Thursday, April 24, 2008

Inequalities That Really Matter (but we seldom think about)

Human beings can be unequal in a variety of different ways.

For example, one person may be taller than another. Or one person may be more intelligent than another person. Some people have more friends and loved ones in their lives than other people. Others might be fluent in more than one language, while some struggle to even read and write in their native tongue.

Given there are innumerable ways in which human beings differ, it is worth pondering which inequalities or differences are the most important and in need of redressing. And in this post I limit my reflections to issues that arise in the case of domestic justice (things look a bit different when we move to considerations of global justice).

So of the various inequalities we could attend to in our society, which ones should we give serious attention to? Inequalities in wealth? Inequalities in opportunities for education? Inequalities in health? Etc. etc.

Well, such questions are ones that often weigh on my own deliberations (e.g. here and here) as I attempt to try to get an accurate sense of the most pressing issues we face. As I’ve noted many times before, I do not consider myself an “egalitarian” in the way that that label is used by most contemporary political philosophers who count themselves as “egalitarians”. But I am interested in the story of why different kinds of inequalities exist, and what, if anything, we could (and ought to) do to redress them. And I usually prefer to classify this in prioritarian rather than egalitarian terms (see this post). But today I feel like exploring these thoughts from an egalitarian standpoint. So please allow me to indulge myself in seeing where these thoughts lead me.

Here is one inequality that you seldom hear anything about, but it is an inequality that I think is actually very important and worth thinking seriously about. Let’s compare the life prospects of the following two individuals- Claire and Katherine.

Both Claire and Katherine live in the same, relatively affluent, city in Canada. In fact, Claire and Katherine are neighbours. And they have known each other for about 10 years now, from the time Claire’s family moved into the house beside Katherine.

But Claire and Katherine are unequal in many respects. Claire is the head cheerleader at her college. She also plays basketball and enjoys running. Claire is a straight “A” student, and recently wrote on article on women and politics for the local newspaper.

Claire’s situation stands in stark contrast to the situation of Katherine. Katherine’s mobility is severely limited. She can barely sit up on her own, and is unable to walk. She relies on others to help feed and bath her. Katherine finds it hard to concentrate for long periods of time and she often forgets who her loved ones and friends are.

If we look at things through a *synchronic lens*, the life prospects of Claire and Katherine as thus very unequal. Claire has a very low risk of developing disease in the next twenty years of her life. Katherine, however, is not expected to live more than five more years. Katherine already suffers dementia, among many other aliments (e.g. high blood pressure, weak bones, poor vision, infertility, etc.).

The case of Claire and Katherine is not an unusual one. It is a scenario typical of many neighbourhoods all around the country (indeed, around the world). You might be wondering what explains the vast difference between the life prospects of Claire and Katherine. Well, the most relevant fact is that Katherine is actually 65 years *older* than Claire. Claire is 20 years old, Katherine is 85 years old.

Now once I give you this further bit of information your moral sensibilities might start to alter. Perhaps you were initially concerned about the inequality between Claire and Katherine, but now that I have revealed their age you are not concerned (or are less concerned then you were before I mentioned this fact). You might feel that the afflictions that Katherine suffers are “natural” and there is nothing we can do about them. Alternatively, you might feel that there is no real inequality between Claire and Katherine when we measure their health prospects over their expected lifetimes, rather than at a particular moment in time. And so perhaps you feel that a comparison of their lives should really be made through a diachronic, rather than synchronic, lens.

But luck egalitarians cannot, I believe, easily cast aside this kind of inequality. Recall that luck egalitarians maintain:

Inequalities in the advantages that people enjoy are just if they derive from the choices people have voluntarily made; however, inequalities deriving from unchosen features of people's circumstances are unjust.

Katherine’s debilitating condition is not the result of her choice (she didn’t choose to experience the cellular damage that comes with aging), but rather it is the result of brute luck. Well, the story is more complex (and interesting) than saying it is just brute luck. Katherine’s condition is the result of our species’ evolutionary history. Why do human’s age the way we do? Why don’t we age like turtles (see this)?

The question of why we age is a very interesting, important and complex question. One influential answer among scientists is that the level of extrinsic mortality is a principal determinant in the evolution of longevity. So in many respects Hobbes was correct when he said that life in the state of nature was “nasty, brutish and short”. Not only was it short in the state of nature, but also in societies that instituted a government. It was only in the twentieth century that real substantive gains were made in life expectancy.

This Time website, for example, has a useful comparison of life expectancy (among other things) in the United States, Italy, Japan and Mexico, from 1900 to 1998. During the last century life expectancy in the US rose by 29 years, Italy by 34 years, Japan by 36 years, and Mexico by 41 years. Nothing like these dramatic increases has ever occurred in the history of humanity! The vast majority of human beings born over 200 years ago would have died before my current age (38).

And so the disadvantages visited upon Katherine are really a legacy of the challenges her (and our) distant ancestors faced. Because very few humans that have ever lived on this planet died from age-related causes (versus poverty, violence, infection, infectious disease, etc.), Katherine’s biology was not designed to protect her from the ravages of time itself.

But the fact that the passage of time killed a very low percentage of human beings in the past does not mean this will necessarily be the case in the future. And while there are many possible things that could kill the world’s existing population (which is currently 6.5+ billion people), the vast majority of these people will most likely suffer age-related morbidity and mortality. And so I think it is accurate to label senescence is the real “scourge” of the 21st century. To say this doesn’t mean we could actually eliminate senescence, but even if we just retard human aging, so that people can enjoy more years of disease-free life, then it would be a very laudable accomplishment.

So if, as many scientists who work on longevity science believe, there might actually be a way to redress the inequality between people in the kind of situation described by Katherine and Claire, then we need to think seriously about what justice requires.

Just a brief point to avoid some likely confusion. I am not suggesting that science will permit us to reverse or undo the disadvantage that Katherine currently suffers (though advances in regenerative medicine might make that possible); rather I am suggesting that it is likely that we may be able to intervene in our biology so that by the time a person reaches their 85th birthday their risk of mortality and morbidity could be significantly reduced compared to what it is for today’s average 85 year-old . While such an intervention would not result in such a person having the health profile of today's 20 year-old, if it just reduces the risk of disease and disability to the level enjoyed by today’s 60 year-old that would be very significant. And if there is a sound basis for believing this could be achieved, then I think egalitarians should favor investing public funds in this science. For anti-aging interventions would not only benefit people like Katherine, they would also benefit Claire (and every other person in the world who is susceptible to senescence!). So everyone wins when society suffers less age-related morbidity.

To fail to invest in the science that could help confer extra disease-free years on humans is irrational and morally indefensible. Contrary to the intuitions of most egalitarians, I believe that tacking human aging is actually a requirement of equality. It is not the only requirement, but it is a requirement none-the-less. Tackling human aging is simply a subset of the more general goal of keeping humans healthy. If we want to prevent cancer, diabetes, AD, bone fractures, infection, age-related macular degeneration, age-related hearing loss, etc. etc., then we should also want to minimize the damage caused by senescence. For these things are the result of this damage. Aging is by far the biggest cause of disease (at least in the developed world, if not the world as a whole). Modifying the biological processes of aging could turn out to be one of the most cost-effective ways of ensuring quality of life for those in the later stages of life.

There is a lot more to be said here. But for now I just wanted to float a few of these ideas out there.