What we owe to impaired agents

According to relational egalitarians, a just society is one where the state considers and treats persons as equals, and persons stand in relations of equality with one another (Anderson, 1999; Lippert-Rasmussen, 2018; O'Neill, 2008; Scheffler, 2003; Schemmel, 2021; Wolff, 1998). Relational egalitarians, however, have so far been mainly concerned with how fully competent adults must be considered and treated as equals, whereas they have said much less about what a relational egalitarian society owes to those individuals whose agential capacities are impaired due to mental health issues, such as depression or drug and alcohol addiction.1 The aim of this article is to address this lacuna in the relational egalitarian literature. Exploring this issue is important for at least two reasons. First, impaired agents represent some of the most vulnerable members of society: they are often looked down upon by others and are deprived of the conditions necessary to exercise their political rights, take part in social cooperation, and establish meaningful social relationships. Therefore, it is crucial to develop an account of what is owed to impaired agents to enrich our understanding of what is required to achieve an inclusive society of equals. Second, this exploration will enable us to address a neglected tension between the demands of relational equality, and shed light on the role of its most fundamental background commitment: the principle of basic moral equality. This article is divided into two parts. In the first part, I propose a novel theory of respect for persons' agential capacities that defines what a relational egalitarian society owes to impaired agents as a matter of respect for their equal standing. In Section 2, I illustrate how the social condition of impaired agents generates a tension between two core demands of relational equality. On the one hand, relational egalitarians argue that the state should express appropriate respect for persons' equal standing by refraining from making demeaning judgments about their variable agential capacities, which would allow ranking them on a scale of moral personality. On the other hand, they maintain that the state should enable everyone to function as equal citizens. However, I argue that a duty to refrain from assessing individuals' agential endowments is sometimes incompatible with a duty to ensure that impaired agents have access to the assistance necessary to be able to function as equal citizens. To overcome this tension, in Section 3, I develop a dualist account of respect for persons' agential capacities. According to this account, respect does not only entail abstaining from assessing individuals' agential capacities, but it also requires a positive duty to offer help and support to address mental health issues that diminish moral personality. Call this kind of respect, positive respect. The principle of positive respect, I argue, offers a coherent and convincing account of how the state should express appropriate respect for impaired agents. In the second part of the article, I show that the dualist account of respect yields original and significant implications for the most fundamental background commitment of relational equality: the principle of basic moral equality. In Section 4, I introduce the moral inequality objection, according to which the theoretical price of accepting a duty of positive respect is moral inequality. This is because such a duty presupposes taking into account the unequal degree to which impaired agents hold their basic agential capacities, thus compromising their status as equals (Arneson, 2015; Christiano, 2015; Floris, 2019). Therefore, so the objection goes, relational egalitarians must reject the dualist account of respect because it undermines the very basis of impaired agents' claim to be considered and treated as equals. In response, in Section 5, I argue that fulfilling a duty of positive respect often does not presuppose a violation of persons' equal moral status. In Section 6, I contend that, when it does, it is still morally more important to fully respect impaired agents by providing them with help and support to (re-)acquire and maintain their ability to stand in relations of equality with others, rather than considering them as equals but failing to offer them the assistance that they need. Relational egalitarians have so far not paid enough attention to the obligations a just society has toward those individuals whose agential capacities are impaired due to mental health issues. This article fills this gap by developing a theory of what is owed to impaired agents as a matter of respect for their equal standing. Crucially, this theory reveals that relational egalitarians must rethink some of their most fundamental premises: respect for persons sometimes requires evaluating individuals' varying agential capacities. And, while this kind of respect often does not violate persons' status as equals, even when it does, this is not as morally problematic as they commonly believe. A central tenet of relational equality is that the state should express appropriate respect for persons' equal standing (Anderson, 1999; Hojlund, 2021; Schemmel, 2021; Voigt, 2018). "Persons" are typically defined in Rawlsian terms as individuals who hold the capacity to develop, revise, and pursue a conception of the good, along with the capacity for a sense of justice up to a sufficient minimum for moral personality (Rawls, 1971: 507).2 Accordingly, the state should express appropriate respect for persons' equal standing by avoiding ranking them on a scale of moral personality based on the degree to which they are capable of rationally advancing their own good and formulating reasonable value commitments. This is a fundamental