radicals to search more widely and probe more deeply for alternative explanations to the problems they experienced. This search led them to new insights which were sometimes adopted by the local community and, in some cases, helped to transform social life in the long-run. References Arthur, Robert, Richard Friend, and Melissa Marschke. "Fostering Collaborative Resilience through Adaptive Comanagement: Reconciling Theory and Practice in the Management of Fisheries in the Mekong Region." Collaborative Resilience: Moving through Crisis to Opportunity. Ed. Bruce Evan Goldstein. Cambridge, Mass., and London: MIT Press, 2012. 255-282. Barnes, Lucy, and Peter A. Hall. "Neoliberalism and Social Resilience in the Developed Democracies." Social Resilience in the Neoliberal Era. Eds. Peter A. Hall and Michèle Lamont. New York: Cambridge University Press, 2013. 209-238. Egnund, Ivar Mortensson. "Motsetningar." Vestmannen 13.6 (1889): 3. Gausemel, Steffen. Rasmus Steinsvik. Oslo: Noregs boklag, 1937. Goldstein, Bruce Evan. "Collaborating for Transformative Resilience." Collaborative Resilience: Moving through Crisis to Opportunity. Ed. Bruce Evan Goldstein. Cambridge, Mass., and London: MIT Press, 2012. 339-358. Hall, Peter A., and Michèle Lamont. "Introduction." Social Resilience in the Neoliberal Era. Eds. Peter A. Hall and Michèle Lamont. New York: Cambridge University Press, 2013. Lamont, Michèle, Jessica S Welburn, and Crystal M Fleming. "Responses to Discrimination and Social Resilience under Neoliberalism: The United States Compared." Social Resilience in the Neoliberal Era. Eds. Peter A. Hall and Michèle Lamont. New York: Cambridge University Press, 2013. 129-57. Steinsvik, Rasmus. "Kva Den Nye Astronomien Kan Lære Oss." Vestmannen 8.2 (1889): 1. ———. "Synnøve Riste." Obituary. Vestmannen 9.11 (1889): 1. Swidler, Ann. "Cultural Sources of Institutional Resilience: Lessons from Chieftaincy in Rural Malawi." Social Resilience in the Neoliberal Era. Eds. Peter A. Hall and Michèle Lamont. New York: Cambridge University Press, 2013.

Women in federal politics are under-represented today and always have been. At no time in the history of the federal parliament have women achieved equal representation with men. There have never been an equal number of women in any federal cabinet. Women have never held an equitable number of executive positions of the Australian Labor Party (ALP) or the Liberal Party. Australia has had only one female Prime Minister, Julia Gillard, and she was the recipient of sexist treatment in the parliament and the media. A 2019 report by Plan International found that girls and women, were “reluctant to pursue a career in politics, saying they worry about being treated unfairly.” The Report author said the results were unsurprisingwhen you consider how female politicians are still treated in Parliament and the media in this country, is it any wonder the next generation has no desire to expose themselves to this world? Unfortunately, in Australia, girls grow up seeing strong, smart, capable female politicians constantly reduced to what they’re wearing, comments about their sexuality and snipes about their gender.What voters may not always see is how women in politics respond to sexist treatment, or to bullying, or having to vote against their principles because of party rules, or to having no support to lead the party. Rather than being political victims and quitting, there is a ground-swell of women who are fighting back. The rage they feel at being excluded, bullied, harassed, name-called, and denied leadership opportunities is being channelled into rage against the structures that deny them equality. The rage they feel is building resilience and it is building networks of women across the political divide. This article highlights some female MPs who are “maintaining the rage”. It suggests that the rage that is evident in their public responses is empowering them to stand strong in the face of adversity, in solidarity with other female MPs, building their resilience, and strengthening calls for social change and political equality.Her-story of Women’s MovementsThroughout the twentieth century, women stood for equal rights and personal empowerment driven by rage against their disenfranchisement. Significant periods include the early 1900s, with suffragettes gaining the vote for women. The interwar period of 1919 to 1938 saw women campaign for financial independence from their husbands (Andrew). Australian women were active citizens in a range of campaigns for improved social, economic and political outcomes for women and their children.Early contributions made by women to Australian society were challenges to the regulations and of female sexuality and