One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these principles will (...) often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity. (shrink)

According to contractualist theories in ethics, whether an action is wrong is determined by whether it could be justified to others on grounds no one could reasonably reject. Contractualists then think that reasonable rejectability of principles depends on the strength of the personal objections individuals can make to them. There is, however, a deep disagreement between contractualists concerning from which temporal perspective the relevant objections to different principles are to be made. Are they to be made on the basis of (...) the prospects the principles give to different individuals ex ante or on the basis of the outcomes of the principles ex post? Both answers have been found to be problematic. The ex ante views make irrelevant information about personal identity morally significant and lead to objectionable ex ante rules, whereas ex post views lead to counterintuitive results in the so-called different harm and social risk imposition cases. The aim of this article is to provide a new synthesis of these views that can avoid the problems of the previous alternatives. I call the proposal ‘risk-acknowledging’ ex post contractualism. The crux of the view is to take into account in the comparisons of different objections both the realized harms and the risks under which individuals have to live. (shrink)

When facing a choice between saving one person and saving many, some people have argued that fairness requires us to decide without aggregating numbers; rather we should decide by coin toss or some form of lottery, or alternatively we should straightforwardly save the greater number but justify this in a non-aggregating contractualist way. This paper expands the debate beyond well-known number cases to previously under-considered probability cases, in which not (only) the numbers of people, but (also) the probabilities of success (...) for saving people vary. It is shown that, in these latter cases, both the coin toss and the lottery lead to what is called an awkward conclusion, which makes probabilities count in a problematic way. Attempts to avoid this conclusion are shown to lead into difficulties as well. Finally, it is shown that while the greater number method cannot be justified on contractualist grounds for probability cases, it may be replaced by another decision method which is so justified. This decision method is extensionally equivalent to maximising expected value and seems to be the least problematic way of dealing with probability cases in a non-aggregating manner. (shrink)

This article discusses some ethical principles for distributing pandemic influenza vaccine and other indivisible goods. I argue that a number of principles for distributing pandemic influenza vaccine recently adopted by several national governments are morally unacceptable because they put too much emphasis on utilitarian considerations, such as the ability of the individual to contribute to society. Instead, it would be better to distribute vaccine by setting up a lottery. The argument for this view is based on a purely consequentialist account (...) of morality; i.e. an action is right if and only if its outcome is optimal. However, unlike utilitarians I do not believe that alternatives should be ranked strictly according to the amount of happiness or preference satisfaction they bring about. Even a mere chance to get some vaccine matters morally, even if it is never realized. (shrink)

It is widely believed that consequentialists are committed to the claim that persons are mere containers for well-being. In this article I challenge this view by proposing a new version of consequentialism, according to which the identities of persons matter. The new theory, two-dimensional prioritarianism, is a natural extension of traditional prioritarianism. Two-dimensional prioritarianism holds that wellbeing matters more for persons who are at a low absolute level than for persons who are at a higher level and that it is (...) worse to be deprived of a given number of units than it is good to gain the same number of units, even if the new distribution is a permutation of the original one. If a fixed amount of well-being is transferred from one person to another and then transferred back again, two-dimensional prioritarianism implies that it would have been better to preserve the status quo. (shrink)

Philosophy & Public Affairs, 34 (2006): 109-35.

John Taurek argues that, in a choice between saving the many or the few, the numbers should not count. Some object that this view clashes with the transitivity of ‘better than’; others insist the clash can be avoided. I defend a middle ground: Taurek cannot have transitivity, but that doesn’t doom his view, given a suitable conception of value. I then formalize and explore two conceptions: one context-sensitive, one multidimensional.

Faced with the choice between saving one person and saving two others, what should we do? It seems intuitively plausible that we ought to save the two, and many forms of consequentialists offer a straightforward rationale for the intuition by appealing to interpersonal aggregation. But still many other philosophers attempt to provide a justification for the duty to save the greater number without combining utilities or claims of separate individuals. I argue against one such attempt proposed by Iwao Hirose. Despite (...) being consequentialist, his argument is aggregation-free since it relies on a non-aggregative value judgement method, instead of interpersonal aggregation, to establish that (other things being equal) a state of affairs is better when more people survive therein. I do not take issue with its consequentialist element; rather, I claim that there is no good reason to adopt the method in question, and thus no good reason to be moved by his argument overall. What we are in search of is not merely a logically possible method that can produce the conclusion that we already want, but one that we have good reason to adopt. Hirose's argument elegantly demonstrates how it could possibly be true that it is right to save the greater number; but it fails to show that we have reason to believe so - even when we do not combine the interests of different individuals. (shrink)

John Taurek famously argued that, in ‘conflict cases’, where we are confronted with a smaller and a larger group of individuals, and can choose which group to save from harm, we should toss a coin, rather than saving the larger group. This is primarily because coin-tossing is fairer: it ensures that each individual, regardless of the group to which he or she belongs, has an equal chance of being saved. This article provides a new response to Taurek’s argument. It proposes (...) that there are two possible types of unfairness that have to be avoided in conflict cases, as far as possible: ‘selection unfairness’, which is the unfairness of not giving individuals an equal chance of being saved; and ‘outcome unfairness’, which is the unfairness of not actually saving them, when others are saved. Since saving the greater number generates less outcome unfa-irness than coin-tossing, it is argued that, in many conflict cases, fairness demands that we save the greater number. (shrink)