demand of what basic "recognition respect"3 for persons qua moral persons requires. Many prominent relational egalitarians share this requirement of basic recognition respect for persons.4 Elizabeth Anderson, for example, accuses luck egalitarianism of being profoundly disrespectful, thus failing the "most important test that any egalitarian theory must meet," because "in attempting to ensure that people take responsibility for their choices, makes demeaning and intrusive judgments of people's capacities to exercise responsibility and effectively dictates to them the appropriate uses of their freedom" (Anderson, 1999: 289). In a similar vein, Samuel Scheffler observes that luck egalitarianism's redistributive policies are based on "judgments that are strongly 'inward looking'" (Scheffler, 2003: 21). Specifically, "the aim of neutralising the distributive effects of brute luck requires intrusive and conceptually problematic judgements about the inner sources of people's disadvantages" (Scheffler, 2003: 28). In his critique of distributive views of equality, Jonathan Wolff also points out that it is fundamentally disrespectful to single out individuals with internal endowment deficits—respect requires refraining from close scrutiny (Wolff, 1998). Finally, Christian Schemmel argues that "it would be fundamentally disrespectful for agents of social justice to undertake any assessments of moral qualities that would allow them to rank individuals on a scale of moral competence (degree of possession of moral powers, in our Rawlsian case)" (Schemmel, 2021: 108). In a relational egalitarian society, then, the state should express appropriate recognition respect for persons' equal standing by refraining from inquiring into, and acting on, differences among individuals in terms of agential endowments, which would allow placing them on a status hierarchy of moral personality and singling out some individuals as "less competent" moral agents. In other words, respect for persons requires abstaining from taking into account variations in degrees of agential capacities when reasoning about how they ought to be treated. Following Ian Carter, we can call this kind of respect, "opacity respect" (Carter, 2011). Imagine a society that intends to implement distributive policies aimed at making those individuals with lesser internal endowments better off, as long as these policies do not presuppose an assessment of persons' agential capacities. Suppose the state decides to provide its citizens with a universal and unconditional basic income. This will undoubtedly improve the conditions of the worse off. But now take the case of John: John holds the agential capacities up to the personhood threshold, but he suffers from an alcohol use disorder, which consists in "the use of heavy doses of alcohol with resulting repeated and significant distress or impaired functioning" (American Psychiatric Association, 2013: 496). Finally, assume that the basic income is insufficient for John to access the medical and psychological treatment he needs. The case of alcoholic John generates a tension between the demands of relational equality. On one hand, relational egalitarians commonly share the intuition that persons, like John, should be offered the necessary help to address their health condition so as to (re-)acquire and maintain the ability to function as equals in society. As Anderson put it, "What citizens ultimately owe one another is the social conditions of the freedoms people need to function as equal citizens" (Anderson, 1999: 320). On the other hand, as we have seen, the commitment to a form of "opacity respect" makes relational egalitarians reluctant to allow the state to pass judgments over persons' agential capacities. Evaluating John's agential capacities would be disrespectful, for it would entail singling him out as disadvantaged in terms of agential endowments, thereby placing John on a scale of moral personality and therefore compromising his status as equal. Arguably, however, refraining from assessing the agential capacities of persons with mental health issues ensures their equal status in name only. This is because impairments to agential capacities constrain individuals' ability to function as equal citizens in several respects. Studies show that substance use and depressive disorders are key factors in reducing political participation (Ojeda, 2015) and significantly impact access to socio-economic opportunities (Henkel, 2011; Pfeifer Schemmel, 2021; Wolff, 2015). However, relying on a form of "opacity respect" deprives relational egalitarians of the theoretical resources necessary to justify a positive duty to offer assistance and support to those persons whose agential capacities are impaired—insofar as it requires refusing to assess persons' agential endowments—thereby rendering them vulnerable to social exclusion and incapable of functioning as equals in society. It might be objected that the tension between these demands of relational equality is only apparent because addressing the specific vulnerability of impaired agents, like John, does not necessarily violate the state's duty to express opacity respect toward its members qua equals. Consider, for instance, the allocation of a compulsory insurance package. If such a scheme is in place, individuals with impaired agential capacities can voluntarily disclose this information to a doctor. The doctor, in turn, does not need to notify any state official about their patient's condition for them to be entitled to the necessary benefits to address their internal impairments. Therefore, the state does not need to violate its duty of opacity respect by considering individual disadvantages in terms of agential capacities when determining how persons should be treated.5 The main problem