reproduction. Early twentieth century feminist organisations such The Women’s Peace Army, United Association of Women, the Australian Federation of Women’s Societies for Equal Citizenship, the Union of Australian Women, the National Council of Women, and the Australian Federation of Women Voters, proved the early forerunners to the 1970s Women’s Liberation Movement (WLM). It was in many of these early campaigns that the rage expressed in the concept of the “personal is political” (Hanisch) became entrenched in Australian feminist approaches to progressive social change. The idea of the “personal is political” encapsulated that it was necessary to challenge and change power relations, achievable when women fully participated in politics (van Acker 25). Attempts by women during the 1970s to voice concerns about issues of inequality, including sexuality, the right to abortion, availability of childcare, and sharing of household duties, were “deemed a personal problem” and not for public discussion (Hanisch). One core function of the WLM was to “advance women’s positions” via government legislation or, as van Acker (120) puts it, the need for “feminist intervention in the state.” However, in advocating for policy reform, the WLM had no coherent or organised strategy to ensure legislative change. The establishment of the Women’s Electoral Lobby (WEL), together with the Femocrat strategy, sought to rectify this. Formed in 1972, WEL was tasked with translating WLM concerns into government policy.The initial WEL campaign took issues of concern to WLM to the incoming Whitlam government (1972-1975). Lyndall Ryan (73) notes: women’s liberationists were the “stormtroopers” and WEL the “pragmatic face of feminism.” In 1973 Whitlam appointed Elizabeth Reid, a member of WLM, as Australia’s first Women’s Advisor. Of her appointment, Reid (3) said, “For the first time in our history we were being offered the opportunity to attempt to implement what for years we had been writing, yelling, marching and working towards. Not to respond would have felt as if our bluff had been called.” They had the opportunity in the Whitlam government to legislatively and fiscally address the rage that drove generations of women to yell and march.Following Reid were the appointments of Sara Dowse and Lyndall Ryan, continuing the Femocrat strategy of ensuring women were appointed to executive bureaucratic roles within the Whitlam government. The positions were not well received by the mainly male-dominated press gallery and parliament. As “inside agitators” (Eisenstein) for social change the central aim of Femocrats was social and economic equity for women, reflecting social justice and progressive social and public policy. Femocrats adopted a view about the value of women’s own lived experiences in policy development, application and outcome. The role of Senator Susan Ryan is of note. In 1981, Ryan wrote and introduced the Sex Discrimination Bill, the first piece of federal legislation of its type in Australia. Ryan was a founding member of WEL and was elected to the Senate in 1975 on the slogan “A woman’s place is in the Senate”. As Ryan herself puts it: “I came to believe that not only was a woman’s place in the House and in the Senate, as my first campaign slogan proclaimed, but a feminist’s place was in politics.” Ryan, the first Labor woman to represent the ACT in the Senate, was also the first Labor woman appointed as a federal Minister.With the election of the economic rationalist Hawke and Keating Governments (1983-1996) and the neoliberal Howard Government (1996-2007), what was a “visible, united, highly mobilised and state-focused women’s movement” declined (Lake 260). This is not to say that women today reject the value of women’s voices and experiences, particularly in politics. Many of the issues of the 1970s remain today: domestic violence, unequal pay, sexual harassment, and a lack of gender parity in political representation. Hence, it remains important that women continue to seek election to the national parliament.Gender Gap: Women in Power When examining federal elections held between 1972 and 2016, women have been under-represented in the lower house. In none of these elections have women achieved more than 30 per cent representation. Following the 1974 election less that one per cent of the lower house were women. No women were elected to the lower house at the 1975 or 1977 election. Between 1980 and 1996, female representation was less than 10 per cent. In 1996 this rose to 15 per cent and reached 29 per cent at the 2016 federal election.Following the 2016 federal election, only 32 per cent of both chambers were women. After the July 2016 election, only eight women were appointed