A central idea of contemporary philosophical egalitarianism's theory of justice is that involuntary inequalities or disadvantages—those that arise through no choice or fault of one's own—should be minimized or rectified in some way. Egalitarians believe that the preferred institutional vehicle for fulfilling these obligations of justice is some form of a welfare state. Of course, contemporary egalitarians disagree about the best way to interpret or understand their theory of justice and institutions: Which inequalities are chosen and which are unchosen? What form of a welfare state will best serve justice? However, no contemporary egalitarian denies that egalitarian justice requires a welfare state that will redistribute income and wealth to aid the involuntarily disadvantaged.

The state that we inhabit plays a significant role in shaping our lives. For not only do its institutions constrain the kinds of lives we can lead, but it also claims the right to punish us if our choices take us beyond what it deems to be appropriate limits. Political philosophers have traditionally tried to justify the state's power by appealing to their preferred theories of justice, as articulated in complex and wide-ranging moral theories—utilitarianism, Kantianism, and the like. One of John Rawls's greatest contributions to political philosophy has been his recognition that this is the wrong way for this field to approach its task. He points to what he calls “the fact of reasonable pluralism,” which is the incontestable fact that in a free society people striving to lead their lives ethically will subscribe to conflicting moral and religious doctrines, many of which will be “reasonable” in the special sense of leaving their adherents willing to cooperate with those with whom they have moral disagreements. And this means that political philosophers can no longer rely on any particular “comprehensive” doctrine in their attempts to justify the state. For doing so would be unfair to those who subscribe to a conflicting reasonable doctrine; it would mean that the coercive power of the state would not be justified to them in terms they can accept, even while they were forced to abide by its terms.

It has often been remarked that bioethics is a quintessentially American phenomenon. Broadly speaking, bioethics as a field has tended to enshrine the value of autonomy, it places individual rights above communal well-being, and it has adopted a largely permissive and optimistic view of emerging biotechnologies. In contrast to much European thinking at the intersection of ethics and medicine, American-style bioethics has been resolutely middlebrow, eschewing grand philosophical schemes in favor of pragmatic policy-making and democratic consensus. It was, then, perhaps only a matter of time before various theorists began proposing a marriage between bioethics and pragmatism, which is the homegrown American philosophy.

Does the welfare state help the poor? This surprisingly simple question often generates more heat than light. By the welfare state, I mean transfer programs aimed at helping the poor through the direct redistribution of income. (This excludes general economic policy, antitrust, the volunteer military, and many other policies that affect the well-being of the poor.) Defenders of the welfare state often assume that the poor benefit from it, while critics suggest that the losses outweigh the gains. The most notable of such criticisms is Charles Murray's Losing Ground, which suggests that the welfare state has failed to achieve its stated ends.

The philosophy of medicine cum bioethics has become the socially recognized source for moral and epistemic direction in health-care decision-making. Over the last three decades, this field has been accepted politically as an authorized source of guidance for policy and law. The field's political actors have included the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the Department of Health, Education, and Welfare, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (hereinafter, “the President's Commission”), the National Bioethics Advisory Commission, and the new (2001) Council on Bioethics; these groups and agencies have (or will) set forth rules on issues ranging from the role of humans in biomedical research to the production of human embryos for research, the definition of death, and the permissibility of human cloning. The members of the field are not just scholars and teachers in an academic realm directed to both theoretical and applied issues. They are, in addition, practitioners of a conceptual and moral trade that possesses a legal and political standing. This essay critically addresses the sudden emergence of bioethics as a societally recognized source of moral guidance, a source replete with authorized moral experts. Attention is directed to moral and conceptual assumptions that have led the philosophy of medicine, and especially bioethics, to acquire a quasi-juridical/political role in guiding clinical choices, framing health-care policy, and directing court holdings.

The media is aglow with reports of the booming economy and rising prosperity in the United States since the early 1990s. Indeed, the run-up in stock prices between 1995 and the end of 1999 has created the impression that all families are doing well in terms of income and wealth. This, however, is certainly not the case. As I shall demonstrate, most American families have seen their level of well-being stagnate over the last quarter-century.

