Priority and Prioritarianism

This paper presents a new kind of problem in the ethics of distribution. The problem takes the form of several "calibration dilemmas," in which intuitively reasonable aversion to small-stakes inequalities requires leading theories of distribution to recommend intuitively unreasonable aversion to large-stakes inequalities—e.g., inequalities in which half the population would gain an arbitrarily large quantity of well-being or resources. We first lay out a series of such dilemmas for a family of broadly prioritarian theories. We then consider a widely endorsed (...) family of egalitarian views and show that, despite avoiding the dilemmas for prioritarianism, they are subject to even more forceful calibration dilemmas. We then show how our results challenge common utilitarian accounts of the badness of inequalities in resources (e.g., wealth inequality). These dilemmas leave us with a few options, all of which we find unpalatable. We conclude by laying out these options and suggesting avenues for further research. (shrink)

Lara Buchak argues for a version of rank-weighted utilitarianism that assigns greater weight to the interests of the worse off. She argues that our distributive principles should be derived from the preferences of rational individuals behind a veil of ignorance, who ought to be risk averse. I argue that Buchak’s appeal to the veil of ignorance leads to a particular way of extending rank-weighted utilitarianism to the evaluation of uncertain prospects. This method recommends choices that violate the unanimous preferences of (...) rational individuals and choices that guarantee worse distributions. These results, I suggest, undermine Buchak’s argument for rank-weighted utilitarianism. (shrink)

The veil of ignorance argument was used by John C. Harsanyi to defend Utilitarianism and by John Rawls to defend the absolute priority of the worst off. In a recent paper, Lara Buchak revives the veil of ignorance argument, and uses it to defend an intermediate position between Harsanyi's and Rawls' that she calls Relative Prioritarianism. None of these authors explore the implications of allowing that agent's behind the veil are averse to ambiguity. Allowing for aversion to ambiguity---which is both (...) the most commonly observed and a seemingly reasonable attitude to ambiguity---however supports a version of Egalitarianism, whose logical form is quite different from the theories defended by the aforementioned authors. Moreover, it turns out that the veil of ignorance argument neither supports standard Utilitarianism nor Prioritarianism unless we assume that rational people are insensitive to ambiguity. (shrink)

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, where theorizing about just (...) principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to drop their (...) financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

This chapter argues that rather than viewing transparency as a right, we should regard it as a finite resource whose allocation involves tradeoffs. It then argues that those tradeoffs should be resolved by using a multi-principle approach to distributive justice. The relevant principles include maximizing welfare, maximizing autonomy, and giving priority to the worst off. Finally, it examines some of the implications for law of recognizing the tradeoffs presented by transparency proposals.

The phenomenon of corruption is a cancer that affects our country and that it is necessary to eradicate; This dilutes the opportunities for economic and social development, privileging the single conjunction of particular interests, political actors in non-legal agreements for their own benefit, which lead to acts of corruption. Recent studies indicate that the level of corruption present in a political system is directly related to the type of institutional structure that defines it (Boehm and Lambsdorff, 2009), as well as (...) the ineffectiveness of the control organisms (Casar, 2015; Cárdenas, 2010, Rojas, 2010, Carbonell, 2009, Restrepo, 2004), which requires citizen action to combat corruption (Sandoval, 2010, Villanueva, 2006). This work, focuses our attention on the federal public administration, presenting as a proposal to empower the citizen action in the fight against corruption and in the National Anticorruption System; the figure of Whistleblowers or generator of citizen alert, based on two fundamental principles: i) recognizing the citizen's obligation to report acts of corruption and ii) the granting by the authority of witness protection. These two actions will result in two important results: i) Consolidate the citizen's complaint to inform society about acts of corruption and ii) and the exercise of freedom of information so that society is able to be informed about acts of corruption. These actions will allow promoting and consolidating a culture of reporting acts of corruption that may constitute a crime as a fundamental pillar in the National Anticorruption System in Mexico. (shrink)

We consider an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off.

