RELATIONAL EGALITARIANISM AND THE GROUNDS OF ENTITLEMENTS TO HEALTHCARE

In recent years, a number of philosophers have argued that much theorizing about the value of equality, and about justice more generally, has focused unduly on distributive issues and neglected the importance of egalitarian social relationships. As a result, relational egalitarian views, according to which the value of egalitarian social relations provides the grounds of the commitment that we ought to have to equality, have gained prominence as alternatives to more fundamentally distributive accounts of the basis of egalitarianism, and of justice-based entitlements. In this paper, I will suggest that reflecting on the kind of explanation of a certain class of our justice-based entitlements that relational egalitarian considerations can offer raises doubts about the project, endorsed by at least some relational egalitarians,of attempting to ground all entitlements of justice in the value of egalitarian social relationships. I will use the entitlement to healthcare provision as my central example. The central claim that I will defend is that even if relational egalitarian accounts can avoid implausible implications regarding the extension of justice-based entitlements to health care, it is more difficult to see how they can avoid what seem to me to be implausible explanations of why individuals have the justicebased entitlements that they do.To the extent that I am correct that relational egalitarian views are committed to offering implausible explanations of the grounds of justice-based entitlements to healthcare, this seems tome to provide at least some support for amore fundamentally distributive approach to thinking about justice in healthcare provision.


Article abstract
In recent years, a number of philosophers have argued that much theorizing about the value of equality, and about justice more generally, has focused unduly on distributive issues and neglected the importance of egalitarian social relationships. As a result, relational egalitarian views, according to which the value of egalitarian social relations provides the grounds of the commitment that we ought to have to equality, have gained prominence as alternatives to more fundamentally distributive accounts of the basis of egalitarianism, and of justice-based entitlements. In this paper, I will suggest that reflecting on the kind of explanation of a certain class of our justice-based entitlements that relational egalitarian considerations can offer raises doubts about the project, endorsed by at least some relational egalitarians, of attempting to ground all entitlements of justice in the value of egalitarian social relationships. I will use the entitlement to healthcare provision as my central example. The central claim that I will defend is that even if relational egalitarian accounts can avoid implausible implications regarding the extension of justice-based entitlements to health care, it is more difficult to see how they can avoid what seem to me to be implausible explanations of why individuals have the justice-based entitlements that they do. To the extent that I am correct that relational egalitarian views are committed to offering implausible explanations of the grounds of justice-based entitlements to healthcare, this seems to me to provide at least some support for a more fundamentally distributive approach to thinking about justice in healthcare provision.

RELATIONAL EGALITARIANISM AND THE GROUNDS OF ENTITLEMENTS TO HEALTHCARE BRIAN BERKEY
ASSISTANT PROFESSOR, DEPARTMENT OF LEGAL STUDIES AND BUSINESS ETHICS, UNIVERSITY OF PENNSYLVANIA

ABSTRACT:
In recent years, a number of philosophers have argued that much theorizing about the value of equality, and about justice more generally, has focused unduly on distributive issues and neglected the importance of egalitarian social relationships. As a result, relational egalitarian views, according to which the value of egalitarian social relations provides the grounds of the commitment that we ought to have to equality, have gained prominence as alternatives to more fundamentally distributive accounts of the basis of egalitarianism, and of justice-based entitlements. In this paper, I will suggest that reflecting on the kind of explanation of a certain class of our justice-based entitlements that relational egalitarian considerations can offer raises doubts about the project, endorsed by at least some relational egalitarians, of attempting to ground all entitlements of justice in the value of egalitarian social relationships. I will use the entitlement to healthcare provision as my central example. The central claim that I will defend is that even if relational egalitarian accounts can avoid implausible implications regarding the extension of justice-based entitlements to health care, it is more difficult to see how they can avoid what seem to me to be implausible explanations of why individuals have the justicebased entitlements that they do.To the extent that I am correct that relational egalitarian views are committed to offering implausible explanations of the grounds of justice-based entitlements to healthcare, this seems to me to provide at least some support for a more fundamentally distributive approach to thinking about justice in healthcare provision.

INTRODUCTION
In recent years, a number of philosophers have argued that much theorizing about the value of equality, and about justice more generally, has focused unduly on distributive issues and neglected the importance of egalitarian social relationships. 1 The distributive theorists that these "relational egalitarians" criticize typically begin from an account of the currency of justice (for example, welfare, resources, primary social goods, or capabilities), and proceed to articulate principles to govern the distribution of that currency (for example, equal distribution, priority for the worse off, equal opportunity, or sufficiency). 2 Egalitarian distributive theorists typically hold that equal distribution of the currency of justice is a baseline that can be deviated from only given a sufficient justification. 3 For my purposes in this paper, the most important feature of distributive views is that they explain individuals' entitlements to particular resources and socially provided services, at least in part, in terms of more general entitlements to shares in the currency of justice. And since entitlements to shares in whatever currency a theorist favours are, on distributive views, themselves grounded in whatever more general interests of individuals are thought to support that currency over alternatives, distributive views ultimately ground at least some entitlements to resources and socially provided services in the justice-relevant interests that those resources or services might promote.
Relational egalitarians claim that distributive theorists have failed to appreciate the role that an ideal of egalitarian social relationships should play in an appropriate conception of the value of equality. Though some who embrace this criticism of prominent distributive approaches do not view relational egalitarianism as a competitor to distributive views, 4 many of the most prominent relational egalitarians do see their approach as an alternative to such views, rather than as a complement to them. 5 My focus in this paper is on relational egalitarian views conceived of as competitors to distributive approaches to equality and justice; none of my arguments applies against the view that distributive approaches should be complemented by a concern for relational equality. 6 For ease of presentation, I will, in the remainder of the paper, use the label "relational egalitarianism" to refer only to views that constitute alternatives to distributive approaches, and "relational egalitarians" to refer only to proponents of such views.
