The purpose of this paper is to identify a kind of discrimination that has hitherto gone unrecognised. ‘Terminalism’ is discrimination against the dying, or treating the terminally ill worse than they would expect to be treated if they were not dying. I provide four examples from healthcare settings of this kind of discrimination: hospice eligibility requirements, allocation protocols for scarce medical resources, right to try laws and right to die laws. I conclude by offering some reflections on why discrimination against (...) the dying has been hard to identify, how it differs from ageism and ableism, and its significance for end-of-life care. (shrink)

This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cases where quality of life suffers because of disability-focused exclusion or (...) injustice differently from cases where lower quality of life results from laws of nature, resource scarcity, or appropriate tradeoffs. Decisionmakers should ignore quality-of-life losses that result from injustice or exclusion when ignoring them would improve the prospects of individuals with disabilities; in contrast, they should consider quality-of-life losses that are unavoidable or stem from resource scarcity or permissible tradeoffs. On this proposal, while health systems should not amplify existing injustice against individuals with disabilities, they are not required to altogether ignore the potential effects of disability on quality of life. (shrink)

Quality-Adjusted Life Years (QALYs) and Disability-Adjusted Life Years (DALYs) are two of the most commonly used health measures to determine resource prioritization and the population burden of disease, respectively. There are different types of problems with the use of QALYs and DALYs for measuring health benefits. Some of these problems have to do with measurement, for example, the weights they ascribe to health states might fail to reflect with exact accuracy the actual well-being or health levels of individuals. But even (...) if these weights represent accurately the well-being levels of individuals, there is room for questioning whether these measures capture everything that we care about in these cases, or whether there are important issues that they leave out, including considerations of fairness or equality. In this regard, the measures have been criticized for treating the aggregation of small benefits as greater than the aggregation of fewer but bigger benefits,1for disregarding fair chances in favor of utility maximization,2and for raising problems when applied in the context of variable population size.3Perhaps one of the most pervasive ethical issues that has been associated with the use of these measures is the fact that they seem to discriminate against disabled people.4Since the measures assume that disabled people have lower well-being and a shorter life span, treating a disabled person’s medical condition contributes less to the maximization of years of life with good health than treating a non-disabled patient’s medical condition. (shrink)

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)

Adaptation to illness, and its relevance for distribution in health care, has been the subject of vigorous debate. In this paper I examine an aspect of this discussion that seems so far to have been overlooked: that some illnesses are difficult, or even impossible, to adapt to. This matters because adaptation reduces suffering. Illness severity is a priority setting criterion in several countries. When considering severity, we are interested in the extent to which an illness makes a person worse-off. I (...) argue that no plausible theory of well-being can disregard suffering when determining to what extent someone is worse-off in terms of health. We should accept, all else equal, that adapting to an illness makes the illness less severe by reducing suffering. Accepting a pluralist theory of well-being allows us to accept my argument, while still making room for the possibility that adaptation is sometimes, all things considered, bad. Finally, I argue that we should conceptualize adaptability as a feature of illness, and thereby account for adaptation on a group level for the purposes of priority setting. (shrink)

This paper introduces a condition for rational choice that states that accepting decision methods and normative theories that sometimes entail that the act of choosing a maximal alternative renders this alternative non-maximal is irrational. The paper illustrates how certain distributive theories that ascribe importance to what the status quo is violate this condition and argues that they thereby should be rejected.

Distributive theories evaluate distributions of goods based on candidate recipients’ characteristics, e.g. how well off candidates are, how deserving they are, and whether they fare below sufficiency. But such characteristics vary across possible worlds, so distributive theories may differ in terms of the world which for them settles candidates’ characteristics. This paper examines how distributive theories differ in terms of whether candidate recipients’ relevant characteristics are grounded in the possible world that would take place if the distributor does not intervene (...) (call it the “input” world) or if they are grounded in each possible world that the distributor can bring about through different decisions (call each an “output” world). We illustrate the importance of this distinction in relation to one distributive theory, prioritarianism. As we show, both input and output versions of prioritarianism are plausible interpretations of the literature, and there are good reasons to take input prioritarianism seriously. Ultimately, however, we argue that input prioritarianism should be rejected. (shrink)

The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it (...) is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify. (shrink)

Effective altruism is a movement which aims to maximise good. Effective altruists are concerned with extreme poverty and many of them think that individuals have an obligation to donate to effective charities to alleviate extreme poverty. Their reasoning, which I will scrutinise, is as follows: -/- Premise 1. Extreme poverty is very bad. -/- Premise 2. If it is in our power to prevent something very bad from happening, without thereby sacrificing anything else morally significant, we ought, morally, to do (...) it. -/- Premise 3. Individuals ought to choose the effective option in preventing very bad things. -/- Premise 4. Donating to effective charities is one of the best ways to alleviate extreme poverty. -/- Conclusion. Individuals ought to donate to effective charities working towards extreme poverty alleviation where doing so does not require them to give up anything of moral significance. -/- I will scrutinise each of these premises in turn. -/- For Premise 1, I focus on hedonistic utilitarianism and criticise its outlook on extreme poverty. I claim that hedonistic utilitarianism might be problematic for effective altruism. -/- Premise 2 is Peter Singer's Weaker Principle of Sacrifice. I introduce several possible interpretations of it, and press several objections to it by stressing overpermissiveness, luck, and rights. I defend strengthening the Weaker Principle of Sacrifice without making it overdemanding. -/- I claim that Premise 3 can be attractive to both consequentialists and non-consequentialists. Nevertheless, by showing that effectiveness sometimes violates fairness, I propose a method which avoids always helping the greater number and always giving everyone equal chances of being helped, which is compatible with effective altruism. -/- Against Premise 4, I assess the systemic change objection, which states that effective altruism unjustifiably distracts individuals from systemic change. By considering risk and the moral standing of the future extremely poor, I claim that the systemic change objection is partially successful, but cannot undermine effective altruism. -/- After analysing all of these, I argue that individuals have an obligation to donate to effective charities to alleviate extreme poverty where doing so does not require them to give up anything of moral significance. (shrink)

The COVID-19 crisis has forced a difficult trade-off between limiting the health impacts of the virus and maintaining economic activity. Welfare economics offers tools to conceptualize this trade-off so that policy-makers and the public can see clearly what is at stake. We review four such tools: the Value of Statistical Life (VSL); the Value of Statistical Life Years (VSLYs); Quality-Adjusted Life-Years (QALYs); and social welfare analysis, and argue that the latter are superior. We also discuss how to choose policies that (...) differentially affect people’s wellbeing. We argue in favor of evaluating policies using a Social Welfare Function (SWF), which evaluates the possible distributions of wellbeing across individuals that may result from a policy. Such a function, we argue, should regard increases in the wellbeing of the less well-off as especially valuable. We then use a model to illustrate how such a framework can help evaluate two broad policy types in response to the pandemic: eradication of the virus, and more lenient control of the spread. Our model reveals how such evaluations depend on many empirical facts but also on key value judgments about the relative importance of health and on the extent of special concern for the worse off. The purpose of this brief is not to make precise recommendations, as conditions vary widely across countries and over time, but to provide a methodology. (shrink)