A natural view in distributive ethics is that everyone's interests matter, but the interests of the relatively worse off matter more than the interests of the relatively better off. I provide a new argument for this view. The argument takes as its starting point the proposal, due to Harsanyi and Rawls, that facts about distributive ethics are discerned from individual preferences in the "original position." I draw on recent work in decision theory, along with an intuitive principle about risk-taking, to (...) derive the view. (shrink)

Our Viewpoint argues that expanding access to less effective or more toxic treatments is supported not only by utilitarian ethical reasoning but also by two other ethical frameworks: those that emphasise equality and those that emphasise giving priority to the patients who are worst off. The inadequate resources available for global health reflect not only natural constraints but also unwise social and political choices. However, pitting efforts to reduce inequality and better fund global health against efforts to put available resources (...) to their best use mistakes complementary objectives for conflicting ones. (shrink)

I review Shlomi Segall's book 'Why Inequality Matters'. I argue that it conclusively establishes that alongside egalitarians, prioritarians and sufficientarians must sometimes regard a prospect as better (in at least one respect) when it is not better (in terms of well-being) for anyone. Sufficientarians and prioritarians must therefore relinquish a treasured anti-egalitarian argument. It also makes a powerful case that among these three views, egalitarians are in the best position to explain such departures from what is in each person’s prudential (...) interest. For egalitarians can point to the natural idea that it is unfair when, due to pure chance, some fare much better than others. By contrast, it remains unclear what value, if any, sufficientarians or prioritarians can appeal to in order to justify their departures from what best promotes people’s well-being. (shrink)

How should we choose between uncertain prospects in which different possible people might exist at different levels of wellbeing? Alex Voorhoeve and Marc Fleurbaey offer an egalitarian answer to this question. I give some reasons to reject their answer and then sketch an alternative, which I call person-affecting prioritarianism.

I here settle a recent dispute between two rival theories in distributive ethics: Restricted Prioritarianism and the Competing Claims View. Both views mandate that the distribution of benefits and burdens between individuals should be justifiable to each affected party in a way that depends on the strength of each individual’s separately assessed claim to receive a benefit. However, they disagree about what elements constitute the strength of those individuals’ claims. According to restricted prioritarianism, the strength of a claim is determined (...) in ‘prioritarian’ fashion by both what she stands to gain and her absolute level of well-being, while, according to the competing claims view, the strength of a claim is also partly determined by her level of well-being relative to others with conflicting interests. I argue that, suitably modified, the competing claims view is more plausible than restricted prioritarianism. (shrink)

Does individual desert matter for distributive justice? Is it relevant, for purposes of justice, that the pattern of distribution of justice’s “currency” (be it well-being, resources, preference-satisfaction, capabilities, or something else) is aligned in one or another way with the pattern of individual desert? -/- This paper examines the nexus between desert and distributive justice through the lens of individual claims. The concept of claims (specifically “claims across outcomes”) is a fruitful way to flesh out the content of distributive justice (...) so as to be grounded in the separateness of persons. A claim is a relation between a person and a pair of outcomes. If someone is better off in one outcome than a second, she has a claim in favor of the first. If she is equally well off in the two outcomes, she has a null claim between the two. In turn, whether one outcome is more just than a second depends upon the pattern of claims between them. -/- In prior work, I have elaborated the concept of claims across outcomes, and have used it to provide a unified defense of the Pareto and Pigou-Dalton axioms. Adding some further, plausible, axioms, we arrive at prioritarianism. -/- Here, I consider the possibility of desert-modulated claims—whereby the strength of an individual’s claim between two outcomes is determined not only by her well-being levels in the two outcomes, and her well-being difference between them, but also by her desert. This generalization of the notion of claims suggests a new axiom of justice: Priority for the More Deserving, requiring that, as between two individuals at the same well-being level, a given increment in well-being be allocated to the more deserving one. -/- If individual desert is intrapersonally fixed, this new axiom, together with a desert-modulated version of the Pigou-Dalton principle, and the Pareto axioms, yields a desert-modulated prioritarian account of distributive justice. Trouble arises, however, if an individual’s desert level can be different in different outcomes. In this case of intrapersonally variable desert, Priority for the More Deserving can conflict with the Pareto axioms (both Pareto indifference and strong Pareto). -/- This conflict, I believe, is sufficient reason to abandon the proposal to make claim strength a function of individual desert on top of well-being levels and differences. If distributive justice is truly sensitive to each individual’s separate perspective—if the justice ranking of outcomes is built up from the totality of individual rankings—we should embrace the Pareto axioms as axioms of justice and reject Priority for the More Deserving. In short: desert-modulated prioritarianism is a nonstarter. Rawls was right to sever distributive justice from desert. (shrink)