Relational-egalitarian views that constitute alternatives to distributive approaches hold that the fundamental value that grounds entitlements of justice is egalitarian social relationships, rather than the kinds of interests that might be taken to support one view about the currency of justice over others. On these relational egalitarian views, entitlements of justice, including distributive entitlements, should be understood as grounded, in some way or other, in the value of egalitarian social relations. For relational egalitarians, then, it is ultimately the value of egalitarian social relationships that explains why individuals have whatever particular entitlements of justice that they do, including entitlements to a share of society's resources, to opportunities, and to the provision of services such as healthcare.
My aim in this paper is to suggest that reflecting on the kind of explanation that relational egalitarians are committed to offering of a certain class of our justicebased entitlements raises doubts about the relational egalitarian project of attempting to ground all entitlements of justice in the value of egalitarian social relationships, rather than allowing that at least some such entitlements might be grounded in the kinds of values underlying distributive approaches. I will use the entitlement to healthcare provision as my central example, since I think that this case highlights the challenge facing relational egalitarians in a particularly striking way. 7 The central claim that I will defend is that even if relational egalitarian views can avoid implausible implications regarding the extension of justice-based entitlements to healthcare, it is more difficult to see how they can avoid what seem to me to be implausible explanations of why individuals have the justice-based entitlements that they do. To put this point another way, I will argue that,even if relational egalitarians can give a plausible answer to the question "Who is entitled to what, when it comes to the social provision of healthcare?," it is less clear that they can offer an equally plausible answer to the question "Why are individuals entitled to the socially provided health care that they are?" To the extent that I am correct that relational egalitarian views are committed to offering implausible explanations of the grounds of justice-based entitlements to healthcare, this seems to me to provide at least some support for a more fundamentally distributive approach to thinking about justice in healthcare provision, since plausible distributive approaches are consistent with quite intuitive explanations of the grounds of justice-based entitlements to healthcare. More generally, the success of my challenge to relational egalitarian explanations of justice-based entitlements to health care would suggest that relational egalitarians will struggle to provide plausible explanations for a number of other widely endorsed entitlements of justice.
The force of the concerns that I will raise for relational egalitarian approaches to justice in healthcare provision, however, do not by themselves generate support for any particular more fundamentally distributive theory. The success of my argument, then, will not necessarily lead us in the direction of what has, in recent years, been the main competitor to relational egalitarianism, both in discussions of health and healthcare justice, and in discussions of egalitarian justice more generally-namely, luck egalitarianism. 8 Luck egalitarianism offers a distinctive type of answer to the question of why individuals are entitled to the socially provided healthcare that they are. That answer is, roughly, that such care is necessary to remedy inequalities in health that are the result of brute luck, rather than the result of option luck, or, in other words, the result of choices for which individuals can be held responsible. And although I am inclined to think that this luck egalitarian answer is at least more plausible than what relational egalitarians can offer, I do not think that it is necessarily the most plausible answer available. 9 I hope, then, that reflecting on the question about the grounds of entitlements of justice in healthcare that I will focus on in this paper can help to lead egalitarian discussions of health and healthcare justice in new directions. I will not, however, attempt to pursue any of those directions here. I will proceed in the remainder of the paper as follows. In section 1, I will describe the key features of relational egalitarianism, drawing primarily on Elizabeth Anderson's development of the view. In particular, I will highlight the kind of explanations that relational egalitarians are committed to offering for justicebased entitlements to resources, opportunities, and service provision. In section 2, I will examine the explanations available to relational egalitarians for entitlements to healthcare provision, and argue that, at least in certain kinds of cases, these explanations seem unsatisfying. The difficulty of providing satisfying explanations for entitlements to healthcare provision within a relational egalitarian framework, I will suggest, provides some reason to favour a more fundamentally distributive approach to justice in health and healthcare provision. I will conclude, in section 3, by briefly highlighting the limits of the argument developed in section 2, and by suggesting how it might inform our thinking about the divide between relational and distributive approaches to justice going forward.

RELATIONAL EGALITARIANISM
While some views that can be described as versions of relational egalitarianism claim only that the value of equality is best understood in relational egalitarian terms, and allow that justice may be an entirely distinct value that can at times compete with equality, my concern in this paper is relational egalitarian approaches that aim to offer alternatives to distributive approaches to justice. 10 Relational egalitarianism, insofar as it constitutes an alternative to such distributive approaches, is both a view about how the value of equality is best understood, and a view about the basis of entitlements of justice, including distributive entitlements. Relational egalitarian views, then, constitute a type of egalitarian view about justice that can be contrasted with the type represented by the distributive views that relational egalitarians have aimed to challenge.
