Abstract

This chapter assesses the ethics of two-tiered health care systems according to two theories—a sufficiency of capabilities approach (CA) and social-relational egalitarianism. It is argued that a particular specification of a sufficiency of CA, based on Nussbaum’s CA and applied to health care justice, seems to provide a normative basis for the permissibility of certain kinds of two-tiered health care systems. A particular theory of equality, social egalitarianism, in contrast, can provide a convincing critique of these systems, and this may seem to jeopardize the plausibility of the CA. This chapter argues, however, that the CA has the potential to accommodate social egalitarianism. For two-tiered systems, this means that they are likely to be deemed morally unacceptable when there are major discrepancies between the benefits or services made available in the first tier in comparison to the second tier and if parallel substitutive insurance systems are instituted.