Greg Bognar has recently offered a prioritarian justification for ‘fair innings’ distributive principles that would ration access to healthcare on the basis of patients' age. In this article, I agree that Bognar's principle is among the strongest arguments for age-based rationing. However, I argue that this position is incomplete because of the possibility of ‘time-relative' egalitarian principles that could complement the kind of lifetime egalitarianism that Bognar adopts. After outlining Bognar's position, and explaining the attraction of time-relative egalitarianism, I suggest (...) various ways in which these two kinds of principle could interact. Since various options have very different implications for age-based rationing, proponents of such a rationing scheme must take a position on time-relative egalitarianism to complement a lifetime prioritarian view like Bognar's. (shrink)

According to the priority view, or prioritarianism, it matters more to benefit people the worse off they are. But how exactly should the priority view be defined? This article argues for a highly general characterization which essentially involves risk, but makes no use of evaluative measurements or the expected utility axioms. A representation theorem is provided, and when further assumptions are added, common accounts of the priority view are recovered. A defense of the key idea behind the priority view, the (...) priority principle, is provided. But it is argued that the priority view fails on both ethical and conceptual grounds. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

We discuss two leading theories of distributive justice: egalitarianism and prioritarianism. We argue that while each has particular merits and shortcomings, egalitarian views more fully satisfy a key requirement of distributive justice: respect for both the unity of the individual and the separateness of persons.

This paper introduces a symposium on Equality versus Priority. It explains how cases involving risk are key to distinguishing these views and discusses a 'social egalitarian' critique of both 'telic egalitarians' and 'telic prioritarians'.

We reply to critics of the World Health Organisation's Report "Making Fair Choices on the Path to Universal Health Coverage". We clarify and defend the report's key moral commitments. We also explain its role in guiding policy in the face of both financial and political constraints on making fair choices.

The Distribution View provides a model that integrates four distributional concerns in the evaluation of risky prospects. Starting from these concerns, we can generate an ordering over a set of risky prospects, or, starting from an ordering, we can extract a characterization of the underlying distributional concerns. Separability of States and/or Persons for multiple-person risky prospects, for single-person risky prospects and for multiple-person certain prospects are discussed within the model. The Distribution View sheds light on public health policies and provides (...) a framework for the discussion of Parfit's Priority View for risky prospects. (shrink)

Risky prospects represent policies that impose different types of risks on multiple people. I present an example from food safety. A utilitarian following Harsanyi's Aggregation Theorem ranks such prospects according to their mean expected utility or the expectation of the social utility. Such a ranking is not sensitive to any of four types of distributional concerns. I develop a model that lets the policy analyst rank prospects relative to the distributional concerns that she considers fitting in the context at hand. (...) I name this model ‘the Distribution View’ posing an alternative to Parfit's Priority View for risky prospects. (shrink)

The Pigou-Dalton (PD) principle recommends a non-leaky, non-rank-switching transfer of goods from someone with more goods to someone with less. This Article defends the PD principle as an aspect of distributive justice—enabling the comparison of two distributions, neither completely equal, as more or less just. It shows how the PD principle flows from a particular view, adumbrated by Thomas Nagel, about the grounding of distributive justice in individuals’ “claims.” And it criticizes two competing frameworks for thinking about justice that less (...) clearly support the principle: the veil-of-ignorance framework, and Larry Temkin’s proposal that fairer distributions are those concerning which individuals have fewer “complaints.” -/- The Article also clarifies the relation between the PD principle and prioritarianism. Prioritarians will surely endorse the PD principle (with the “good” individual well-being), but they are also committed to a distinct axiom of separability: the moral value of someone’s well-being change does not depend upon her position relative to others. The PD principle neither implies separability, nor is implied by it. Although prioritarianism is very plausible, the case for the PD principle is yet more compelling than for the combination of that principle with separability. In discussing prioritarianism, we should differentiate between these two, logically independent aspects of the view. -/- . (shrink)