Several prominent relational egalitarians clearly conceive of their views as offering alternatives to distributive approaches to justice, in addition to offering an account of the value of equality. Anderson, for example, explicitly contrasts the view that she develops with luck egalitarian approaches to justice. She says that, contrary to what is implied by luck egalitarianism, on her relational egalitarian view, "the proper negative aim of egalitarian justice is not to eliminate the impact of brute luck from human affairs, but to end oppression" (1999, p. 288). Elsewhere, she makes it clear that, on her view, it is relational egalitarian principles that explain when inequality in the distribution of "non-relational goods" is and is not unjust. 11 She says, for example, that while "luck egalitarians claim that inequality is unjust when it is accidental… [,] relational egalitarians claim that inequality is unjust when it disadvantages people: when it reflects, embodies, or causes inequality of authority, status, or standing" (2010, p. 1-2, italics in original). 12 Samuel Scheffler endorses a slightly weaker view than Anderson's about the connection between relational equality and the requirements of distributive justice. On his view, the content of principles of distributive justice is explained by a range of values, including, but not limited to, equality as understood in relational terms (2015, p. 42). Like Anderson, however, he insists that relational egalitarianism is "a genuine alternative to the distributive view" of egalitarian justice, as opposed to a version of such a view (2015, p. 23). He adds that "if we accept the relational view, this will affect the way we think about the content of distributive justice" (ibid). Specifically, the relational approach that Scheffler favours "asks what the broader [relational] ideal of equality implies about distributive questions" (ibid). Like Anderson, then, Scheffler believes that relational egalitarianism will play an important role at least in explaining a range of distributive entitlements, and that the explanations offered for such entitlements by distributive views should be rejected. 13 Christian Schemmel is, among self-described relational egalitarians, perhaps the most explicit about understanding relational egalitarianism as a view about justice, in addition to a view about how we should understand the value of equality. Relational egalitarianism, he says, "is a view about social justice" (2011, p. 366). He notes that "it is unclear what social justice as relational equality demands in distributive terms" (ibid, p. 365), and aims to argue that "a relational egalitarian conception of social justice yields powerful intrinsic and instrumental reasons of justice to care about distributive inequality in socially produced goods -despite its according center stage to just social relationships and not to the distribution of goods per se" (ibid). On Schemmel's view, then, the requirements of distributive justice are explained by the requirements of just social relationships, which are, on the relational egalitarian view of justice that he endorses, the fundamental justice-relevant value. 14 It is clear, then, that at least some prominent relational egalitarians hold that the value of egalitarian social relationships provides the ground-level explanation for entitlements of justice, including distributive entitlements. This should not be surprising, since relational egalitarianism was developed by its early proponents as an alternative to distributive approaches to equality and justice, and in particular to luck egalitarianism. 15 Before I move on to consider the kinds of explanations that can be given in relational-egalitarian terms for entitlements of justice to socially provided healthcare, it is worth highlighting some further key features of relational egalitarian views. This will serve as additional background for thinking about the distributive implications of relational egalitarianism, and the kinds of explanations that can be offered within the relational egalitarian framework for distributive entitlements.
According to Anderson, a central, minimal aim of relational egalitarianism is to eliminate relations of oppression, including domination, exploitation, and marginalization (1999, p. 313; see also Schemmel 2011, p. 366). Opposing these hierarchical relations, relational egalitarians "seek a social order in which persons stand in relations of equality" (Anderson 1999, p. 313; see also Anderson 2012, p. 40 andScheffler 2015, p. 21-23). Achieving relational equality, according to Anderson, requires eliminating at least three types of hierarchy, which are "typically based on ascriptive group identities such as race, ethnicity, caste, class, gender, religion, language, citizenship status, marital status, age, and sexuality" (2012, p. 42). The first are "hierarchies of domination or command," in which some are "subject to the arbitrary, unaccountable authority of social superiors and thereby made powerless" (2012, p. 42-43). The second are "hierarchies of esteem," in which "those occupying inferior positions are stigmatized -subject to publicly authoritative stereotypes that represent them as proper objects of dishonor, contempt, disgust, fear, or hatred on the basis of their group identities" (2012, p. 43; see also Schemmel 2011, p. 380-385). And the third are "hierarchies of standing," in which the interests of those favoured are "given special weight in the deliberations of others and in the normal (habitual, unconscious, often automatic) operation of social institutions" (2012, p. 43; see also Scheffler 2015, p. 35, 37-38 andSchemmel 2012).
In virtue of their concern to eliminate these forms of hierarchy, relational egalitarians are committed to democratic norms according to which everyone is entitled to participate in open discussion as part of a project of collective self-determination, and everyone's claim to be heard and treated with equal respect is to be acknowledged. Relational egalitarians, then, are committed to a requirement of political equality (Anderson 2012, p. 46-47;Scheffler 2015, p. 37). Standing in relations of political equality requires that all citizens have the capabilities that are necessary to function as equal citizens in a democratic state (Anderson 1999, p. 316). The value of relations of political equality, then, will ground entitlements of justice to whatever is necessary for citizens to function as equals in a democratic state, such as a sufficient level of socially provided education.
Anderson's view is not, however, concerned only with the way in which the various types of hierarchy described might undermine political equality. Equal political rights, along with social provision of all of the necessary conditions for individuals to exercise those rights, are, at least in principle, consistent with private relations of domination and exploitation. But Anderson takes these inegalitarian private relations to be unjust as well, and so holds that the capabilities necessary to avoid private oppression must be socially provided. More generally, she accepts a broad view of social equality, according to which individuals must be capable of relating to each other as equals not only within the political arena, but also in civil society more broadly, including in market transactions and in the range of activities that constitute the broader social life of a society. 16 There is, I think, quite a bit that is appealing about Anderson's characterization of her view and about the claim that egalitarian social relationships are a fundamental concern of justice. And the view does seem to be able to incorporate a wide range of the entitlements to resources, services, and opportunities that egalitarians of all types are typically committed to endorsing. For example, having the capability to function as an equal citizen clearly requires having access to adequate food, clothing, and shelter, as well as sufficient education. It also plausibly requires, as Anderson points out (1999, p. 317), effective access to medical care. The ideal of social equality seems clearly capable of grounding entitlements to a sufficient income, to equal opportunity in the pursuit of desirable careers, and to a wide range of familiar social and political rights.
