Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear and much-needed introduction to (...) this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

In many societies, the aging of the population is becoming a major problem. This raises difficult issues for ethics and public policy. On what is known as the fair innings view, it is not impermissible to give lower priority to policies that primarily benefit the elderly. Philosophers have tried to justify this view on various grounds. In this article, I look at a consequentialist, a fairness-based, and a contractarian justification. I argue that all of them have implausible implications and fail (...) to correspond to our moral intuitions. I end by outlining a different kind of consequentialist justification that avoids those implications and corresponds better to our considered moral judgments. (shrink)

Some philosophers and disability advocates argue that disability is not bad for you. Rather than treated as a harm, it should be considered and even celebrated as just another manifestation of human diversity. Disability is mere difference. To most of us, these are extraordinary claims. Can they be defended?

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

:The distinction between brute luck and option luck is fundamental for luck egalitarianism. Many luck egalitarians write as if it could be used to specify which outcomes people should be held responsible for. In this paper, I argue that the distinction can’t be used this way. In fact, luck egalitarians tend to rely instead on rough intuitive judgements about individual responsibility. This makes their view vulnerable to what’s known as the neutrality objection. I show that attempts to avoid this objection (...) are unsuccessful. I conclude that until it provides a better account of attributing responsibility, luck egalitarianism remains incomplete. (shrink)

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I also discuss (...) some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title. (shrink)

This paper begins with a simple illustration of the choice between individual and population strategies in population health policy. It describes the traditional approach on which the choice is to be made on the relative merits of the two strategies in each case. It continues by identifying two factors—our knowledge of the consequences of the epidemiological transition and the prevalence of responsibility-sensitive theories of distributive justice—that may distort our moral intuitions when we deliberate about the choice of appropriate risk-management strategies (...) in population health. It argues that the confluence of these two factors may lead us to place too much emphasis on personal responsibility in health policy. (shrink)

Longevity is valuable. Most of us would agree that it’s bad to die when you could go on living, and death’s badness has to do with the value your life would have if it continued. Most of us would also agree that it’s bad if life expectancy in a country is low, it’s bad if there is high infant mortality and it’s bad if there is a wide mortality gap between different groups in a population. But how can we make (...) such judgments more precise? How should we evaluate the harm of mortality in a population? Although philosophers have written a lot about the harm of death for individuals, very little work has been done on the harm of mortality for populations. In this article, I take the first steps towards developing a theory of the harm of population mortality. Even these first steps, I argue, lead to surprising results. (shrink)

The precautionary approach has been widely considered reasonable for many issues in environmental policy, including climate change. It has also been recognized, however, that standard formulations of the precautionary principle suffer from many difficulties. An influential strategy to avoid these difficulties is to formulate a narrow version of the principle on the basis of the maximin rule. Rawls proposed that following the maximin rule can be rational under certain conditions. Defenders of this strategy argue that these conditions are approximated when (...) it comes to issues like climate change. In the first part of this paper, I argue that the Rawlsian conditions do not establish the unique rationality of the maximin rule, hence the precautionary principle cannot be defended on its basis. When the Rawlsian conditions are approximated, other principles can also lead to reasonable choices. In particular, a prioritarian principle can capture the precautionary approach and serve a useful role in climate change policy. I develop this proposal in the second part. (shrink)

In a recent paper, Michael Otsuka and Alex Voorhoeve present a novel argument against prioritarianism. The argument takes its starting point from empirical surveys on people's preferences in health care resource allocation problems. In this article, I first question whether the empirical findings support their argument, and then I make some general points about the use of ‘empirical ethics’ in ethical theory.

Cost-effectiveness analysis is the standard analytical tool for evaluating the aggregate health benefits of treatments, interventions, or health programs. It works by comparing the ratio of costs and benefits of different alternatives. The lower the ratio, the more effective the treatment, intervention, or program. The use of cost-effectiveness analysis can ensure that scarce health care resources are allocated in a way that maximizes the satisfaction of health needs. According to a common objection, however, the use of cost-effectiveness analysis for setting (...) priorities in the allocation of health care resources may lead to unfair discrimination against people with disabilities.The aim of the first part of this .. (shrink)

