One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that all (...) are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

It is generally accepted that morally justified healthcare rationing must be non-discriminatory and cost-effective. However, given conventional concepts of cost-effectiveness, resources spent on disabled people are spent less cost-effectively, ceteris paribus, than resources spent on non-disabled people. Thus, it is reasonable to assume that standard cost-effectiveness discriminates against the disabled. Call this thedisability discrimination problem.Part of the disability discrimination involved in cost-effectiveness stems from the way in which health-related quality of life is accounted for and measured. This paper offers and (...) defends a patient-sensitive account of health-related quality of life, which can effectively make cost-effectiveness less discriminatory against the disabled and thus more morally justified. (shrink)

Tännsjö’s book Setting Health-Care Priorities defends the view that there are three main normative theories in the domain of distributive justice, and that these theories are both highly plausible in themselves, and practically convergent in their normative conclusions. All three theories point to a somewhat radical departure from the present distribution of medical resources: in particular, they suggest redirecting resources from marginal life extension to the care of mentally ill patients. In this paper I wish to argue, firstly, that prioritarianism (...) should not be considered as an amendment to utilitarianism, as it is in Tännsjö’s view, but as a distinctive fourth option. This can best be appreciated if we focus on a reading of the theory that emphasizes its derivation from egalitarianism and its attempt to develop an intermediate approach between utilitarian and egalitarian intuitions. Secondly, in response to Tännsjö’s central objection to prioritarianism, I will argue that the theory does not apply in intrapersonal cases but is only relevant for decisions regarding the interpersonal distribution of benefits. Finally, I will suggest that a practical convergence of the four theories on specific issues such as artificial reproduction or mood enhancement is far less likely than Tännsjö seems to believe. (shrink)

Political philosophers often formulate the problem of distributive justice as the problem of how the government ought to distribute different types of goods—for example, income or health care—to its citizens. They therefore presuppose that the government is a unitary agent that governs its citizens directly. However, although a number of governments are unitary in this way, many are federations, exhibiting a division of sovereignty between two or more levels of government having independent grounds of authority. In contrast to unitary states, (...) therefore, within a federation, two or more levels of government directly govern their citizens and are directly accountable to them. Because of the way in which different levels of government in a federation can separately affect the distribution of goods in society, federations face resource allocation problems that are far more complex than those of unitary states. In addition to determining what a just distribution of goods is, federations must also determine (1) whether distributive justice is a shared responsibility amongst different levels of government, and, if so, (2) how this shared responsibility should be allocated between them. (shrink)

Pre-natal-diagnosis technologies allow parents to discover whether their child is likely to suffer from serious disability. One argument for state funding of access to such technologies is that doing so would be “cost-effective”, in the sense that the expected financial costs of such a programme would be outweighed by expected “benefits”, stemming from the births of fewer children with serious disabilities. This argument is extremely controversial. This paper argues that the argument may not be as unacceptable as is often assumed. (...) In doing so, it sets out a more general framework for assessing the relevance of efficiency calculations to policy-making. The final section also investigates the relationship between the paper’s arguments and claims about parental responsibility for child-bearing and rearing, with reference to Scanlon’s work on “substantive responsibility”. (shrink)

Pre-natal-diagnosis technologies allow parents to discover whether their child is likely to suffer from serious disability. One argument for state funding of access to such technologies is that doing so would be “cost-effective”, in the sense that the expected financial costs of such a programme would be outweighed by expected “benefits”, stemming from the births of fewer children with serious disabilities. This argument is extremely controversial. This paper argues that the argument may not be as unacceptable as is often assumed. (...) In doing so, it sets out a more general framework for assessing the relevance of efficiency calculations to policy-making. The final section also investigates the relationship between the paper’s arguments and claims about parental responsibility for child-bearing and rearing, with reference to Scanlon’s work on “substantive responsibility”. (shrink)

In my article above, I cite an earlier article by Frances Kamm, ‘Deciding Whom to Help, Health-Adjusted Life Years, and Disabilities’, in Public Health, Ethics, and Equity, eds. S. Anand, F. Peters, and A. Sen circulated as a working paper of the Center for Population Studies, Harvard University). However, I failed to correctly identify her position on one view that she took up in that article, and also failed to cite a proposal she developed in that article similar to one (...) I took up in my paper. (shrink)

We review methods for economic evaluation recently developed in health economics by focusing on the epistemic and non-epistemic values they embody. The emphasis is on insights into valuing health,...

Many ethical theorists believe that a given distribution of healthcare is morally justified only if (1) it is cost-effective and (2) it does not discriminate against older adults and disabled people. However, if (3) cost-effectiveness involves maximizing the number of quality-adjusted life-years (QALYs) added by a given unit of healthcare resource, or cost, it seems the pursuit of cost-effectiveness will inevitably discriminate against older adults and disabled patients. I show why this trilemma is harder to escape than some theorists think. (...) We cannot avoid it by using age- or disability-weighted QALY scores, for example. I then explain why there is no sense of “discrimination” on which discrimination isbothunjust, and thus something healthcare rationing must avoid,andsomething cost-effective healthcare rationing inevitably involves. I go on to argue that many of the reasons we have for not favoring rationing that maximizes QALYs outside the healthcare context apply in healthcare as well. Thus, claim (1) above is dubious. (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)

How should states and international organizations allocate global health resources? This paper examines proposals for distributing these resources in the literature. First, we look at the literature on the metrics for measuring what matters and consider how they might be modified to avoid some common objections—e.g., that these measures discriminate against the disabled or fail to give due weight to helping the young (or old) or those in present (or future) generations. Second, we canvas existing approaches to evaluating allocations of (...) health‐related resources utilizing such measures and advance a new way of doing so. We suggest that it is important to provide substantive arguments for directly evaluating alternative allocations, but there is also room for deliberation about fair procedures for selecting allocation criteria and securing just outcomes. (shrink)