The unique feature of relational egalitarianism that is important for my purposes in this paper is not the content of the entitlements that it entails (though these will differ from the entitlements entailed by at least some alternative egalitarian views), but rather the fact that these entitlements are taken to be grounded in the more fundamental value of egalitarian social relationships. Here is how Anderson puts this point with respect to the distribution of resources: "Certain patterns in the distribution of goods may be instrumental to securing [egalitarian social] relationships, follow from them, or even be constitutive of them. But [relational] egalitarians are fundamentally concerned with the relationships within which goods are distributed" (1999, p. 313-314; see also Scheffler 2003, p. 23 andSchemmel 2011, p. 365). 17 In other words, on relational egalitarian views, any distributive entitlements of justice that individuals have must be explained by their status as a means to egalitarian social relationships, as a necessary consequence of egalitarian social relationships, or as an essential feature of egalitarian relationships themselves. More generally, entitlements of justice must be explained in terms of the value of egalitarian social relationships. 18 Egalitarian social relationships are, then, something of a master value within relational egalitarian views. Individuals' fundamental entitlement of justice is to be capable of standing in egalitarian relations with all of their fellow citizens; and they are derivatively entitled to anything that is a necessary means to, a necessary consequence of, or a constitutive element of such relations.
It is clear that distributive entitlements will sometimes be necessary means to egalitarian social relationships. For example, access to adequate education is surely a necessary condition of becoming capable of functioning as an equal citizen in a democratic society. It also seems at least plausible that certain distributive entitlements might follow as a consequence of the fact that citizens in fact stand in egalitarian social relationships. For example, if a society's economic structure is designed in a way that fosters fair equality of opportunity 19 and the egalitarian social relations that can plausibly be thought to be encouraged in conditions in which individuals engage in economic activity on fair terms, it seems plausible that the distributive outcomes of voluntary transactions generate entitlements of justice. 20 It is at least somewhat less clear what it might mean for a distributive pattern or set of entitlements to be constitutive of egalitarian social relationships. One approach to developing this possibility, which will be relevant to the discussion of entitlements to healthcare provision, is to claim that social provision of certain goods or services is an essential expression, via social institutions, of citizens' equal status. 21 The central idea behind this approach is that part of what it is to stand in egalitarian relationships with one's fellow citizens is to live under shared institutions whose policies properly express the equal status of all. If it can then be argued that, in the absence of policies ensuring the provision of certain goods or services to all, the relevant institutions could not possibly be taken to properly express the equal status of all citizens, then we could conclude that those policies are a necessary condition of egalitarian social relations, not because they are a necessary means of bringing about some other state of affairs that is important from the perspective of relational equality, but instead because they constitute the only available way of expressing the equal status of all in policy.

RELATIONAL EGALITARIANISM AND ENTITLEMENTS TO HEALTHCARE
What do the central features of relational egalitarian views noted in the previous section imply about justice-based entitlements to healthcare? One thing that they imply is that, on a relational egalitarian view, the content of individuals' entitlements to healthcare will depend on what, in the way of healthcare, is necessary to ensure that they are capable of standing in egalitarian social relations to their fellow citizens. In addition, the explanation of why individuals are entitled to what they are, and why they are not entitled to other things, will be that the things to which they are entitled are necessary to ensure that they are capable of standing in egalitarian social relations to their fellow citizens, while the lack of other things from which they might benefit is at least consistent with the development and maintenance of egalitarian social relations. 22 One possible concern about a relational egalitarian account of entitlements to healthcare is that it will not be able to account for all of the entitlements that we intuitively think people have as a matter of justice. In other words, we might worry that relational egalitarianism has implausible implications regarding the extension of entitlements to healthcare. We might worry about this because there seem to be cases in which we think that people are entitled to socially provided healthcare, but in which it is at best unclear whether the care to which we think they are entitled can plausibly be understood as necessary to the development or maintenance of egalitarian relationships, constitutive of such relationships, or an essential expression, via health policy, of citizens' equal status. Consider the following case: Valerie suffers from condition X, which flares up occasionally. When it flares up, it makes it quite painful for Valerie to walk more than a short distance. Nonetheless, she remains capable of getting anywhere that she wants to go, and the condition does not prevent her from performing any essential tasks at her job. No one treats her any differently as a result of her condition, and having it in no way undermines the bases of her self-respect. Still, her life would be significantly better if she were able to avoid the pain that the condition causes.
In order to see why relational egalitarianism might face a problem regarding cases like Valerie's, it will be helpful to consider, first, what we should say if it turns out that her condition is entirely untreatable. Would we think that she simply could not stand to her fellow citizens in an egalitarian relationship of the kind that Anderson and other relational egalitarians have in mind? Surely this cannot be the case. Those with untreatable chronic pain, and many other untreatable conditions, are clearly capable of standing in egalitarian relations to their fellow citizens. It would, I think, be an obviously unacceptable implication of a conception of the egalitarian relationships that ground entitlements of justice if it turned out that Valerie, or, for example, someone with an untreatable physical disability requiring the use of a wheelchair to get around, simply cannot stand in the sort of relations to her (or his) fellow citizens that ground entitlements of justice. Now consider what a relational egalitarian can say about Valerie's entitlement to socially provided treatment for condition X in a case in which such treatment is available. I assume that relational egalitarians will want to hold that, at least as long as the treatment is not extremely expensive, and as long as there are not many more urgent justice-relevant concerns that need to be addressed and ought to take priority, Valerie will be entitled to socially provided treatment. But if her pain is not a barrier to her ability to stand in egalitarian relations to her fellow citizens when it is untreatable, then at least certain ways of accounting for her entitlement to treatment are not going to be available to the relational egalitarian. Specifically, it cannot be claimed that alleviating pain of the kind that she experiences is necessary for the development or maintenance of egalitarian social relations between those who suffer from that kind of pain and their fellow citizens. After all, the pain is not itself a barrier to such relations, as we saw from considering the case in which it is untreatable.
