A key question in disability studies, philosophy, and bioethics concerns the relationship between disability and well-being. The mere difference view, endorsed by Elizabeth Barnes, claims that physical and sensory disabilities by themselves do not make a person worse off overall—any negative impacts on welfare are due to social injustice. This article argues that Barnes’s Value Neutral Model does not extend to intellectual disability. Intellectual disability is (1) intrinsically bad—by itself it makes a person worse off, apart from a non-accommodating environment; (...) (2) universally bad—it lowers quality of life for every intellectually disabled person; and (3) globally bad—it reduces a person’s overall well-being. While people with intellectual disabilities are functionally disadvantaged, this does not imply that they are morally inferior—lower quality of life does not mean lesser moral status. No clinical implications concerning disability-based selective abortion, denial of life-saving treatment, or rationing of scarce resources follow from the claim that intellectual disability is bad difference. (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)

This essay discusses implications of incommensurability of values for justified decision-making, ethics and justice. Under particular conditions incommensurability of values causes what might be called ‘incomplete comparability’ of options. Some leading theorists interpret this in terms of ‘imprecise equality’ and ‘imprecise comparability.’ This interpretation is mistaken and conceals the implications of incommensurability for practical and ethical reasoning. The aim of this essay is to show that, in many cases, incommensurability prevents the assignment of determinate weights to competing values. This may (...) have problematic consequences for a complete and impartial justification of decisions concerning conflicting values to the extent that they depend on the need of weighing them. (shrink)

Ronald Dworkin’s Justice for Hedgehogs renews and amplifies his earlier attacks on metaethics. This article reviews the main lineaments of Dworkin’s anti-metaethical arguments and discusses, in detail, a number of issues which arise from them. First, it is suggested that Dworkin’s appraisal of what is doing most of the explanatory work in his account is largely askew. Second, it is claimed that Dworkin’s allegation that expressivism is self-defeating is wide of the mark, but that another charge in the same vicinity (...) might be more effective. Third, it is argued that Dworkin’s incuriosity about moral metaphysics is misplaced. What his arguments actually support is an opposition to leaving metaphysical hostages to fortune, rather than an opposition to pursuing greater clarification about moral metaphysics. In this connection, it is tentatively suggested that Dworkin might be tempted by a certain version of naturalism. (shrink)

This article examines arguments concerning enhancement of human persons recently presented by Michael Sandel (2004). In the first section, I briefly describe some of his arguments. In section two, I consider whether, as Sandel claims, the desire for mastery motivates enhancement and whether such a desire could be grounds for its impermissibility. Section three considers how Sandel draws the distinction between treatment and enhancement, and the relation to nature that he thinks each expresses. The fourth section examines Sandel's views about (...) parent/child relations and also how enhancement would affect distributive justice and the duty to aid. In conclusion, I briefly offer an alternative suggestion as to why enhancement may be troubling and consider what we could safely enhance. (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)

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)

"In this article, I argue that under current resource constraints, institutional arrangements seeking to ensure commonly accepted egalitarian goals would engender the decrease of health status of many who do not currently enjoy particularly high levels of health.".

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)

Hastings Center Report, Volume 51, Issue 5, Page 18-29, September‐October 2021.