Measured inequality has increased tremendously between the 1960s and 1990s, not only in the United States but throughout the majority of industrial nations. Wages among people of the same race and gender have become less equal. The hours worked by men have fallen, and the drop has been more pronounced among those who earn lower wages—as a result, inequality in labor income, which is the product of the wage rate and hours worked, has increased relative to inequality in wage rates. Moreover, among married couples, employment of the wives of high-income men has increased until these wives are approximately as likely to be employed outside the home as are the wives of low-income men, who have always worked for wages. In addition, due to assortative mating, wage rates of husbands and wives are positively correlated, and it is clear that the growth in inequality of labor incomes among families has outstripped the growth in inequality in individual labor income. Finally, only the highest-income families have savings in excess of home equity and company-sponsored pensions, which implies that inequality in wealth among families has been exacerbated by the growth in stock prices.

In this essay, I argue that the way American bioethics has traditionally conceived of the distinction between public and private has given rise to some ethically problematic blind spots in its analyses to date. Furthermore, I argue that bioethics's view of the public and private spheres has reinforced a shortsighted view of bioethics's analytical sphere of influence. In particular, it has led bioethics to conceptualize issues largely from the perspective of health professionals, eschewing analyses of the problems of health and health information that patients and their intimates face outside of professional relationships and traditional health-care settings. It has also led some bioethical analyses to reflect, and to some degree reinforce, relationships of power that they might instead challenge.

Inequality in income and wealth distribution in society is said to be a great concern to many social critics. Rarely is the issue of inequality in income or wealth distribution, as such, a concern for the majority of Americans as individuals, however.

When many people think of bioethics, they think of gripping issues in clinical medicine such as end-of-life decision-making, controversies in biomedical research such as that over work with stem cells, or issues in allocating scarce health-care resources such as organs or money. The term “bioethics” may evoke images of moral controversies being discussed on news programs and talk shows. But this “controversy of the day” focus often treats ethical issues in medicine superficially, for it addresses them as if they could be examined and discussed in isolation from the context in which they are situated. Such a focus on the latest controversies fails to take into account that medicine is a social institution and that the controversies in bioethics often reflect deeper social and moral issues that transcend the boundaries of medicine and ethics. If one moves beyond the issue-of-the-day approach to bioethics, one can see that the field must address these deeper issues.

The inequalities of wealth and fortune form a central part of the human condition, and these over time have been a constant source of social unease. Whether they should be praised and preserved or endured or corrected is an issue that produces uniform discord. One source of this difficulty in analysis stems from the possible ways in which these persistent inequalities arise. It is easy to condemn any differences in wealth created by the victor's expropriation of the vanquished's honest toil. It is far more difficult to condemn those identical differences when they are attributable to the thrift and foresight of the successful relative to the laziness or self-destructiveness of the impoverished. Furthermore, most find it morally ambiguous how best to respond to differences between persons that are the result of luck or chance, such that they do not reflect positively or negatively on either the character of those who have done well or those who have done poorly.

The distinctive aim of applied ethics is to provide guidance as to how we ought to act, as individuals and as shapers of social policies. In this essay, I argue that applied ethics as currently practiced is inadequate and ought to be transformed to incorporate what I shall call social moral epistemology. This is a branch of social epistemology, the study of the social practices and institutions that promote (or impede) the formation, preservation, and transmission of true beliefs. For example, social epistemologists critically evaluate the comparative advantages of adversarial versus inquisitorial criminal proceedings as mechanisms for the discovery of truth.

If an array of goods is for sale on a market, one's wealth, the tradable resources one owns, determines what one can purchase from this array. One's income is the increment in wealth one acquires over a given period of time. In any society, we observe some people having more wealth and income, and some having less. At any given time, some societies have a greater average wealth than others. Across time, we can observe societies becoming richer or poorer and showing more or less equal distributions of wealth among their members. Does it matter from an ethical standpoint whether some people have more income and wealth than others? Does securing a more equal distribution of income and wealth either constitute the achievement of something that is intrinsically morally desirable or serve as a reliable means to the achievement of some intrinsic moral value? If we suppose that justice demands, in many circumstances, the equalization of the income or wealth of persons, what principles of justice generate this demand?