with this line of argument, however, is that it makes the positive duty to offer assistance conditional on the recipient asking for it. This, however, does not seem plausible: if A sees that B is in danger, A should offer B help without waiting for B to realize that they are in need of assistance and even if B does not ask for it—at least when we are entitled to assume that B would not be opposed to being offered help. This point is particularly significant for the cases at hand because mental health issues are often the cause of both epistemic and volitional limitations that prevent a person from actively seeking help (Warren, 2018: 213–218). For example, it is precisely because of his alcohol use disorder that John may not recognize that he has a problem—being alcoholic—that needs to be addressed or that, despite acknowledging his health condition, he may lack the strength of will sufficient to ask for assistance. For this reason, I argue that the ex-ante provision of public assistance, which relies on persons' ability and willingness to actively seek help, is insufficient to provide appropriate assistance to those individuals who are epistemically or volitionally incapable of asking for help due to internal impairments. Instead, society should also offer ex-post help and support by promoting outreach programs aimed at identifying those individuals who are out of reach of traditional health care services to improve access to service as well as service uptake.6 For instance, in Portugal, teams of social workers are deployed to reach out to the most marginalized drug addicts, who live in abandoned housing or on the streets, and encourage them to seek treatment (Hari, 2015: 244–245). Similarly, in recent years, the city and county of Los Angeles have set up teams of mental health, medical, and substance abuse professionals who operate in socially deprived areas, such as Skid Row, providing assistance to individuals who struggle with addiction and mental illness (Holland, 2015). These healthcare and social services are necessary to foster the active inclusion of those persons whose agential capacities are impaired due to mental health issues by providing them with assistance to (re-)acquire and maintain their ability to fully participate as equals in society. However, they are inconsistent with a commitment to opacity respect because they presuppose singling out individuals or social groups who are entitled to special measures of assistance in light of agential deficits (Carter, 2011: 504–506). Therefore, I conclude that unconditional and universal forms of assistance that are compatible with opacity respect are insufficient to ensure that impaired agents have access to what they need to function as equal citizens. Relational egalitarians argue that the state should express appropriate respect for persons by refraining from raking them on a scale of moral personality. Hence, it should abstain from evaluating the degree to which persons are capable of rationally developing and pursuing their own interests and formulating reasonable value commitments, as a matter of respect for their equal standing. In the previous section, I showed that this commitment is, however, in tension with another fundamental demand of relational equality, wherein the state should enable everyone to function as equal citizens. This is because refusing to assess individuals' agential endowments is sometimes incompatible with a positive duty to offer assistance to persons whose agential capacities are impaired, thereby making them vulnerable to social exclusion and incapable of standing in relations of equality with others. Accordingly, in this section, I argue that relational egalitarians should abandon the monist view of basic respect for persons' agential capacities and embrace a dualist account, which includes not only (i) a duty of opacity respect to refrain from inquiring into the level of persons' agential capacities, but also (ii) a duty of what I call "positive respect" to assess individuals' varying capacities when this is necessary to provide impaired agents with what they need to (re-)acquire and maintain the ability to function as equal citizens.7 In a relational egalitarian society, then, the state should express appropriate respect for all persons' equal standing by balancing these potentially conflicting requirements. In what follows, I address two objections that can be raised against the principle of positive respect. This will help us further clarify this notion and illustrate how it should be balanced against the other requirement of basic respect for persons' agential capacities. First, it might be objected that the tension between the demands of relational equality is not one between different requirements of respect for persons' agential capacities but rather one between what respect for persons' agency requires, on the one hand, and what concern for persons' welfare (or interests) entails, on the other.8 In reply, it should be noticed that our focus here is on what a relational egalitarian society owes to impaired agents qua persons, that is, individuals whose agential capacities are impaired but have not dropped below the minimum threshold of moral personality. What is at stake, then, is not primarily a concern for impaired agents' welfare, but what respect for their agency requires. This point is not merely terminological but has substantive implications for the content of the positive duty toward impaired agents. Since impaired agents are still agents and the positive duty is a response to their agency, the latter is not a paternalistic duty to bypass their agency for the sake of furthering their own good but one to offer assistance to address mental health issues that diminish their agential capacities.9 Thus, for example, a