to the Turnbull Ministry: six women in Cabinet and two women in the Outer Cabinet (Parliament of Australia). Despite the higher representation of women in the ALP, this is not reflected in the number of women in the Shadow Cabinet. Just as female parliamentarians have never achieved parity, neither have women in the Executive Branch.In 2017, Australia was ranked 50th in the world in terms of gender representation in parliament, between The Philippines and South Sudan. Globally, there are 38 States in which women account for less than 10 per cent of parliamentarians. As at January 2017, the three highest ranking countries in female representation were Rwanda, Bolivia and Cuba. The United Kingdom was ranked 47th, and the United States 104th (IPU and UNW). Globally only 18 per cent of government ministers are women (UNW). Between 1960 and 2013, 52 women became prime ministers worldwide, of those 43 have taken office since 1990 (Curtin 191).The 1995 United Nations (UN) Fourth World Conference on Women set a 30 per cent target for women in decision-making. This reflects the concept of “critical mass”. Critical mass proposes that for there to be a tipping balance where parity is likely to emerge, this requires a cohort of a minimum of 30 per cent of the minority group.Gender scholars use critical mass theory to explain that parity won’t occur while there are only a few token women in politics. Rather, only as numbers increase will women be able to build a strong enough presence to make female representation normative. Once a 30 per cent critical mass is evident, the argument is that this will encourage other women to join the cohort, making parity possible (Childs & Krook 725). This threshold also impacts on legislative outcomes, because the larger cohort of women are able to “influence their male colleagues to accept and approve legislation promoting women’s concerns” (Childs & Krook 725).Quotas: A Response to Gender InequalityWith women representing less than one in five parliamentarians worldwide, gender quotas have been introduced in 90 countries to redress this imbalance (Krook). Quotas are an equal opportunity measure specifically designed to re-dress inequality in political representation by allocating seats to under-represented groups (McCann 4). However, the effectiveness of the quota system is contested, with continued resistance, particularly in conservative parties. Fine (3) argues that one key objection to mandatory quotas is that they “violate the principle of merit”, suggesting insufficient numbers of women capable or qualified to hold parliamentary positions.In contrast, Gauja (2) suggests that “state-mandated electoral quotas work” because in countries with legislated quotas the number of women being nominated is significantly higher. While gender quotas have been brought to bear to address the gender gap, the ability to challenge the majority status of men has been limited (Hughes).In 1994 the ALP introduced rule-based party quotas to achieve equal representation by 2025 and a gender weighting system for female preselection votes. Conversely, the Liberal Party have a voluntary target of reaching 50 per cent female representation by 2025. But what of the treatment of women who do enter politics?Fig. 1: Portrait of Julia Gillard AC, 27th Prime Minister of Australia, at Parliament House, CanberraInside Politics: Misogyny and Mobs in the ALPIn 2010, Julia Gillard was elected as the leader of the governing ALP, making her Australia’s first female Prime Minister. Following the 2010 federal election, called 22 days after becoming Prime Minister, Gillard was faced with the first hung parliament since 1940. She formed a successful minority government before losing the leadership of the ALP in June 2013. Research demonstrates that “being a female prime minister is often fraught because it challenges many of the gender stereotypes associated with political leadership” (Curtin 192). In Curtin’s assessment Gillard was naïve in her view that interest in her as the country’s first female Prime Minister would quickly dissipate.Gillard, argues Curtin (192-193), “believed that her commitment to policy reform and government enterprise, to hard work and maintaining consensus in caucus, would readily outstrip the gender obsession.” As Curtin continues, “this did not happen.” Voters were continually reminded that Gillard “did not conform to the traditional.” And “worse, some high-profile men, from industry, the Liberal Party and the media, indulged in verbal attacks of a sexist nature throughout her term in office (Curtin 192-193).The treatment of Gillard is noted in terms of how misogyny reinforced negative perceptions about the patriarchal nature of parliamentary