In the distribution of resources, persons must be respected, or so many philosophers contend. Unfortunately, they often leave it unclear why a certain allocation would respect persons, while another would not. In this paper, we explore what it means to respect persons in the distribution of scarce, life-saving resources. We begin by presenting two kinds of cases. In different age cases, we have a drug that we must use either to save a young person who would live for many more (...) years or an old person who would only live for a few. In different numbers cases, we must save either one person or many persons from certain death. We argue that two familiar accounts of respect for persons―an equal worth account, suggested by Jeff McMahan, and a Kantian account, inspired by the Formula of Humanity―have implausible implications in such cases. We develop a new, “three-tiered” account: one that, we claim, generates results in such cases that accord better with many people’s considered judgments than those produced by its rivals. (shrink)

Opponents of genetic enhancement technologies often argue that the pursuit of these technologies will lead to self-defeating collective outcomes, massive social inequalities, or other forms of collective harm. They assume that these harms will outweigh individual benefits. Defenders of genetic enhancement technologies counter that individual benefits will outweigh collective harms and there will be no conflict between individual and collective interests. The present contribution tries to advance the debate by providing a more detailed discussion of the conditions under which individual (...) and collective interests may conflict.It presents a simple model that clarifies the conditions in which the use of genetic enhancement technologies may lead to self-defeating collective outcomes and social inequalities. It argues that given current inequalities, these conditions might indeed obtain as new genetic knowledge leads to a transition in population health. If they do, then genetic enhancement will steepen the social gradient in health. Thus, regulating access to enhancement technologies should be a matter of social justice. (shrink)

Quality of life research aims to develop and apply indices for the measurement of human welfare. It is an increasingly important field within the social sciences and its results are an important resource for policy making and evaluation. This paper explores the conceptual background of quality of life research. It focuses on its single most important issue: the controversy between the use of ``objective social indicators'' and the use of people's ``subjective evaluations'' as proxies for welfare. Most quality of life (...) researchers today argue that people's own evaluations have an indispensable role in quality of life measurement. I argue that their position must be defended on philosophical grounds, because their use of evaluations commits them to some particular theories of welfare. I explore the connections between theories of welfare in philosophy and the use of evaluations in quality of life research. I conclude that even though evaluations may have a role in particular applications, they are unlikely to have a role in all applications. (shrink)

A few decades ago, there was a lively debate on the problem of overpopulation. Various proposals to limit population growth and to control fertility were made and debated both in academia and in th...

This paper provides a general framework for conceptualizing triage for intensive care unit admissions in public health emergencies such as the COVID‐19 pandemic. It applies this framework to some of the guidelines issued during the pandemic and addresses some controversial issues, including the role of age, the use of lives or life years, and the relevance of quality of life considerations. The paper defends a view on which triage protocols for public health emergencies should aim to maximize the number of (...) life years saved, may take into account age as a proxy, and should ignore quality of life considerations. (shrink)

One way of evaluating health is in terms of its impact on well-being. It has been shown, however, that evaluating health this way runs into difficulties, since health and other aspects of well-being are not separable. At the same time, the practical implications of the inseparability problem remain unclear. This paper assesses these implications by considering the relations between theories, components, and indicators of well-being.

Jennifer Prah Ruger (2011) rightly points out that social cooperation is essential for achieving health justice. But she is unhappy with the approach to cooperation that social scientists and philosophers have taken. Her main objection is that their models are based on narrow self-interest. Her own proposal, which she calls "shared health governance", is based on public moral norms instead. If individuals and institutions internalized and followed such norms, justice in health could be achieved. -/- In this commentary, I show (...) that Ruger fundamentally misdiagnoses the problem of social cooperation and health justice. Because of the faulty diagnosis, her own proposal is at best unworkable, at worst utopian. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

This article discusses L. W. Sumner's theory of well-being as authentic happiness. I distinguish between extreme and moderate versions of subjectivism and argue that Sumner's characterization of the conditions of authenticity leads him to an extreme subjective theory. More generally, I also criticize Sumner's argument for the subjectivity of welfare. I conclude by addressing some of the implications of my arguments for theories of well-being in philosophy and welfare measurement in the social sciences.

Ethics, Policy & Environment, Volume 15, Issue 2, Page 222-224, June 2012.