Faced with a choice between saving one stranger and saving a group of strangers, some people endorse weighted lotteries, which give a strictly greater chance of being saved to the group of strangers than the single stranger. In this paper I attempt to criticize this view. I first consider a particular version of the weighted lotteries, Frances Kamm's procedure of proportional chances, and point out two implausible implications of her proposal. Then, I consider weighted lotteries in general, and claim (1) (...) that the correct thing to distribute is not the chance of being saved but the good of being saved, (2) that assigning some chance to the single stranger is not the only way to give a positive (and equal) respect to the people concerned, and (3) that the weighted lottery appears to be deceptive since it would show the respect to the single stranger in a negligible way. (shrink)

Many authors in ethics, economics, and political science endorse the Lottery Requirement, that is, the following thesis: where different parties have equal moral claims to one indivisible good, it is morally obligatory to let a fair lottery decide which party is to receive the good. This article defends skepticism about the Lottery Requirement. It distinguishes three broad strategies of defending such a requirement: the surrogate satisfaction account, the procedural account, and the ideal consent account, and argues that none of these (...) strategies succeed. The article then discusses and discharges some remaining grounds for resistance to these skeptical conclusions, as well as the possibility of defending a weaker version of a normative lottery principle. The conclusion is that we have no reason to believe that where equal claims conflict, we are morally required to hold a lottery, as opposed to simply picking one of the parties on more subjective grounds or out of pure whim. In addition to the practical consequences of this skeptical view, the article sketches some theoretical implications for debates about saving the greater number and about axiomatic utilitarianism. (shrink)

Deontic constraints prohibit an agent performing acts of a certain type even when doing so will prevent more instances of that act being performed by others. In this article I show how deontic constraints can be interpreted as either maximizing or non-maximizing rules. I then argue that they should be interpreted as maximizing rules because interpreting them as non-maximizing rules results in a problem with moral advice. Given this conclusion, a strong case can be made that consequentialism provides the best (...) account of deontic constraints. (shrink)

Is an outcome where many people are saved and one person dies better than an outcome where the one is saved and the many die? According to the standard utilitarian justification, the former is better because it has a greater sum total of well-being. This justification involves a controversial form of moral aggregation, because it is based on a comparison between aggregates of different people's well-being. Still, an alternative justification—the Argument for Best Outcomes—does not involve moral aggregation. I extend the (...) Argument for Best Outcomes to show that any utilitarian evaluation can be justified without moral aggregation. (shrink)

Suppose you find yourself in a situation in which you can either save both A and B or save only C. A, B and C are relevantly similar – all are strangers to you, none is more deserving of life than any other, none is responsible for being in a life-threatening situation, and so on. John Taurek argued that when deciding what to do in such a situation, you should flip a coin, thereby giving each of A, B and C (...) a 50% chance of survival . Only by doing this can we treat each person with the appropriate degree of respect. Taurek seemed to be employing the “Equal Greatest Chance” principle , according to which, when deciding whom to save, one must give each person the greatest possible chance of survival consistent with everyone else having the same chance. An obvious alternative is the “Save the Greater Number” principle . I describe an example that shows that EGC is false. I show that the example also demonstrates the falsity of other related views, including Jens Timmermann’s “Individualist Lottery Principle.” I conclude that SGN is true. And I extend the argument to other kinds of cases, showing that which person should be saved may depend on whether some additional well-being may be gained for someone in the process. (shrink)

The rule of rescue holds that special weight should be given to protecting the lives of assignable individuals in need, implying that less weight is given to considerations of cost-effectiveness. This is sometimes invoked as an argument for funding or reimbursing life-saving treatment in public healthcare even if the costs of such treatment are extreme. At first sight one might assume that an individualist approach to ethics—such as Scanlon’s contractualism—would offer a promising route to justification of the rule of rescue. (...) In this chapter I argue that contractualism cannot endorse the rule of rescue, whereas a collectivist approach that appeals to group solidarity would offer support for rescue cases. The argument, however, has its limitations, and though solidarity is of central concern in shaping public healthcare, there are good reasons for not endorsing the rule of rescue as a moral basis for allocating scarce resources in clinical care. (shrink)

A very short, exegetical paper about Taurek's "Should the Numbers Count?," arguing against the view that Taurek requires giving chances.

You and I lead different lives. While we share a society and a world, our existence is separate from one another. You and I matter individually, by ourselves. My dissertation is about this simple thought. I argue that this simple insight, the separateness of persons, tells us something fundamental about morality. My dissertation seeks to answer how the separateness of persons matters. I develop a precise view of the demands of the separateness of persons. The separateness of persons imposes both (...) a requirement on the justification of first-order moral principles as well as a requirement on the content of first-order moral principles. In specifying these demands, I argue that respecting the separateness of persons requires taking into consideration each person’s point of view separately. This requires taking into account the moral relations in which individuals stand to one another. I make use of this relational understanding of the separateness of persons to advance various debates in moral and political philosophy. I argue for a framework to assess to which extent the veil of ignorance can be reconciled with the separateness of persons. I also argue for a new view on the ethics of risk which is a form of contractualism that discounts risks only by their objective risk. Furthermore, I argue for a new solution to the problem of aggregation that is skeptical of aggregation and can set plausible limits to aggregation. Lastly, I provide a new relational agent-based justification for deontological constraints. In addition to answering how the separateness of persons matters, I defend the separateness of persons against challenges. Most importantly, I argue that the importance of the separateness of persons is not undermined even if we believe that our personal identity, i.e. whether we persist as the same person, is unimportant. (shrink)