politics. The rage this created in public and media spheres was double-edged. On the one hand, some were outraged at the sexist treatment of Gillard. On the other hand, those opposing Gillard created a frenzy of personal and sexist attacks on her. Further attacking Gillard, on 25 February 2011, radio broadcaster Alan Jones called Gillard, not only by her first-name, but called her a “liar” (Kwek). These attacks and the informal way the Prime Minister was addressed, was unprecedented and caused outrage.An anti-carbon tax rally held in front of Parliament House in Canberra in March 2011, featured placards with the slogans “Ditch the Witch” and “Bob Brown’s Bitch”, referring to Gillard and her alliance with the Australian Greens, led by Senator Bob Brown. The Opposition Leader Tony Abbott and other members of the Liberal Party were photographed standing in front of the placards (Sydney Morning Herald, Vertigo). Criticism of women in positions of power is not limited to coming from men alone. Women from the Liberal Party were also seen in the photo of derogatory placards decrying Gillard’s alliances with the Greens.Gillard (Sydney Morning Herald, “Gillard”) said she was “offended when the Leader of the Opposition went outside in the front of Parliament and stood next to a sign that said, ‘Ditch the witch’. I was offended when the Leader of the Opposition stood next to a sign that ascribed me as a man’s bitch.”Vilification of Gillard culminated in October 2012, when Abbott moved a no-confidence motion against the Speaker of the House, Peter Slipper. Abbott declared the Gillard government’s support for Slipper was evidence of the government’s acceptance of Slipper’s sexist attitudes (evident in allegations that Slipper sent a text to a political staffer describing female genitals). Gillard responded with what is known as the “Misogyny speech”, pointing at Abbott, shaking with rage, and proclaiming, “I will not be lectured about sexism and misogyny by this man” (ABC). Apart from vilification, how principles can be forsaken for parliamentary, party or electoral needs, may leave some women circumspect about entering parliament. Similar attacks on political women may affirm this view.In 2010, Labor Senator Penny Wong, a gay Member of Parliament and advocate of same-sex marriage, voted against a bill supporting same-sex marriage, because it was not ALP policy (Q and A, “Passion”). Australian Marriage Equality spokesperson, Alex Greenwich, strongly condemned Wong’s vote as “deeply hypocritical” (Akersten). The Sydney Morning Herald (Dick), under the headline “Married to the Mob” asked:a question: what does it now take for a cabinet minister to speak out on a point of principle, to venture even a mild criticism of the party position? ... Would you object if your party, after fixing some areas of discrimination against a minority group of which you are a part, refused to move on the last major reform for that group because of ‘tradition’ without any cogent explanation of why that tradition should remain? Not if you’re Penny Wong.In 2017, during the postal vote campaign for marriage equality, Wong clarified her reasons for her 2010 vote against same-sex marriage saying in an interview: “In 2010 I had to argue a position I didn’t agree with. You get a choice as a party member don’t you? You either resign or do something like that and make a point, or you stay and fight and you change it.” Biding her time, Wong used her rage to change policy within the ALP.In continuing personal attacks on Gillard, on 19 March 2012, Gillard was told by Germaine Greer that she had a “big arse” (Q and A, “Politics”) and on 27 August 2012, Greer said Gillard looked like an “organ grinder’s monkey” (Q and A, “Media”). Such an attack by a prominent feminist from the 1970s, on the personal appearance of the Prime Minister, reinforced the perception that it was acceptable to criticise a woman in this position, in ways men have never been. Inside Politics: Leadership and Bullying inside the Liberal PartyWhile Gillard’s leadership was likely cut short by the ongoing attacks on her character, Liberal Deputy leader Julie Bishop was thwarted from rising to the leadership of the Liberal Party, thus making it unlikely she will become the Liberal Party’s first female Prime Minister. Julie Bishop was Australia’s Minister for Foreign Affairs from 2013 to 2018 and Deputy Leader of the Liberal Party from 2007 to 2018, having entered politics in 1998.With the impending demise of Prime Minister Turnbull in August 2018, Bishop sought support from within the Liberal Party to run for the leadership. In the second round of leadership votes Bishop stood for the leadership in a three-cornered race, coming last in the vote to