What we owe to impaired agents

Abstract

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).

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 & Strunk, 2016). In addition, substance use and depressive disorders undermine individuals' access to a range of relational resources, such as friendships and membership in associations, which are essential for maintaining and exercising the capacity for a conception of the good and the capacity for a sense of justice (Cordelli, 2015). More generally, impaired agential capacities diminish opportunities to establish meaningful social relationships, hindering persons' ability to be social contributors and to be recognized as such by others (Brownlee, 2020).

The right of persons to the social conditions that enable them to function as equal citizens—that is, to have the effective ability to exercise their political rights and participate in the economy and the activities of civil society—is a fundamental requirement of the ideal of relational equality (Anderson, 1999; 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?

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 equality (Carter, 2011).

However, if this is true, then relational egalitarians have compelling reasons to reject the dualist account of respect because positive respect seems irreconcilable with a commitment to the principle of moral equality. Indeed, by requiring us to inquire into and take account of the unequal degree to which impaired agents hold their basic agential capacities, a duty of positive respect presupposes ranking them on a scale of moral personality, thereby undermining the very basis of their claim to be considered and treated as equals. Regarding a person as morally unequal, however, is an unacceptable price to pay for justifying a duty of positive respect. Call this the moral inequality objection.

One possible answer to the moral inequality objection is to deny that Carter's opacity respect view offers a plausible justification for persons' moral equality. While opacity respect is a requirement of what respect for persons entails, it is not the basis of moral equality.¹⁶ If so, when positive respect violates opacity respect, it does not thereby undermine persons' status as equals because this is not ultimately grounded in opacity respect.

In my view, however, Carter provides a coherent and plausible theory of the basis of persons' moral equality, at least in the context of the relationship between the state and its citizens.¹⁷ Therefore, in what follows, I argue that accepting that persons' moral equality is grounded in a duty of opacity respect does not provide relational egalitarians with strong reasons to reject the dualist account of respect. In particular, I defend two claims: first, I argue that there are cases in which the tension between positive respect and opacity respect does not compromise impaired agents' status as equals in the eyes of the state. Second, I contend that in those cases where the fulfillment of a duty of positive respect does entail a violation of moral equality, it is still morally more important to fully respect impaired agents, even at the cost of temporarily considering them as unequal. Thus, contrary to what relational egalitarians commonly believe, the principle of respect for persons is sometimes incompatible with the principle of moral equality, and the former takes priority over the latter.

Let us begin by explaining what a duty of positive respect entails. This duty involves a two-stage process: first, the state must identify individuals with impaired agential capacities and offer them help in overcoming the mental health problems that diminish these agential capacities. As noted in Section 2, mental health issues are often the cause of both epistemic and volitional limitations that prevent a person from seeking or accepting help. Therefore, the state should attach incentives to the choice of accepting or refusing assistance and support.¹⁸ Second, it must establish public forms of assistance to provide those who are entitled to it with the assistance that they need.

If this is what a duty of positive respect requires, it is unclear how fulfilling this duty does not undermine a person's equal moral status. After all, when the state identifies individuals with mental health issues and offers them assistance and support, it presupposes that the state has assessed the level of their subvenient agential capacities, thereby determining their comparative position on the scale of moral personality. Hence, they are no longer moral equals in the eyes of the state.

However, to see why a duty of positive respect does not always entail a comprehensive assessment of persons' agential capacities, it is important to recall that the range property of moral personality supervenes upon the capacity for a conception of the good and the capacity for a sense of justice. And, crucially, these subvenient agential capacities, in turn, presuppose the possession of other moral powers. As to the former, for example, Michael Cholbi identifies three moral powers necessary for being a rational agent: (1) recognition: the power to recognize ends as minimally choice-worthy; (2) discrimination: the capacity to select, among the ends that are choice-worthy, those ends that are worth pursuing; (3) satisfaction: the capacity to exercise instrumental rationality (Cholbi, 2017: 134). As to the latter, it seems plausible to hold that, at a minimum, the capacity for a sense of justice supervenes upon two moral powers: (1) empathy: the power to adopt the other's standpoint; (2) sympathy: the power to be influenced by the other's standpoint (Sibley, 1953).

Accordingly, a duty of positive respect does not always necessitate a comprehensive assessment of a person's subvenient agential capacities. When the state recognizes that a person's moral personality is impaired, it does not necessarily imply an overall evaluation of all the subvenient agential capacities. Rather, it only presupposes that the state assesses the level of those agential capacities that are affected by the internal impairment in question. However, the assessment of some subvenient moral powers is insufficient to make sound inferences about a person's overall moral personality. Therefore, the state is unable to determine their comparative position on a scale of moral personality, as a matter of opacity respect. As a result, they have equal moral status in the eyes of the state. In other words, for the state to satisfy its duty of positive respect, it is not necessary to lift the opacity veil, but it is sufficient to pierce it, at least in some circumstances. And piercing the opacity veil is a kind of violation of opacity respect that does not compromise a person's status as equal, for it does not allow ranking them on a scale of moral personality.

