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Summary literature Advances in Health and Society
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Literature Advances in Healthand Society
Week 1
Matthews, D. (2015): The case against equality of
opportunity. Commentary on VOX media.
It's an incoherent, impossible ideal. Everyone wants equality of opportunity. Huge amounts of time,
money, and intellectual effort are devoted to this idea, that a just world is one in which opportunity
is equal, even if outcomes aren't. The only problem? No one really wants equality of opportunity, nor
anything close to it. Nor should they. Pursuing true equality of opportunity would require turning
America into a dystopian, totalitarian nightmare — and even then, it would still prove impossible.
Moreover, equality of opportunity is simply a bad goal. It assumes that life is a zero-sum competition
for wealth and status, that the most important thing is ensuring that only the smartest and hardest-
working among us end up the victors. It assumes there will always be an underclass; it just wants to
reserve membership for those who truly deserve it.
A decent society shouldn't try to build a better aristocracy. It should try to achieve a reasonable and
rising standard of living for all.
Pure equality of opportunity is deeply illiberal, and no one who understands its true implications
would ever endorse it. Equality of opportunity promises not just sufficient opportunities to all
families, but equivalent ones. Think for a second about what that means. For one thing, any actions
taken by affluent families meant to help their kids get ahead are prima facie illegitimate. That means
no private schools. No fancy preschool or daycare. No au pairs or nannies. No after-school tutors. No
summer camps. No violin lessons.
But the problem goes much deeper than monetary inequality. Children taught the trade of
programmers by their parents are left with a highly marketable skill that earns them hundreds of
thousands of dollars and social prestige later in life. Children of taught the trade of musicians by their
parents face exceptionally difficult odds in finding work and won't make as much as the children of
programmers. If we take equality of opportunity seriously, the musicians children deserve
compensation from the government to make up for the wrong. That is absurd. There are important
values other than equality — like the freedom of parents to raise children how they like, and the
importance of goals other than money or social standing — that tell us it would be disastrous to
micromanage the skills parents teach their children. The deepest difficulty with achieving full equality
of opportunity is that parents, in practice, endow their children with a diverse array of opportunities
(playing violin, French cooking, speaking mandarin, etc), some of which are going to be more
valuable on average, but we need this plurality of skills. Equality of opportunity would make every
parenting choice a matter of public policy, to be regulated accordingly. It's a deeply, deeply illiberal
ideal.
Besides, even in a world of pure equality of opportunity, where environmental inequalities were
eliminated and the Will Huntings of the world had an equal shot at success, there would be
inequality. There would be an overclass and an underclass, people who do better or worse due to no
fault of their own.
,Also, equality of opportunity is nearly impossible to measure. The things we can measure are i.e.
income, poverty, life expectancy, education, illness, etc. We can measure this, because they are
outcomes – the things opportunity egalitarians define themselves in opposition to. By embracing the
outcomes, we give ourselves goals to strive for, a basis to determine if our politics are working, a
clear path forward. By rejecting them, we are left with a morass of conceptual confusion. Equality of
opportunity is a distraction. It takes our eyes off the prize.
Equality of opportunity is not the goal. The goal is a good life for all. We should settle for nothing
less.
Bricard, D., Jusot, F., Trannoy, A., & Tubeuf, S. (2013).
Inequality of opportunity in health and the principle of
natural reward: evidence from European countries.
Abstract
This paper aims to quantify and compare inequalities of opportunity in health across European
countries considering two alternative normative ways of treating the correlation between effort, as
measured by lifestyles, and circumstances, as measured by parental and childhood characteristics.
In Europe at the whole, inequalities in opportunities stand for almost 50% of the health inequality
due to circumstances and efforts in Barry scenario and 57.5% in Roemer scenario. The comparison of
the magnitude of inequalities of opportunity in health across European countries shows considerable
inequalities in Austria, France, Spain, Germany, whereas Sweden, Poland, Belgium, the Netherlands
and Switzerland present the lowest inequalities of opportunities. The normative principle on the way
to treat the correlation between circumstances and effort makes little difference in Spain, Austria,
Greece, France, Czech Republic, Sweden and Switzerland whereas it would matter the most in
Belgium, the Netherlands, Italy, Germany, Poland and Denmark.
In most countries, inequalities of opportunity in health are mainly driven by social background
affecting adult health directly, and so would require policies compensating for poorer initial
conditions. On the other hand, our results suggest a strong social and family determinism of lifestyles
in Belgium, the Netherlands, Italy, Germany, Poland and Denmark, which emphasizes the importance
of inequalities of opportunities in health within those countries and calls for targeted prevention
policies.