Ageing without Ageism? contributes to the essential and timely discussion of age, ageism, population ageing, and public policy. It demonstrates the breadth of the challenges posed by these issues by covering a wide range of policy areas: from health care to old-age support, from democratic participation to education, and from family to fiscal policy. With contributions from 21 authors the discussion bridges the gap between academia and public life by putting in dialogue fresh philosophical analysis and specific new policy proposals. (...) It approaches familiar issues like age discrimination, justice between age groups, and democratic participation across the ages from novel perspectives. (shrink)

Cost-effectiveness analysis (CEA) is an analytical tool in health economics. One of the most important objections to it is that its use can lead to unjust discrimination against people with disabilities. This chapter evaluates this objection. It begins by clarifying its nature, then it examines some alleged forms of discrimination. It argues that they are either not cases of unjust discrimination, or they are based on misunderstandings of CEA. However, the chapter does point out that there is one case in (...) which the use of CEA may disadvantage people with disabilities. It goes on to consider several proposals for explaining the wrongness of discrimination but argues that none of them accommodates this case. It concludes that the case should not be thought as a matter of unjust discrimination; rather, it should be thought of as raising an issue for justice in the allocation of health-care resources. (shrink)

Consider two cases. In Case 1, you must decide whether you save the life of a disabled person or you save the life of a person with no disability. In Case 2, you must decide whether you save the life of a disabled person who would remain disabled, or you save the life of another disabled person who, in contrast, would also be cured as a result of your intervention. It seems that most people agree that you should give equal (...) chances in Case 1: saving the life of the person with no disability would be unfair discrimination against the person with disability. Yet, in Case 2, it appears that many people believe that you are at least permitted to save straightaway the person who would have no disability after your intervention. There would be no unfair discrimination against the other person. I argue that these judgments present a puzzle for theories of resource allocation in normative ethics. The puzzle is straightforward for consequentialists: the two cases have the same outcomes, but the judgments are different. But the puzzle also presents a problem for nonconsequentialist views. After introducing the cases, I show this by reviewing a number of proposals for solving the puzzle. I argue that none of these proposals are successful. I then make my own proposal and conclude by spelling out its implications. (shrink)

Ethics, Policy & Environment, Volume 14, Issue 2, Page 147-149, June 2011.

With healthcare systems under pressure from scarcity of resources and ever‐increasing demand for services, difficult priority setting choices need to be made. At the same time, increased attention to patient involvement in a wide range of settings has given rise to the idea that those who are eventually affected by priority setting decisions should have a say in those decisions. In this paper, we investigate arguments for the inclusion of patient representatives in priority setting bodies at the policy level. We (...) find that the standard justifications for patient representation, such as to achieve patient‐relevant decisions, empowerment of patients, securing legitimacy of decisions, and the analogy with democracy, all fall short of supporting patient representation in this context. We conclude by briefly outlining an alternative proposal for patient participation that involves patient consultants. (shrink)

Something has been going wrong on many college campuses in the last few years. Speakers are shouted down. Students and professors say they are walking on eggshells and are afraid to speak honestly. Rates of anxiety, depression, and suicide are rising--on campus as well as nationally. How did this happen? First Amendment expert Greg Lukianoff and social psychologist Jonathan Haidt show how the new problems on campus have their origins in three terrible ideas that have become increasingly woven into (...) American childhood and education: What doesn't kill you makes you weaker; always trust your feelings; and life is a battle between good people and evil people. These three Great Untruths contradict basic psychological principles about well-being and ancient wisdom from many cultures. Embracing these untruths--and the resulting culture of safetyism--interferes with young people's social, emotional, and intellectual development. It makes it harder for them to become autonomous adults who are able to navigate the bumpy road of life. Lukianoff and Haidt investigate the many social trends that have intersected to promote the spread of these untruths. They explore changes in childhood such as the rise of fearful parenting, the decline of unsupervised, child-directed play, and the new world of social media that has engulfed teenagers in the last decade. They examine changes on campus, including the corporatization of universities and the emergence of new ideas about identity and justice. They situate the conflicts on campus within the context of America's rapidly rising political polarization and dysfunction. This is a book for anyone who is confused by what is happening on college campuses today, or has children, or is concerned about the growing inability of Americans to live, work, and cooperate across party lines. (shrink)

An advanced-level logic textbook that presents proof construction on equal footing with model building. Potentially relevant to students of mathematics and computer science as well.

Consequence is at the heart of logic, and an account of consequence offers a vital tool in the evaluation of arguments. This text presents what the authors term as 'logical pluralism' arguing that the notion of logical consequence doesn't pin down one deductive consequence relation; it allows for many of them.