I argue that prioritarianism cannot be assessed in abstraction from an account of the measure of utility. Rather, the soundness of this view crucially depends on what counts as a greater, lesser, or equal increase in a person’s utility. In particular, prioritarianism cannot accommodate a normatively compelling measure of utility that is captured by the axioms of John von Neumann and Oskar Morgenstern’s expected utility theory. Nor can it accommodate a plausible and elegant generalization of this theory that has been (...) offered in response to challenges to von Neumann and Morgenstern. This is, I think, a theoretically interesting and unexpected source of difficulty for prioritarianism, which I explore in this article. (shrink)

We shall focus on moral theories that are solely concerned with promoting the benefits (e.g., wellbeing) of individuals and explore the possibility of such theories ascribing some priority to benefits to those who are worse off—without this priority being absolute. Utilitarianism (which evaluates alternatives on the basis of total or average benefits) ascribes no priority to the worse off, and leximin (which evaluates alternatives by giving lexical priority to the worst off, and then the second worst off, and so on) (...) ascribes absolute priority to the worse off (i.e., favors even a very small benefit to a worse off person over very large benefits to large numbers of better off people). Neither extreme view, we assume, is plausible. (shrink)

In A Theory of Justice, John Rawls provides several arguments contractors in the original position using maximin reasoning, which leads directly to the difference principle. These arguments are inadequate to support the claim that maximin reasoning is the uniquely rational approach to choice in the original position.

In this extended book review, I summarize Adler's views and critically analyze his key arguments on the measurement of well-being and the foundations of prioritarianism.

This paper critically analyses the priority-setting rules used by the National Institute for Health and Clinical Excellence (NICE) in the UK and proposed by the Netherlands' Council on Public Health and Health Care (RVZ). It argues that neither gives proper weight to improving the lot of those who are worse off than others.

Michael Otsuka, Alex Voorhoeve and Marc Fleurbaey have challenged the priority view in favour of a theory based on competing claims. The present paper shows how their argument can be used to recast the priority view. All desert claims in distributive justice are comparative. The stronger a party’s claims to a given benefit, the greater is the value of her receiving it. Ceteris paribus, the worse-off have stronger claims on welfare, and benefits to them matter more. This can account for (...) intuitions that at first appear egalitarian, as the analysis of an example of Larry Temkin’s shows. The priority view, properly understood, is desert-adjusted utilitarianism under the assumption that no other claims pertain. (shrink)

Discrimination might be considered unjust on account of the comparative disadvantage it imposes, the absolute disadvantage it imposes, the disrespect it shows, or the prejudice it shows. This article argues that each of these accounts overlooks some cases of unjust discrimination. In response to this state of affairs we might combine two or more of these accounts. A promising approach combines the comparative disadvantage and absolute disadvantage accounts.

Policy-makers must sometimes choose between an alternative which has somewhat lower expected value for each person, but which will substantially improve the outcomes of the worst off, or an alternative which has somewhat higher expected value for each person, but which will leave those who end up worst off substantially less well off. The popular ex ante Pareto principle requires the choice of the alternative with higher expected utility for each. We argue that ex ante Pareto ought to be rejected (...) because it conflicts with the requirement that, when possible, one ought to decide as one would with full information. We apply our argument in an analysis of US policy on screening for breast cancer. -/- . (shrink)

This articles proposes that theories and principles of distributive justice be considered substantively egalitarian iff they satisfy each of three conditions: (1) they consider the bare fact that a person is in certain circumstances to be a conclusive reason for placing another relevantly identically entitled person in the same circumstances, except where this conflicts with other similarly conclusive reasons arising from the circumstances of other persons; (2) they can be stated as 'equality of x for all persons', making no explicit (...) or implicit exclusion of persons or individuals and showing no greater concern and respect for some rather than others; and (3) they pursue equality in a dimension that is valuable to egalitarians. On this construal, prioritarianism and Dworkinian equality of resources, a view often identified as luck egalitarian, are not substantively egalitarian, but equality of opportunity, the standard form of luck egalitarianism, may be. (shrink)

The difference between the unity of the individual and the separateness of persons requires that there be a shift in the moral weight that we accord to changes in utility when we move from making intrapersonal tradeoffs to making interpersonal tradeoffs. We examine which forms of egalitarianism can, and which cannot, account for this shift. We argue that a form of egalitarianism which is concerned only with the extent of outcome inequality cannot account for this shift. We also argue that (...) a view which is concerned with both outcome inequality and with the unfairness of inequality in individuals‘ expected utilities can account for this shift. Finally, we limn an alternative view, on.. (shrink)