Introduction
Inspired by the philosophical concept of equality of opportunity, a number of recent publications in
health economics have focused on drawing the line between legitimate and illegitimate causes of
health inequalities. The main argument is that differences in observed health outcomes are explained
by factors for which the individual can be held responsible, called effort, such as healthy lifestyles,
and by factors for which the individual should not be held responsible, called circumstances, such as
social and family background. The distinction between efforts and circumstances is at the core of the
implementation of equality of opportunity policies and is based on the concept of individual
responsibility. Equality of opportunity principles recommend first to respect the impact of individual
responsibility, namely effort, on the outcome; this is the principle of natural reward, and second to
,compensate the impact of characteristics independent of individual responsibility, namely
circumstances; this is the principle of compensation.
One requires therefore distinguishing the respective contributions of efforts and circumstances to
overall health inequalities, so that policy-makers are able to identify the effort which should be
rewarded and the circumstances that should be compensated. The challenge when doing so is that
the two components cannot be assumed to be independent and one needs to decide how the
correlation between efforts and circumstances should be treated. Two main alternative views have
been debated in the literature within this context (debates on the distinction between legitimate and
illegitimate inequalities in health):
According to Roemer (1998) effort is disembodied from the impact of circumstances; the
correlation between efforts and circumstances is independent from individual responsibility.
NIET KIJKEN NAAR EIGEN VERANTWOORDELIJKHEID
According to Barry (2005) effort should be entirely rewarded and the correlation of effort
and circumstances does not require to be acknowledged. NIET KIJKEN NAAR
OMSTANDIGHEDEN, MAAR NAAR INSPANNING
To illustrate: Would we hold sons of smokers less responsible to smoke than sons of non-
smokers? From Roemer viewpoint, sons of smokers are less responsible than sons of non-
smokers; from Barry viewpoint, parental circumstances are not relevant and sons of smokers are
as responsible as sons of non-smokers for smoking.
This paper quantifies and compares inequality of opportunity in health in different European
countries and assess whether it empirically matters to adopt Barry or Roemer view on the magnitude
of inequalities of opportunity in each of these countries. In particular, the paper investigates whether
the correlation between effort and circumstances differ from one country to another.
Our results show differences in inequalities of opportunity across European countries with larger
inequalities in Austria, France, Spain, and Germany, and lower inequalities in Sweden, Poland,
Belgium, the Netherlands, and Switzerland. The share of inequalities of opportunity in health
inequalities due to circumstances and efforts varies from 30% in the less unequal countries to 80% in
the most unequal countries, whereas it represents 50% at the aggregate level. The way the
correlation between efforts and circumstances is changing the measure of inequalities of opportunity
also varies between countries where the difference between the alternative scenarios is not
significant.
Methods
Estimation strategy
Let us assume that individual health status H is a function of circumstances C, efforts E, demographic
variables D and an error term u: H = f (C, E, D, u)
The vector of circumstances C consists of a set of variables beyond individual control related to
health status in adulthood such as childhood conditions and family background. Circumstances are
considered as a source of illegitimate inequalities and efforts are considered as a source of legitimate
inequalities. The vector of circumstances includes a number of social conditions in childhood,
parents’ longevity and parents' health-related behaviours. Social conditions include the occupation of
the main breadwinner during childhood. The vector of efforts E captures individual responsibility for
health, such as lifestyles. The vector of circumstances includes a number of social conditions in
childhood, parents’ longevity and parents' health-related behaviours. The vector of demographic
, variables D captures biological determinants such as age and sex. Controlling for demographics is
essential for international comparisons in order to control for differences in population composition.
Discussion
The aim of this paper is to quantify and compare inequalities of opportunity in health in Europe and
to assess whether it matters empirically to adopt Barry or Roemer viewpoint on the treatment of the
correlation between efforts and circumstances. Our results firstly attest the existence of inequalities
of opportunity in health in Europe. The share of inequalities of opportunity in health inequalities due
to circumstances and efforts varies from 30% in the less unequal countries to 70% in the most
unequal countries, whereas it represents 50% at the aggregate level. The way the correlation
between efforts and circumstances matters for the assessment of inequalities of opportunity also
varies across countries. The difference between scenarios is negligible in Switzerland and Sweden but
is particularly important in Belgium and the Netherland where taking into account the indirect effect
of circumstances through lifestyles induces a 20% increase in inequalities of opportunity. Inequalities
of opportunity in Europe represent on average half of the health inequalities due to circumstances
and efforts and there are large variations across countries.
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