To illustrate this point, consider the case of Sophia, who suffers from panic disorders. While such an impairment may diminish Sophia's ability to efficiently pursue her goals, it is unclear why it should also affect her understanding of valuable ends, and her ability to choose which ends are valuable to her. More importantly, it is difficult to see how panic attacks might diminish Sophia's sense of justice, as they are unrelated to her ability to develop principles of justice. Therefore, when the state recognizes that Sophia is entitled to health care assistance because she suffers from panic disorders, this only presupposes that it is aware of the overall level of Sophia's capacity for a conception of the good, at most. However, this information alone is insufficient to determine Sophia's position on the scale of moral personality, as the level of Sophia's capacity for a sense of justice is still covered by the opacity veil. Consequently, the state cannot draw conclusive comparative judgments between Sophia's overall agential capacities and those of others. Therefore, Sophia retains her equal moral status in the eyes of the state.

It may be objected that, in some cases, it is reasonable to suppose that a mental health problem could impair both the capacity for a conception of the good and the capacity for a sense of justice. In other words, it is sometimes unclear whether a mental health problem undermines only (part of) one of the subvenient agential capacities or the moral personality as a whole. For instance, consider Mike, who holds the basic agential capacities up to the threshold for moral personality but suffers from dysthymia, a persistent depressive disorder characterized by a “depressed mood for most of the day, for more days than not, […] for at least 2 years” (American Psychiatric Association, 2013: 168). On one hand, one may hold that the depressive disorder only diminishes Mike's capacity for a conception of the good, as he may be unable or unwilling to formulate and advance his conception of the good. On the other hand, it is plausible to suggest that it may also impair Mike's capacity for a sense of justice by reducing his concern for how his actions can impact himself and others.

Even in these cases, however, a duty of positive respect need not entail a comprehensive assessment of someone's subvenient agential capacities. This is because, as discussed in the previous section, a dualist account of respect grounds an obligation to satisfy the duty of positive respect in a way that minimizes the violation of the duty of opacity respect. Therefore, in cases where it is reasonable to assume that both subvenient agential capacities may be impaired, the state must proceed under the assumption that only one of the two is diminished, as a matter of opacity respect. In other words, when the state recognizes that Mike is entitled to healthcare because he suffers from dysthymia, assuming it undermines his capacity for a conception of the good, it must “turn a blind eye”¹⁹ to the possibility that his capacity for a sense of justice is also impaired.

To be sure, at the second stage, a comprehensive evaluation of Mike's agential capacities is indeed necessary to determine the assistance he requires. However, such a comprehensive evaluation will be carried out by health personnel who must be under a deontological duty of professional confidentiality not to disclose this information. And the state must refuse to collect this information as relevant to the assessment of Mike's status, as a matter of opacity respect. Therefore, Mike can go into and come out from a public institution on an equal standing.

In conclusion, I argue that sometimes the fulfillment of a duty of positive respect simply presupposes taking into account only those specific subvenient agential capacities that are diminished by the impairment in question. However, this kind of violation of opacity respect does not compromise a person's status as equal because it does not involve a comprehensive assessment of all the subvenient agential capacities, which would allow raking them on a scale of moral personality. Therefore, a duty to offer assistance and support to impaired agents does not necessarily undermine their equal status in the eyes of the state.

A critic may concede that a duty of positive respect entails piercing the opacity veil when offering assistance to overcome mental health issues that hinder only some agential capacities, such as some forms of panic or depressive disorders. However, they may point out that certain impairments clearly diminish all the agential capacities upon which moral personality supervenes. For example, research evidence suggests that some kinds of drug addiction, like heroin addiction, impair both the capacity for a conception of the good and the capacity for a sense of justice (Levy, 2006; Markowitz, 2005). Accordingly, when the state identifies a person with a heroin use disorder and offers them healthcare assistance, this presupposes that it is aware that their subvenient agential capacities are both impaired, thereby being able to determine their comparative position on a scale of moral personality and thus compromising their status as an equal. Therefore, the moral inequality objection, so the critic concludes, retains its force, at least in some circumstances. Providing assistance to address some mental health issues implies lifting the opacity veil, thus revealing a person's comparative position on a scale of moral personality; hence, it is irreconcilable with the principle of moral equality.

In response, I argue that while the fulfillment of the duty of positive respect may sometimes undermine impaired agents' status as equals, relational egalitarians still have compelling reasons to maintain that it is morally preferable to temporarily regard impaired agents as unequals but provide them with the help necessary to (re-)acquire and maintain their ability to function as equals, rather than considering them as equals but failing to offer them the assistance that they need.

To appreciate this, consider the case of Emily, who struggles with a heroin use disorder. When the state offers help and support to Emily, it implies that it has unveiled Emily's position on the scale of moral personality, insofar as heroin addiction diminishes both her capacity for a conception of the good and her capacity for a sense of justice. Accordingly, Emily does not have equal status in the eyes of the state, at least until her internal impairments have been addressed.²⁰ However, it should be clear that this does not entail that Emily has no rights qua a moral person; on the contrary, Emily is a moral person in the eyes of the state, for she is still within the range of moral personality. Therefore, most importantly, she is entitled to be provided with assistance to address the mental health issues that diminish her agential capacities qua a moral person.