This may not seem like a significant problem, since, as I noted earlier, relational egalitarians can claim, of some entitlements of justice, that social provision is an essential expression, via social institutions, of citizens' equal status. And it may seem quite plausible to say that providing treatment for pain like Valerie's, when it is available, is such an essential expression. Failure to provide it, we might think, would amount to the community expressing that she has an inferior status within society, since viewing her as an equal would seem to require the sort of concern about her pain that would generate social provision of available treatment.
This seems to me to be the kind of explanation that a relational egalitarian will likely have to offer for entitlements to treatment in cases like Valerie's, 23 which I assume they will generally want to endorse. But I think that there are reasons to be concerned about explanations of this kind. One reason for concern is that it is far from clear that the appeal to the need for policy to express the equal status of citizens is distinctive of relational egalitarianism. 24 This, of course, does not provide any reason to reject a relational egalitarian approach. It does, however, prevent relational egalitarians from appealing to the fact that their view allows for this kind of explanation in order to provide support for their approach as against alternatives. A second reason for concern is that it is not clear that the appeal to the need for policy to express the equal status of citizens avoids implicit commitment to claims that, it seems to me, relational egalitarians are committed to rejecting, and which are endorsed by proponents of more fundamentally distributive approaches.
First, a wide variety of egalitarian views, including luck egalitarian views, hold that policy must reflect and express the equal status of citizens. Of course, there is disagreement about exactly which policies properly do this, since there is also disagreement about which fundamental values must inform policy if it is to have the appropriate expressive content. What is supposed to be distinctive about relational egalitarianism is that it holds that the value of egalitarian social relationships, not other values, must ground policy in order to properly reflect and express citizens' equal status. In order to be a distinctive view, relational egalitarianism requires an independent account of the content and requirements of egalitarian social relationships, which can then serve as a criterion for assessing candidate entitlements of justice. On such a view, in order for something to be an entitlement of justice, it must be necessary for the promotion or maintenance of egalitarian relationships as defined by the relevant view, or else constitutive of such relationships. If something is neither necessary as a means to nor constitutive of egalitarian social relations, then it is difficult to see how proponents of the view that such relations are the fundamental value that grounds entitlements of justice can claim that providing that thing is necessary to express citizens' equal status. In the absence of an argument that appeals to an independent account of the content of egalitarian social relations for the claim that providing treatment for Valerie's pain is either necessary as a means to or constitutive of such relations, then, it seems ad hoc for a relational egalitarian to claim that the provision of treatment is a necessary expression of her equal status. 25 Since her condition is not itself a barrier to egalitarian social relations (as was shown by considering the case in which it is untreatable), the explanation of why the claim that providing treatment is an essential expression of her equal status is true cannot be that providing the treatment is a necessary means to bringing about, or is constitutive of, the conditions for egalitarian social relations. Instead, if it is true that providing treatment for her condition is the only way that the community can properly express her equal status, the explanation for this would seem to be that alleviating her pain matters in itself, in a way that is relevant to justice-that is, it matters even though the presence of the pain is not itself a barrier to egalitarian social relations between her and her fellow citizens. But this is something that, it seems to me, a relational egalitarian cannot say. What is supposed to be distinctive of relational egalitarianism is that it holds that our fundamental justice-relevant interest is in egalitarian social relationships with our fellow citizens, and that any other justice-relevant interest that we have is derivative of that fundamental interest. On this view, to the extent that we have a justice-relevant interest in, say, the alleviation of pain, which grounds entitlements to things like medical care, this has to be explained, ultimately, in terms of our fundamental justice-relevant interest in egalitarian social relationships. Where an interest that people have is not connected in the right way to their interest in egalitarian social relations, relational egalitarians have to accept that it is not a justice-relevant interest that can ground justice-based entitlements. And trying to avoid this implication, where it seems intuitively implausible, by claiming that providing for the interest is an essential expression of a person's equal status, seems objectionably ad hoc. 26

V O L U M E 1 3 N U M É R O 3 A U T O M N E / F A L L
Note that more explicitly distributive views seem to be able to handle cases like Valerie's quite a bit more easily. Many such views accept that avoidance of pain is itself a fundamental justice-relevant interest, 27 while others accept that our justice-based entitlements to resources and services are themselves explained by our broader interests, including the interest in avoiding pain. 28 I suspect that the best response on behalf of relational egalitarianism is to argue that if the community were to fail to provide available treatment for Valerie's condition, this would in fact undermine what could otherwise be egalitarian social relations between her and her fellow citizens. This could not be because her condition itself makes egalitarian relations impossible, but must instead be because the community's failure to provide relief when it could have done so will necessarily affect the way in which Valerie can relate to her fellow citizens. In particular, the thought is that the community's refusal to provide available treatment would make it impossible for her to engage with her fellow citizens on terms of equality, perhaps because the community's chosen policy cannot be plausibly interpreted other than as an indication that she is viewed as having inferior status.
On the one hand, it seems to me plausible that the community's failure to provide available treatment to Valerie would, at least in some circumstances, undermine what could otherwise be egalitarian social relations between her and her fellow citizens. Because of this, it seems true that relational egalitarians can plausibly insist that their view is consistent with the intuition that she is entitled, as a matter of justice, to socially provided treatment. It is, however, difficult to see how the ground-level explanation of her entitlement could lie in the value of egalitarian social relations, as it must for a relational egalitarian. This is because when we ask why it is that failure to provide treatment would undermine the possibility of egalitarian social relations, the answer cannot be that the condition itself is incompatible with egalitarian relations. Instead, it seems to be the failure to alleviate avoidable pain that makes it the case that, in the absence of socially provided treatment, egalitarian social relations would be undermined. We take it that Valerie would be justified in thinking that the community is not treating her as it should, that she is being denied something to which she is entitled as a matter of justice. And it is the fact that she would be justified in objecting to the policy, on independent grounds, that explains why the policy would undermine the possibility of egalitarian social relations. If we did not think that there are good independent grounds for objecting to the policy, then we would not have any reason for thinking that it would undermine egalitarian social relations. Therefore, the fact that the policy would undermine egalitarian social relations cannot explain why Valerie would be justified in objecting to it. Instead, the order of explanation goes the other way. But relational egalitarians cannot accept what seems to be the right direction of explanation here. It seems to be the case that Valerie's independent interest in pain avoidance explains why she would be justified in objecting to a policy that does not include socially provided treatment for her condition, and the fact that she would be justified in objecting to the policy explains why the policy would undermine the possibility of egalitarian social relations between her and her fellow citizens. But this line of explanation attributes to Valerie a fundamental justice-relevant interest in pain avoidance, and that seems to be something that relational egalitarians are committed to rejecting.
