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 asymmetry is the view in population ethics that, while we ought to avoid creating additional bad lives, there is no requirement to create additional good ones. The question is how to embed this intuitively compelling view in a more complete normative theory, and in particular one that treats uncertainty in a plausible way. While arguing against existing approaches, I present new and general principles for thinking about welfarist choice under uncertainty. Together, these reduce arbitrary choices to uncertainty-free ones, regardless (...) of how the latter should be made. I illustrate these principles by developing two theories of the asymmetry, reflecting different views about the non-identity problem. In doing so, I clarify some other major choice-points, presenting new arguments that creating additional good lives can justify (but not require) doing harm. Finally, I consider what the developed theories have to say about the importance of extinction risk and the long-run future. (shrink)

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, focusing on (...) discrimination and on fundamental egalitarian and social justice concerns. (shrink)

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional rather than a residual system. They argue that the concept contradicts the idea of comprehensiveness; leads to unsustainable expenditures; is too indeterminate for policy; and supports only a prioritarian distribution. I argue that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and that UHC is a (...) solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy are not transparent about the source of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option. (shrink)

: In some cases in which rational and moral agents experience moral uncertainty, they are unable to assign exact degrees of moral value—in a non-arbitrary way—to some of the different acts available to them, and so are unable to choose with certainty the best act. This article presents a new justification for the use of lotteries in this kind of situation. It is argued that sometimes the only rational thing for a morally motivated agent to do here is to use (...) a lottery. (shrink)

A central point of debate over environmental policies concerns how future costs and benefits should be assessed. The most commonly used method for assessing the value of future costs and benefits is economic discounting. One often-cited justification for discounting is uncertainty. More specifically, it is risk aversion coupled with the expectation that future prospects are more risky. In this paper I argue that there are at least two reasons for disputing the use of risk aversion as a justification for discounting (...) when dealing with longterm decisions, one technical and one ethical. Firstly, I argue that technically, it implies an inconsistency between theory and practice. And secondly, I argue that discounting for uncertainty relies on a form of individualism which, while reasonable in standard microeconomic theory where an agent chooses how to spread her own consumption over her own lifetime, is inappropriate in the context of intergenerational social decisions. (shrink)

Alternative allocations of a fixed bundle of healthcare resources often involve significantly different indirect, non-health effects. The question arises whether these effects must figure in accounts of the conditions under which a distribution of healthcare resources is morally justifiable. In this article we defend a Scanlonian, affirmative answer to this question: healthcare resource managers should sometimes select an allocation which has worse direct, health-related effects but better indirect, nonhealth effects; they should do this when the interests served by such a (...) policy are more urgent than the healthcare interests better served by an alternative allocation. We note that there is a prima facie case for the claim that such benefits (and costs) are relevant—i.e. they are real benefits, and in other contexts our decisions can permissibly be guided by them. We then proceed to rebut three lines of argument that might be thought to defeat this prima facie case: they appeal to fairness, the Kantian Formula of Humanity as an End in Itself, and the equal moral worth of persons, respectively. (shrink)

The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among patients and lack (...) of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions. (shrink)

Contrary to popular belief, population-wide preventive measures are rarely cost-reducing. Yet they can still be cost-effective, and indeed more cost-effective than treatment. This is often true of preventive measures that work by slightly reducing the already low risks of death faced by many people. This raises a difficult moral question: when we must choose between life-saving treatment, on the one hand, and preventive measures that avert even more deaths, on the other, is the case for prevention weakened when it works (...) by reducing many healthy people’s already low risks by a further tiny amount? I argue the answer is no. (shrink)

The main body of this paper assesses a leading recent theory of fairness, a theory put forward by John Broome. I discuss Broome's theory partly because of its prominence and partly because I think it points us in the right direction, even if it takes some missteps. In the course of discussing Broome's theory, I aim to cast light on the relation of fairness to consistency, equality, impartiality, desert, rights, and agreements. Indeed, before I start assessing Broome's theory, I discuss (...) two very popular conceptions of fairness that contrast with his. One of these very popular conceptions identifies fairness with the equal and impartial application of rules. The other identifies fairness with all-things-considered moral rightness. (shrink)

In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures to allocate scarce life-saving resources. In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims (...) to these resources rather than use RAND to allocate such resources. (shrink)

It is widely accepted that one of the main objectives of government expenditure on health care is to generate health. Since health is a function of both length of life and quality of life, the quality-adjusted life-year (QALY) has been developed in an attempt to combine the value of these attributes into a single index number. The QALY approach - and particularly the decision rule that healthcare resources should be allocated so as to maximise the number of QALYs generated - (...) has often been equated with the utilitarian philosophy of maximising `the greatest happiness of the greatest number'. This paper considers the extent to which the measurement and aggregation of QALYs really is utilitarian by developing a new taxonomy in order to classify utilitarianism and the different aspects of the QALY approach. It is shown that the measurement of QALYs is consistent with a number of different moral positions and that QALYs do not have to be aggregated according to the maximisation rule. Therefore it is inappropriate to necessarily equate QALYs with utilitarianism. It is shown that much turns on what in principle the QALY represents and how in practice it can be operationalised. The paper highlights the category confusion that is often present here and suggests possible avenues for future theoretical and empirical research. (shrink)