There is a widespread feeling that health is special; the rules that are usually used in other policy areas are not applied in health policy. Health economists, for example, tend to be reluctant to offer economists' usual prescription of competition and consumer choice, even though they have largely failed to justify this reluctance by showing that health economics involves special features such as public goods, externalities, adverse selection, poor consumer information, or unusually severe consequences.

Bioethics as a field began some years before it was finally named in the early 1970s. In many ways, bioethics originated in response to urgent matters of the moment, including the controversy over disconnecting Karen Quinlan's respirator, the egregious paternalism of Donald Cowart's doctors in the famous “Dax” case, the abuse of research subjects in the notorious Tuskegee Syphilis Study, and the need to devise an intellectual framework for the development of federal regulations to protect human subjects of research. The phrase “new and unprecedented” became a common description of the topics and issues to which people who later came to be called “bioethicists” responded. It should come as no surprise that bioethics and its practitioners soon came to the self-understanding that their work was new and unprecedented, much as the innovations of biomedical science and their clinical applications were thought to be.

Neither income nor wealth should be too highly unequal. But there is a fundamental distinction between pay for work and the ownership of capital assets. The reasons to moderate these inequalities therefore differ, and the arguments are best considered separately.

This is a simple essay. It raises a familiar question about equality, adduces a very small amount of empirical evidence about the social consequences of equality as distinct from prosperity, and broods on the difficulty of providing a really persuasive answer to the question raised. I begin with the view that there simply cannot be anything intrinsically wrong with inequality, move on to the view that there are extrinsic reasons for anxiety, dividing these into conceptual and empirical reasons, though without any great commitment to the clarity of that distinction in this context, and end with some reflections on recent social and political theory. The essay thus begins with what I hope are clear and (what I am sure are) very simple thoughts, before muddying the water pretty thoroughly thereafter.

In this essay, I survey egalitarian and utilitarian approaches to the distribution of scarce life-saving medical resources. In my view, the major criterion for the distribution of scarce life-saving medical resources (hereinafter sometimes the “distribution of life”) should be life expectancy: we should distribute life so as to maximize life-years. In Section II, I discuss the life-year maximization approach and situate it within utilitarian theory.

With the human genome mapped, and with the mapping of more than one hundred animal genomes in progress, the amount of genetic data available is increasing exponentially. This exponential increase in data is having an immediate impact on the process of drug development. By using techniques of information technology to manipulate data regarding the genes, proteins, and biochemical pathways associated with various diseases, scientists are beginning to be able to design drugs in a systematic fashion. In the context of any given disease, scientists look to see whether a gene, a protein for which the gene codes, or another protein in the relevant biochemical pathway could be the “target” biological molecule, the “knocking out” of which would halt or slow the disease's progression. Once a target molecule has been identified and characterized structurally, drug therapies that would be likely to knock out this target can be identified and tested systematically. The merger of information technology and genetic technology has changed the process of pharmaceutical development so much that a new term—bioinformatics—has been coined to describe this new approach to such development.

We are all equal, sort of. We are not equal in terms of our physical or mental capacities. Morally speaking, we are not all equally good. Evidently, if we are equal, it is not in virtue of our actual characteristics, but despite them. Our equality is of a political rather than metaphysical nature. We do not expect people to be the same, but we expect differences to have no bearing on how people ought to be treated as citizens. Or when differences do matter, we expect that they will not matter in the sense of being a basis for class distinction. We admire tenacity, talent, and so on, but do not take such features to entitle their bearers to be treated as “upper class.” Neither are people who are relatively lacking in these features obliged to tolerate being treated as “lower class.” As a society, we have made moral progress. Such progress consists in part of progress toward political and cultural equality.