Furthermore, having an unequal status does not imply that every right of Emily should be overridden by every right that unimpaired agents have. This is because when determining the right course of action, both the moral status of the beings and the significance of the claims at stake must be taken into account. For example, even if we believe that human beings have a moral status that is superior to that of nonhuman animals, this does not entail that torturing an animal is morally preferable to pinching a human's arm, for the difference in the significance of the claims at stake clearly outweighs the inequality of the beings' moral statuses. Consequently, since Emily's right to positive respect is a fundamental right she possesses as a moral person, such a right should take precedence over the less fundamental rights held by individuals whose moral personality is not impaired, in cases of scarce resources and conflicting claims.²¹

We can now see that the moral inequality objection fails to provide relational egalitarians with compelling reasons to reject the dualist account of respect. First, it should be recalled that a commitment to the monist view of basic respect for persons' agential capacities is inconsistent with a duty to provide assistance to impaired agents, even when doing so does not undermine their status as equals. This conclusion, however, is inconsistent with the ideal of relational equality: individuals whose agential capacities are impaired have a fundamental right to be helped in addressing mental health issues that diminish their moral personality so as to be able to function as equal citizens. Accordingly, even if one doubts that fulfilling a duty of positive respect is morally more important than considering persons as equals, this does not mean that the former should be disregarded as irrelevant. In other words, suggesting that there is no obligation to offer assistance to individuals like alcoholic John and dysthymic Mike, even when their equal status is not in question, is a disturbing conclusion.

Second, I argue that abstaining from taking account of impaired agents' internal endowment deficits is more problematic than inquiring into their level of agential capacities, even when the latter, but not the former, compromises their equal moral status. This is because while refraining from assessing Emily's agential capacities allows us to consider her as an equal, the ascription of equal status turns out to be unduly formal. As explained in Section 2, while Emily holds equal rights in a society where she is treated as opaque by political institutions, the state is unable to offer her the necessary assistance unless and until she asks for it. Consequently, Emily's heroin addiction becomes a significant barrier to her political participation and her ability to access socio-economic opportunities and relational resources, thereby rendering her vulnerable to social exclusion and incapable of functioning as an equal citizen. On the other hand, a dualist account of respect entails that, although the state may temporarily regard Emily as having an unequal status, it has a duty of justice to offer her support in overcoming drug addiction. Specifically, Emily retains a very stringent right to be provided with the assistance necessary to (re-)acquire and maintain the ability to stand in relations of equality with others.

All in all, then, I argue that the dualist view of respect offers a more plausible account of what a relational egalitarian society owes to impaired agents than the monist view of respect. The former implies that impaired agents may sometimes temporarily lose their status as equals while holding a very stringent right to be offered help in addressing mental health issues that diminish their ability to function as equal citizens. The latter, instead, fails to ensure that impaired agents have access to the assistance that they need, even when this would not compromise their equal moral status, for the sake of a principle of equality devoid of much of its substantive content.

In conclusion, the moral inequality objection fails to undermine the dualist account of respect. Sometimes the duty of positive respect is compatible with considering persons as equals, and when the former is irreconcilable with the latter, it is still morally more important to fulfill the duty of positive respect even at the cost of moral inequality, rather than considering impaired agents as equals but failing to provide them with what they need to function as equal citizens.

Relational egalitarians have so far not said much about what society owes to those individuals whose agential capacities are impaired due to mental health issues such as depression or substance addiction. In this article, I attempted to address this shortcoming. I argued that 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 assessing their agential capacities, which would allow ranking them on a scale of moral personality. On the other hand, they hold that the state should provide everyone with what they need to function as equal citizens. Yet, refraining from evaluating individual agential endowments is sometimes incompatible with enabling impaired agents to function as equal citizens.

To overcome this tension, I developed a novel dualist account of respect for persons' agential capacities. According to this account, respect does not only entail abstaining from assessing persons' agential capacities but also requires a positive duty to offer assistance in addressing mental health issues that diminish moral personality, thereby ensuring that impaired agents have access to the social conditions necessary to (re-)acquire and maintain their ability to stand in relations of equality with others. I argued that this dualist account offers a coherent and plausible explanation of how the state should express appropriate respect for all persons' equal standing. Furthermore, it reveals that relational egalitarians must reconsider some of their most fundamental premises: respect for persons requires assessing individuals' agential capacities, at least sometimes. And while this kind of respect often does not compromise persons' status as equals, even when it does, this is not as morally problematic as they commonly believe.

Research for this article was funded by the European Union's Horizon Europe research and innovation program under the Marie Skłodowska-Curie grant agreement No. 101060448, and by the British Academy under the Postdoctoral Fellowship Scheme grant No. PF22\220010.

The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.