There is a closely related and, I think, simpler point that we can see in light of the line of reasoning that I have developed. It now seems that there is a way in which the relational egalitarian can get what will seem, at least in many cases, to be the correct answer about Valerie's entitlement to treatment for her painful condition. It does seem true that the community's failure to provide treatment would, in the absence of conditions that would justify this failure, undermine the possibility of egalitarian social relations between her and her fellow citizens. So, relational egalitarianism can, it seems, avoid extension problems in cases like Valerie's. It can, that is, give what appear to be the correct answers to questions about who is entitled to what in the way of healthcare. I suspect that this will be true in at least most cases, so that relational egalitarian views will not face any significant problems regarding the extension of entitlements to healthcare. But in cases like Valerie's, the explanation that relational egalitarians must give of why individuals are entitled to the healthcare that they are seems difficult to accept. If we ask why Valerie is entitled as a matter of justice to treatment for her condition, the right explanation seems to be that she has an important interest in the avoidance of pain that the community is obligated to take seriously when making health policy. That is a straightforward and, it seems to me, intuitively compelling answer to the question. The relational egalitarian, on the other hand, must say that she is entitled to treatment because the failure to provide it would, in some way or other, undermine egalitarian social relations. I have acknowledged that when it is true that a person is entitled to treatment, but not provided with it, this is likely to undermine egalitarian social relations. But it simply does not seem as though this fact can constitute the ground-level explanation of why someone like Valerie is entitled to treatment for her condition. To see why, imagine that we are asked whether we think that she is entitled to treatment, and aim to answer this question in a way that is consistent with a commitment to relational egalitarianism. It would appear that what we would have to say is something like the following: Well, of course the condition is quite painful, but what we really need to know in order to determine whether she is entitled to treatment is whether failing to provide it would undermine egalitarian social relations. If it would, then she is entitled to the treatment. Otherwise, justice does not require that it be provided.
It may be true that, barring unusual conditions, every failure to treat a treatable painful condition would undermine egalitarian social relations. If this is the case, then relational egalitarianism will not have any particular problems getting the right extension when it comes to healthcare policy. But its explanations of why it is that people are entitled to the treatment that they are strike me as difficult to accept, and certainly less intuitive than the alternative of referring directly to the sort of justice-relevant interest in pain avoidance that more fundamentally distributive views can allow that we have. 29

CONCLUSION: RELATIONAL AND DISTRIBUTIVE APPROACHES TO JUSTICE
The fact that relational egalitarian views face the kind of difficulty that I have highlighted when it comes to providing plausible explanations of justice-based entitlements to healthcare seems to me to constitute a significant challenge to the relational egalitarian project of grounding entitlements of justice in the value of egalitarian social relationships. Nevertheless, I do not take the argument that I have offered in this paper to amount to anything like a decisive case against relational egalitarian approaches to justice, or a vindication of a more fundamentally distributive approach. What I have offered is a characterization of a challenge for relational egalitarianism that, it seems to me, has not been fully appreciated in discussions of the view thus far. I take myself, then, to have presented relational egalitarians with a plausible line of objection to their view, which an adequate defence of the view must address.
One response that a relational egalitarian might offer to my challenge is to acknowledge that the explanations of entitlements to healthcare that are available on the relational egalitarian approach are indeed counterintuitive, but to claim that we nonetheless ought to accept them, since the more fundamentally distributive approaches that are consistent with more intuitively plausible explanations face even more significant objections. 30 I accept that this is a possibility worth taking seriously, although I am at least cautiously optimistic about the prospects of developing an approach that avoids commitment to the kinds of explanations of entitlements to services such as healthcare provision that I have criticized, while also accommodating what seems to me to be the central valuable insight that relational egalitarian views have brought to recent discussions of justice, namely that individuals have a fundamental justice-relevant interest in standing in egalitarian social relations to their fellow citizens.
One way of attempting to develop such a view is to include egalitarian social relations within a pluralist account of the currency of justice. 31 Although this approach has been suggested by some luck egalitarians (Lippert-Rasmussen 2015b), I suspect that it may be at least somewhat easier to develop within views that include distributive principles that are inconsistent with luck egalitarianism than within views that include central luck egalitarian commitments. For example, the luck egalitarian commitment to permitting distributive inequalities that are the result of choices for which individuals can be held responsible appears to put at least some pressure on a view to permit distributive inequalities that might threaten egalitarian social relations. More generally, the fact that people find themselves on the disadvantaged side of inegalitarian relations with some of their fellow citizens can, in principle, be the result of choices for which they can be held responsible. 32 There appears, then, to be at least some difficulty facing those luck egalitarians who might attempt to incorporate egalitarian social relations directly into the currency of justice and to combine that account of the currency of justice with a luck egalitarian distributive principle.