The idea that fictions may educate us is an old one, as is the view that they distort the truth and mislead us. While there is a long tradition of passionate assertion in this debate, systematic arguments are a recent development, and the idea of empirically testing is particularly novel. Our aim in this chapter is to provide clarity about what is at stake in this debate, what the options are, and how empirical work does or might bear on its (...) resolution. We distinguish between merely influencing people’s opinions and providing genuine learning, where the latter requires that the source of the change in opinion should be reliable. Other important ideas here are the extent to which authors of fiction may be considered to provide testimony, or something like it, and the possibility of recognizing an unstated purpose in the project of the fictional work. We ask whether fictions can furnish us not merely with ideas but with reasons for believing them, perhaps by constituting thought experiments. We consider whether the focus should be on understanding rather than on knowledge, and whether fictions can inform us about the qualities of another’s experiences. We briefly describe some experimental work of recent decades and suggest that the evidence for learning from fiction is currently meagre. (shrink)

The Rhetorical Invention of Man examines how the category "Man" has dominated Western thinking since the sixteenth century. This category, a historical anomaly according to Michel Foucault and Jacques Derrida, has produced distortions in our ability to understand reality that do great harm to our health, morals, and environment.

The heroes and villains of the Star Wars saga are probably the most widely recognized fictional characters in the Western world. In particular, the saga is a celebration of friendship and family bonds. Though it is a story of conflict and warfare, grand political concerns about the fate of the galaxy are kept in the background, as the story focuses more on action and the relationships among the main characters. The overwhelming loyalty that the heroes of Star Wars feel for (...) friends and family is a traditional feature of heroes, from ancient history to today. Weighing the actions of fictional characters like Luke and his pals can help us reflect on how we should act in the real world. In some ways, the moral views of early philosophers move us too far toward civic duty and away from the traditional values of loyalty to friends and family. (shrink)

Contemporary philosopher Alvin Plantinga is best known for tackling the problem of evil and rationality of belief in God from a Calvinist perspective. Welty provides a Reformed intro and analysis.

Despite the modern trappings the values of the Sons of SAMCRO and their old ladies are even more traditional than those of mainstream society. The parallels between the culture depicted in Sons of Anarchy and the one depicted by Homer's epics make the show philosophically interesting, because moral philosophy in Greece began as a reaction against Homeric values. Just as the Sons bear the Reaper on their cuts, Homeric warriors often decorated their armor with violent images to make clear their (...) status as killers. Those who have drawn blood for the club wear the “Men of Mayhem” patch. There are many ways in which the Homeric heroes outstrip the brutality of SAMCRO. The parallels between SAMCRO's and Homer's conceptions of a good life show us both what is commendable and condemnable about life in the MC. (shrink)

This essay reads Helen Phillips’s extraordinary novel of motherhood, The Need (2019), alongside recent theorists of post-politics. Phillips’s novel is illuminating because it reveals how an adequate understanding of the post-political requires supplementing current accounts with the categories of gender and heterogeneous time. The Need subverts the postfeminist articulation of politics as an arena in which “feminism” is practicable only in preemptively curtailed and diminished form. It does so by cracking open the “reality” enforced by neoliberal motherhood to show how (...) its apparent solidity rests on the excision of alternate times—on a foreclosure of the temporal otherness that is the condition for historical change. (shrink)

This paper reflects on a simple, ingenious and celebrated result by Amartya Sen, ‘The Impossibility of a Paretian Liberal’ (1970). Sen’s result, sometimes called the 'Liberal Paradox', has attracted — particularly in the years soon after its publication — a vast literature, including responses and reflections from Sen himself. Much of the literature involves attempts to ‘escape’ the Liberal Paradox by proposing ways to avoid or resolve the problem it seems to identify. But despite the extensive attention, and perhaps a (...) sense among philosophers in related areas that the result is somehow relevant to liberalism or to political philosophy in general, it is still not clear why the result matters philosophically. I am sceptical about the significance of the Liberal Paradox: in this paper, I articulate various ways in which political philosophers might be urged to care about the Paradox, and argue that each of them is either implausible or of only moderate interest. (shrink)

Since the time of Charles Darwin, there has been concern that the theory of evolution provides fuel for skepticism. This paper presents new arguments that humanity's evolutionary origins are grounds for accepting that the universe is not as it appears to be to us. Firstly, it is argued that we should expect to have an incomplete capacity to comprehend the universe: both the mental limitations of all non-human life and the narrow interests of most humans provide evidence for this. Secondly, (...) it is argued that we should expect the universe as it appears to us to have nothing more than a relationship of correlation to the universe as it actually is: both simplicity and the huge number of ways in which the universe may be represented provide reason for evolution to produce such a correlative system. (shrink)