commitment to positive respect does not justify mandatory participation in therapy sessions or recovery groups. The dualist account of respect, therefore, shows that respect for persons' moral agency does not only entail a negative duty to refrain from assessing their agential capacities and let them exercise their agency as they see fit. Instead, it also implies a positive duty to ensure that persons have access to the social conditions necessary to (re-)acquire and maintain their unimpaired agential abilities. Moreover, it reveals that more liberal relational egalitarian views, which are reluctant to accept (coercive) paternalistic forms of intervention,10 also have the theoretical resources to justify a positive duty to offer assistance and support to those persons whose agential capacities are impaired due to mental health issues, as a matter of respect for their equal standing. A second objection consists in observing that a duty of positive respect presupposes a certain degree of intrusiveness to ensure that persons are offered help in maintaining an unimpaired moral personality. However, since everyone presumably would suffer from some kind of internal impairment at some point in their life, this positive duty seems to legitimize a kind of Orwellian society where citizens live under constant state surveillance aimed at "fixing" or "curing" their agential capacities. Not only is holding that respect entails such pervasive and deep intervention in persons' lives independently implausible, but it also makes a duty of opacity respect redundant. Call this the excessive intervention objection. To address the excessive intervention objection, it is necessary first to understand what kinds of internal impairments call for intervention based on a duty of positive respect. The World Health Organization defines impairment as "any loss or abnormality of psychological, physiological, or anatomical structure or function" (WHO, 1980). Many have pointed out that this definition presupposes an arbitrary conception of "normality," which is unable to generate any normative prescriptions.11 For our purposes, however, it should be recalled that we are working within a theoretical framework, which assumes that "moral personality" is the value that defines what a person is. Hence, it is reasonable to understand the internal impairments in question here, as deficiencies in the functioning of a person's moral personality, which diminish their agential capacities, but not to a level lower than the minimum threshold for moral personality. The question, then, is: what kinds of deficiencies generate demands of positive respect? Although individual cases can pose difficult or insoluble diagnostic dilemmas, psychiatry has developed publicly accepted methods – currently embodied in DSM IV – by which agreed upon diagnoses can generally be established. Our very general concern to meet people's health care needs for treatment of disease and impairment can be precisely focused around reliably identifiable instances (Buchanan et al., 2000: 142–143). Since the fulfillment of a duty of positive respect might entail a violation of opacity respect, we must be very cautious in determining the circumstances that justify an infringement of the latter for the satisfaction of the former—in particular, in the context of the relationship between political institutions and the citizens.12 Therefore, it seems appropriate to defer to medical expertise to identify clear cases of internal impairments that trigger a duty of positive respect. However, this does not imply that trust in medical psychiatry should be blind or sufficient. On the one hand, standard psychiatric classifications, such as those found in the Diagnostic and Statistical Manual of Mental Disorders, have faced significant criticism for overpathologizing normal life problems, classifying various daily life activities and behavioral patterns as "mental disorders" that must be addressed and managed appropriately (Billieux et al., 2015). Therefore, it is paramount that the classification of internal impairments designated as mental disorders, which diminish individuals' agential capacities and therefore warrant intervention based on positive respect, is made accountable, first and foremost, to those who are affected by it and, more generally, to society at large.13 On the other hand, medicine alone is unable to determine all the causes of internal impairments to individuals' agential capacities. Social empirical research is crucial to identifying the environmental and social causes that contribute to the emergence of these impairments. A commitment to positive respect, in fact, not only justifies the provision of healthcare but also entails that society has a duty to address the social determinants of health that lead to impairments to persons' agential capacities.14 Limiting the range of internal impairments that generate a demand for positive respect to those mental disorders identified by medical psychiatry as clear obstacles to moral personality is not the only reason why such a duty does not legitimize frequent intrusion into persons' lives. Another reason lies in the fact that this duty should be understood diachronically: what is morally relevant is to ensure not that persons have an unimpaired moral personality at any given point in time, but rather that they preserve unimpaired agential capacities throughout their lives. Put simply, positive respect justifies intervention not if a person consumes alcohol excessively during a night out with their friends, but if they develop an alcohol use disorder. The excessive intervention objection, however, states that a positive duty to help with mental health issues should be rejected if it allows for deep, even if infrequent, intervention in persons' lives. In