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Consider, alternatively, the relative ease with which it appears possible to combine a pluralist account of the currency of justice that includes egalitarian social relations with, for example, a sufficientarian distributive principle. If we hold that justice requires that everyone be provided with a sufficient share of the elements that make up a pluralist account of the currency of justice, it seems open to us to hold that, with respect to social relations, sufficiency requires equality. We can, on this type of view, also hold that sufficiency with respect to goods and services such as income and healthcare requires that all citizens be provided, insofar as this is possible, with, for example, a share of these goods that allows them to live a pleasant, rich, and satisfying life. 33 And since pain avoidance is clearly a constitutive feature of the values that, on this type of view, ground the entitlement to a sufficient share of goods and services, Valerie's entitlement to treatment for her condition can be explained in a way that is much more intuitively plausible than the explanations available on relational egalitarian views. 34 It is unclear to me what the best version of a view of this general type might look like, and also unclear whether such a view can ultimately be defended. I cannot pursue the matter further here, but must leave it for future work. What I do hope to have accomplished in this paper is to have provided some reasons for those who are attracted to relational egalitarian approaches to justice to take seriously the possibility that at least some entitlements of justice must be grounded in values other than egalitarian social relationships. If I have succeeded in this aim, then the project of developing a view that takes both egalitarian social relationships and basic interests such as pain avoidance as fundamental justice-relevant interests should become more appealing than it has appeared to be thus far. This would, it seems to me, be a positive development within debates about the fundamental values that ground requirements and entitlements of justice.

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The seminal contribution is Anderson (1999); see also Anderson (2010 and and Scheffler (2003Scheffler ( , 2005Scheffler ( , and 2015). 2 Important discussions within the distributive framework include Dworkin (1981a and1981b) and Cohen (1989). 3 Both luck egalitarian views (e.g., Cohen 1989) and Rawlsian views (e.g., Rawls 1999) share this feature. 4 See, for example, Wolff and De-Shalit (2007), Fourie (2012), and Lippert-Rasmussen (2012, 2015a, and 2015b. 5 See, for example, Anderson (1999, 2010), Scheffler (2003, 2005, and Schemmel (2011 and. 6 Indeed, I am inclined to think that this view is correct. 7 For sympathetic discussion of relational egalitarian approaches to health and health care justice, see Voigt and Wester (2015) and Kelleher (2016). 8 For recent discussion of the relationship between luck egalitarianism and relational egalitarianism (or democratic egalitarianism, as it is sometimes called) see Anderson (2010) and Lippert-Rasmussen (2012, 2015a, and 2015b. With regard to health and healthcare, see Kelleher (2016, p. 89-94). For a defence of a luck-egalitarian approach to justice in health and healthcare provision, see Segall (2010). 9 Once again, some who endorse the criticism that prominent distributive approaches are problematic because they have neglected the value of egalitarian social relations do not reject distributive accounts entirely, and so hold that the right kind of commitment to the value of relational equality is not necessarily incompatible with at least some distributive approaches, potentially including luck egalitarian approaches. The contrast that I suggest between luck egalitarian and relational egalitarian answers to the question of why individuals are entitled to the socially provided healthcare that they are applies only to relational egalitarian views that constitute competitors to distributive approaches such as luck egalitarianism. 10 I am grateful to an anonymous reviewer for prompting me to clarify this. Views that include a relational egalitarian component that is treated as separable from, and potentially in competition with, justice can be found in Cohen (2009) and Mason (2012). 11 Presumably Anderson uses the phrase "non-relational goods" to refer to the various kinds of goods that distributive theorists might think constitute part of the proper currency of justice. 12 Further evidence that Anderson conceives of her relational egalitarian view as, at least in part, a view about justice, and about distributive justice in particular, can be found in her claim that "relational egalitarians identify justice with a virtue of agents (including institutions). It is a disposition to treat individuals in accordance with principles that express, embody, and sustain relations of social equality. Distributions of socially allocated goods are just if they are the result of everyone acting in accordance with such principles" (Anderson 2010, p. 2; see also Anderson 2012, p. 44). 13 It is a bit difficult to state precisely to what extent my argument in this paper constitutes a challenge to Scheffler's overall view, since he does not specify which values, apart from relational equality, can contribute to explaining distributive entitlements. It seems to me, however, that Scheffler's insistence that the relational egalitarian view that he endorses constitutes a genuine alternative to distributive views puts at least some pressure on him to reject the kinds of explanations of entitlements to socially provided healthcare that I will argue seem most plausible. 14 See also Schemmel's remarks about the justice-relevance of relational egalitarian considerations in his 2012 contribution (p. 124-125, 128-129, 131, 133-134). 15 This fact about the development of relational egalitarianism is noted by Schemmel (2011, p. 389). It is most explicit in Anderson (1999 and2010) and Scheffler (2003 and2005). 16 Anderson discusses what she views as the problematically inegalitarian relationships that exist in contemporary workplaces between superiors and subordinates in her 2017 contribution. 17 Kasper Lippert-Rasmussen describes relational egalitarianism's concern for distributive matters in a somewhat narrower way. Relational egalitarians, he says, "contend that distribution matters only instrumentally in virtue of its impact on social relations and the degree to which these are suitably egalitarian" (2012, p. 118). This description seems to me unduly narrow, since Anderson's claim that some distributive requirements might be constitutive of egalitarian social relations seems at least plausible. I am grateful to an anonymous reviewer for helping me to clarify the relationship between Anderson's and Lippert-Rasmussen's descriptions of relational egalitarianism's concern for distributive issues. 18 Schemmel's (2011) argument that range constraints on distributive inequality are required as a matter of justice clearly proceeds on the assumption that this claim is correct. 19 For the ideal of fair equality of opportunity, see Rawls (1999, p. 73-78). 20 It is important that, for relational egalitarians, the conditions in which individuals engage in economic transactions must actually realize egalitarian social relationships in order for the distributive outcomes of voluntary transactions to generate robust entitlements of justice. This requirement will, on at least many views of what egalitarian social relationships consist in and require, rule out entitlements being generated in all of the cases in which, for example, right libertarians will take them to be generated. 