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)

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)

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)

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)

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)

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)

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)

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)

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 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.

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 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)

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)

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)

: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)

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)

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)

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 14, Issue 2, Page 147-149, June 2011.

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

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)

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)