Norman Daniels’s theory of ‘accountability for reasonableness’ is an influential conception of fairness in healthcare resource allocation. Although it is widely thought that this theory provides a consistent extension of John Rawls’s general conception of justice, this paper shows that accountability for reasonableness has important points of contact with both utilitarianism and intuitionism, the main targets of Rawls’s argument. My aim is to demonstrate that its overlap with utilitarianism and intuitionism leaves accountability for reasonableness open to damaging critiques. The important (...) role that utilitarian-like cost-effectiveness calculations are allowed to play in resource allocation processes disregards the separateness of persons and is seriously unfair towards individuals whose interests are sacrificed for the sake of groups. Furthermore, the function played by intuitions in settling frequent value conflicts opens the door for sheer custom and vested interests to steer decision-making. (shrink)

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)

Central to the Rawls–Harsanyi dispute is the question of whether the core modeling device of Rawls' theory of justice, the original position, justifies Rawls' principles of justice, as Rawls suggests, or whether it justifies the average utility principle, as Harsanyi suggests. Many commentators agree with Harsanyi and consider this dispute to be primarily about the correct application of normative decision theory to Rawls' original position. I argue that, if adequately conceived, the Rawls–Harsanyi dispute is not primarily a dispute about the (...) correct application of normative decision theory to Rawls' original position. Instead, Rawls and Harsanyi aim to model different moral ideals, and this difference in their moral assumptions leads them to significantly different conclusions about justice. There is no winner in the Rawls–Harsanyi dispute. Instead, the dispute merely clarifies the moral ideals and their formal representations that need to be assumed in order to justify either Rawls' contractualist principles of justice or the average utility principle. Thus understood, the Rawls–Harsanyi dispute offers a promising starting point for future research that can deepen and enrich our understanding of the demands of justice. (shrink)

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

Suppose you can save only one of two groups of people from harm, with one person in one group, and five persons in the other group. Are you obligated to save the greater number? While common sense seems to say ‘yes’, the numbers skeptic says ‘no’. Numbers Skepticism has been partly motivated by the anti-consequentialist thought that the goods, harms and well-being of individual people do not aggregate in any morally significant way. However, even many non-consequentialists think that Numbers Skepticism (...) goes too far in rejecting the claim that you ought to save the greater number. Besides the prima facie implausibility of Numbers Skepticism, Michael Otsuka has developed an intriguing argument against this position. Otsuka argues that Numbers Skepticism, in conjunction with an independently plausible moral principle, leads to inconsistent choices regarding what ought to be done in certain circumstances. This inconsistency in turn provides us with a good reason to reject Numbers Skepticism. Kirsten Meyer offers a notable challenge to Otsuka’s argument. I argue that Meyer’s challenge can be met, and then offer my own reasons for rejecting Otsuka’s argument. In light of these criticisms, I then develop an improved, yet structurally similar argument to Otsuka’s argument. I argue for the slightly different conclusion that the view proposed by John Taurek that ‘the numbers don’t count’ leads to inconsistent choices, which in turn provides us with a good reason to reject Taurek’s position. (shrink)

According to the Competing Claims View we decide between alternatives by looking at the competing claims held by affected individuals. The strength of these claims is a function of two features: how much they stand to benefit by each alternative, and how badly off they would be in its absence. The view can be, and is, endorsed by both egalitarians and prioritarians. For the former the second condition will concern looking at how badly off the person is relative to others, (...) whereas for the latter it will be how badly off she is in absolute terms. In this paper I want to argue that neither should be endorsed. The egalitarian version of CCV breaks down when attempting to assess the competing claims of possible persons who may never exist. Also, the view, on at least one plausible interpretation, leads to intransitive judgements. The prioritarian version of CCV, in turn, is vulnerable to its own unique objection, namely delivering an anti-prioritarian and rather implausible verdict in certain Single Person Cases. (shrink)

In this thesis, I discuss the aggregation problem for T. M. Scanlon’s “contractualism”. I argue that Scanlonian contractualists have the following two options when it comes to the aggregation problem. First, they can choose to limit aggregation directly via a specific version of the Relevance View, “Sequential Claims-Matching”. Second, Scanlonian contractualists can adopt a so-called “mixed solution” of which I propose a specific version. My mixed solution does not limit aggregation. Rather, it either avoids some of the counterintuitive results in (...) certain cases, or at least makes these same results look a lot less counterintuitive by putting them into perspective thanks to a plausible plurality of precisely specified values. The stakes between these two options are as follows. The first option justifies Scanlon’s intuition in one vs. many cases of which his “World Cup Case” is one example, but it comes at the cost of a seemingly quite limited range of application: any version of the Relevance View only works in cases in which we have no more than two groups of competing claimants. The second option has the exact opposite implications: my mixed solution cannot justify Scanlon’s intuition in one vs. many cases, but it could be applied to any case with any number of groups of competing claimants. In this choice between pre-theoretical intuition and feasibility, I would urge Scanlonian contractualists to choose feasibility. (shrink)

Tolstoy's The Death of Ivan Ilyich describes how a man's exposure to imminent death allows him to secure redemption from a flawed life. Through close textual attention to Tolstoy's novella and extensive engagement with Frances Kamm's treatment of it, this article quarrels with this of Ivan's case, offering a sourer, more pessimistic view. It is argued that Ivan's reconciliation to death is facilitated by a series of mistakes he makes en route to his dying moments. Two more general lessons are (...) drawn: first, that we are all vulnerable to the mistakes Ivan makes, and second, that reflection on the quality of our lives does not present us with any obvious resources for coming to terms with our own deaths. (shrink)

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same (...) way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications. (shrink)

Rationing in healthcare remains very much a taboo topic. Before COVID-19, it rarely received public attention, even when it occurred in everyday practices, mainly in the form of implicit rationing, as it continues to do today. There are different definitions, types and levels of healthcare rationing, according to different perspectives. With the aim of contributing to a more coherent debate on such a highly emotional healthcare issue as rationing, here are provided a number of reflections from a patient advocate perspective (...) which are specifically focused on bedside rationing, the most troublesome level, both for patients and clinicians, particularly in regard to cancer care. Oncology, with its numerous expensive therapies and increasing number of patients, is undeniably one of the main areas contributing to the increase in healthcare costs. However, the fixed budgets of today's publicly financed health systems cannot allow unlimited access to the potentially beneficial treatments to all patients. Bedside rationing constitutes the last phase of many decision-making processes occurring at different interrelated levels (macro-levels), both inside and outside healthcare systems, which implicitly and inevitably result in a bottleneck determined by the upstream decisions themselves. Shifting from implicit to explicit bedside rationing essentially means moving from a paternalistic to a citizen-before-patient approach; this implies, first of all, a cultural change. Practical bedside rationing is an ethically complex topic, but one that needs to be urgently addressed in a transparent and open debate. In this scenario, the oncological community – patients, patient advocates and clinicians – can and should play an important role. (shrink)