21 For an argument that takes this form, but which focuses on range constraints on distributive inequality, rather than on entitlements to socially provided healthcare, see Schemmel (2011, p. 371-375). 22 Voigt and Wester describe the implications of relational egalitarianism for entitlements to healthcare in this way (2015, p. 211), and they note that both Anderson (1999, p. 317) and Scheffler (2003, p. 23) suggest this as well. 23 For discussion, see Voigt and Wester (2015, p. 212-214). 24 As an anonymous reviewer helpfully points out, it seems consistent with Ronald Dworkin's view that coercive institutions must express equal concern, via policy, for those subject to their authority (2000, p. 1). 25 In some circumstances, relational egalitarians (and others) might plausibly deny that Valerie is entitled to treatment for her pain, and so accept that there is no argument that can, or needs to, be made to the effect that providing it is an essential expression, via social institutions, of her equal status. This would plausibly be true in cases in which society faces a shortage of resources and there are more urgent priorities that must be addressed first, or perhaps in cases in which the treatment is, for reasons that cannot be justly remedied by society's institutions, extremely costly. It might also be true in cases in which society has chosen to prioritize providing a variety of other goods and services to Valerie and people like her, and has reasonably left treatment for her particular condition off the list of socially provided services. I am assuming, however, that relational egalitarians will, in at least some cases, want to insist that Valerie is entitled to socially provided treatment, and I am considering what kinds of explanations they can offer for this entitlement in those cases. I am grateful to an anonymous reviewer for prompting me to clarify this. 26 Relational egalitarians might claim that the explanation of Valerie's entitlement to treatment for her pain is that relating as equals within a political community requires that everyone's interests, or at least their justice-relevant interests, are equally taken into account in decisions made on behalf the community (see Scheffler 2015, p. 35 and 38). While this claim is plausible, for reasons that are given in the remainder of this section, I believe that the structure of the explanation that it allows relational egalitarians to provide for entitlements to socially provided healthcare is less plausible than alternative explanatory structures available on distributive views. I am grateful to an anonymous reviewer for prompting me to consider this type of explanation. 27 All welfarist views clearly have this implication, regardless of their position on the appropriate distributive principles, as do all positions that take welfare to be among the components of the correct currency of justice. For a view of the latter type, see Cohen (1989). At least some distributive views, however, may face greater difficulty offering quite as simple and intuitive an explanation of Valerie's entitlement to socially provided treatment. It seems to me that this provides at least some reason to favour views that include welfare as part of the currency of justice, though I cannot defend that claim here. 28 Consider, for example, a view on which resources are accepted as the currency of justice because of concerns about the implications of views that include welfare as part of the currency in cases involving expensive tastes (Dworkin 1981a, p. 228-240). Proponents of such a view might plausibly hold that a central part of the explanation of our resourcist entitlements is that the resources to which we are entitled will typically serve as means to promote various interests that we have, including, potentially, the interest in avoiding pain. 29 A large issue that arises for views that accept the kind of explanation of entitlements to socially provided healthcare that I claim is plausible is whether they can justify limiting the entitlements to members of a particular political community. Relational egalitarians might claim that it is an advantage of their approach that it can more easily justify this limitation, since it is plausible and widely accepted that the demands of social equality apply only within, and not across, political communities. I obviously cannot address this issue in any detail, but it seems to me that there are two reasons to doubt that relational egalitarians can claim a clear advantage over distributive views here. The first is that there are no obvious grounds for thinking that distributive theorists cannot consistently hold that an individual's interest in pain avoidance grounds entitlements of justice only within their particular community. And the second is that it is not obvious that there are compelling grounds on which relational egalitarians can deny that the value of egalitarian social relations can ground entitlements, and therefore obligations, of justice that apply across the boundaries of political communities. 30 The idea here is that we should judge competing theoretical positions according to a standard of relative plausibility and, at least provisionally, accept the one, of the sufficiently plausible alternatives, that is most plausible in comparison with the others. This will, at least in many cases, commit us to accepting views that we acknowledge face potentially significant objections, simply because all of the available views face at least some significant objections. For an argument that adopts this notion of relative plausibility as its standard, see Murphy (2000). 31 Lippert-Rasmussen (2015b) develops a view of this kind, on which he includes social standing in the currency of justice within a luck egalitarian framework. G. A. Cohen (2009) suggests that an ideal of "community," which bears strong resemblances to what relational egalitarians typically have in mind when referring to egalitarian social relations, might constitute a set of background conditions within which principles of luck egalitarian distributive justice should operate. Cohen's view does not, strictly speaking, build egalitarian social relations into the currency of justice, as he understands it. A view that incorporates Cohen's set of normative commitments could, however, be described in those terms. 32 Of course, in the actual world, inegalitarian social relations overwhelmingly do not derive from choices for which those on the disadvantaged side can be held responsible. 33 This is, of course, a rather imprecise criterion. It is, however, sufficient for my merely illustrative purposes here. Anderson (1999) suggests that relational egalitarianism might be best interpreted as implying a sufficientarian distributive requirement; for criticism see Schemmel (2011). 34 As an anonymous reviewer points out, it may be that, on some sufficientarian views, Valerie will not be entitled to socially provided treatment for her condition. If we think that the correct view of justice should imply that she is, at least in some cases (e.g., those in which it is not too expensive), entitled to treatment, then we should reject those sufficientarian views. The important point for my purposes is that sufficientarian views that do imply that she is entitled to socially provided treatment can provide what seems to be a quite plausible explanation of her entitlement.