Peter Dutton and Scott Morrison. Bishop resigned as the Foreign Affairs Minister and took a seat on the backbench.When asked if the Liberal Party would elect a popular female leader, Bishop replied: “When we find one, I’m sure we will.” Political journalist Annabel Crabb offered further insight into what Bishop meant when she addressed the press in her red Rodo shoes, labelling the statement as “one of Julie Bishop’s chilliest-ever slapdowns.” Crabb, somewhat sardonically, suggested this translated as Bishop listing someone with her qualifications and experience as: “Woman Works Hard, Is Good at Her Job, Doesn't Screw Up, Loses Out Anyway.”For political journalist Tony Wright, Bishop was “clearly furious with those who had let their testosterone get the better of them and their party” and proceeded to “stride out in a pair of heels in the most vivid red to announce that, despite having resigned the deputy position she had occupied for 11 years, she was not about to quit the Parliament.” In response to the lack of support for Bishop in the leadership spill, female members of the federal parliament took to wearing red in the parliamentary chambers signalling that female members were “fed up with the machinations of the male majority” (Wright).Red signifies power, strength and anger. Worn in parliament, it was noticeable and striking, making a powerful statement. The following day, Bishop said: “It is evident … that there is an acceptance of a level of behaviour in Canberra that would not be tolerated in any other workplace across Australia" (Wright).Colour is political. The Suffragettes of the early twentieth century donned the colours of purple and white to create a statement of unity and solidarity. In recent months, Dr Kerryn Phelps used purple in her election campaign to win the vacated seat of Wentworth, following Turnbull’s resignation, perhaps as a nod to the Suffragettes. Public anger in Wentworth saw Phelps elected, despite the electorate having been seen as a safe Liberal seat.On 21 February 2019, the last sitting day of Parliament before the budget and federal election, Julie Bishop stood to announce her intention to leave politics at the next election. To some this was a surprise. To others it was expected. On finishing her speech, Bishop immediately exited the Lower House without acknowledging the Prime Minister. A proverbial full-stop to her outrage. She wore Suffragette white.Victorian Liberal backbencher Julia Banks, having declared herself so repelled by bullying during the Turnbull-Dutton leadership delirium, announced she was quitting the Liberal Party and sitting in the House of Representatives as an Independent. Banks said she could no longer tolerate the bullying, led by members of the reactionary right wing, the coup was aided by many MPs trading their vote for a leadership change in exchange for their individual promotion, preselection endorsements or silence. Their actions were undeniably for themselves, for their position in the party, their power, their personal ambition – not for the Australian people.The images of male Liberal Members of Parliament standing with their backs turned to Banks, as she tended her resignation from the Liberal Party, were powerful, indicating their disrespect and contempt. Yet Banks’s decision to stay in politics, as with Wong and Bishop is admirable. To maintain the rage from within the institutions and structures that act to sustain patriarchy is a brave, but necessary choice.Today, as much as any time in the past, a woman’s place is in politics, however, recent events highlight the ongoing poor treatment of women in Australian politics. Yet, in the face of negative treatment – gendered attacks on their character, dismissive treatment of their leadership abilities, and ongoing bullying and sexism, political women are fighting back. They are once again channelling their rage at the way they are being treated and how their abilities are constantly questioned. They are enraged to the point of standing in the face of adversity to bring about social and political change, just as the suffragettes and the women’s movements of the 1970s did before them. The current trend towards women planning to stand as Independents at the 2019 federal election is one indication of this. Women within the major parties, particularly on the conservative side of politics, have become quiet. Some are withdrawing, but most are likely regrouping, gathering the rage within and ready to make a stand after the dust of the 2019 election has settled.ReferencesAndrew, Merrindahl. Social Movements and the Limits of Strategy: How Australian Feminists Formed Positions on Work and Care. Canberra. 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