response, then, it is important to recall that the duty of positive respect and the duty of opacity respect are two basic requirements of respect for persons' agential capacities, which need to be balanced against each other. Hence, there will be cases in which opacity respect has priority over positive respect and others in which the latter outweighs the former. Thus, opacity respect serves as a constraint on the depth, or intrusiveness, of the interventions that can be justified for the sake of positive respect. To appreciate this, consider the following example. Drug addiction severely impairs individuals' agential capacities and thus warrants intervention based on positive respect. Now, imagine a society where state officials are authorized to conduct brain scans on individuals to gauge their agential capacities, and citizens are required to install a similar device in their habitations. This enables the state to identify individuals struggling with drug addiction and provide them with the necessary assistance. A proponent of the dualist account of respect has the theoretical resources to condemn these practices on the grounds that the demand of positive respect—offering assistance to persons with drug dependence—does not justify such a severe violation of opacity respect, whereby the state can evaluate persons' level of all their agential capacities as well as intrude substantially into their personal lives. To be sure, more will have to be said about the specific circumstances in which opacity respect has priority over positive respect and vice versa. However, the salient point here is that a dualist account of respect grounds an obligation to fulfill positive respect in such a way as to minimize the violation of opacity respect. Therefore, the former does not entail excessively deep, or intrusive, interference in persons' lives. To conclude, in the previous section, I argued that a duty of opacity respect to refrain from evaluating persons' varying agential capacities is sometimes incompatible with ensuring that individuals with impaired agential capacities are provided with what they need to function as equal citizens. This, however, is inconsistent with what a relational egalitarian society owes to impaired agents as equals. To overcome this difficulty, in this section, I developed a dualist account of respect for persons' agential capacities, wherein respect does not only entail refraining from inquiring into the level of individuals' agential endowments but also requires assessing persons' varying capacities when it is necessary to offer assistance and support to address mental health issues that diminish moral personality. The upshot is that, in a relational egalitarian society, the state should express appropriate respect for all persons' equal standing by balancing these potentially conflicting demands, thereby ensuring that everyone is capable of standing in relations of equality with each other. In the second part of the article, I show that the dualist account of respect for persons' agential capacities has significant implications for one of the most fundamental background commitments of the ideal of relational equality: the principle of basic moral equality. Relational egalitarians generally hold that the ideal of relational equality is ultimately grounded in the principle of basic moral equality: persons are each other's equals, and therefore they ought to be considered and treated as such (Anderson, 1999: 313; Kolodny, 2014: 300; Scheffler, 2003: 22; Schemmel, 2021: 3; Viehoff, 2019: 18). However, recent contributions to the literature on the basis of moral equality have shown that, despite its widespread acceptance, providing a plausible justification for the principle of moral equality is by no means an easy task. The reason for this is that if persons ought to be considered and treated as equals, this must be because there is something about persons which makes them each other's equals; however, the basic agential capacities that ground persons' moral status—that is, the capacity for a conception of the good and the capacity of a sense of justice—are possessed to unequal degrees. Some people are more rational and reasonable than others. However, if persons are unequal in the possession of the properties that confer moral status upon them, how come they should be considered and treated as equals? Put differently, how can the possession of some scalar status-conferring properties ground persons' equal moral status? (Arneson, 2015; Christiano, 2015). This is the so-called variations objection (Floris, 2019). Arguably, one of the most influential theories of the basis of persons' moral equality has been developed by Carter. According to Carter, the solution to the variations objection lies precisely in a commitment to opacity respect: by requiring us to refrain from evaluating persons' agential capacities, opacity respect provides an independent moral requirement that explains why the variations above the threshold for moral personality should be ignored when assessing persons' moral status. More precisely, opacity respect supplies a principled justification for why what is morally salient is that persons possess the "range property" of the moral personality15—that is, they hold the subvenient scalar agential capacities for a conception of the good and a sense of justice within a certain range, regardless of the different degrees to which they possess these scalar properties above the threshold for moral personality. Persons, therefore, are equal in the possession of the range property and, as such, cannot be ranked on a scale of moral personality. Thus, not only is opacity respect a fundamental requirement of basic recognition respect for persons, but it is also the basis of persons' moral equ