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)

Despite being increasingly available to us all, retirement pensions remain unequally distributed: between rich and poor, young and old, men and women, and possibly different generations. As this topic receives little attention in moral and political philosophy, the articles in this thesis aim to deliver an original account of justice in retirement pensions along liberal egalitarian lines. The first part defends retirement pensions as a distribution of free time. It shows that including free time in the list of goods that (...) liberal egalitarians prioritise is plausible and avoids problems that would otherwise arise with other candidates, most notably leisure. Retirement as free time is an essential feature of liberal egalitarian societies by (re)distributing the means to pursue any life project, and especially valuable for the poor who work and contribute the longest. The second part makes a case for 'libertirement', a proposal to increase the freedom to enjoy free time across life, as a matter of justice between those who live long and those who die early. Specifically, I propose adding reverse pensions and sabbaticals on top of old-age retirement. Besides showing the importance of longevity for age-group justice, I also draw implications for distributing unconditional basic income and income taxes across life, which I suggest may offer alternative paths to libertirement. Finally, the third part discusses the cases of pension inequality between genders and generations, pushing us to refine our account further. I conclude that there is often a mismatch between liberal egalitarian justice and the design of retirement schemes. The solution is often but not always to reform these systems. Sometimes, we have reasons to revise our very own principles of justice. (shrink)

This article is a critical discussion of the book Setting Health-Care Priorities by Torbjörn Tännsjö. This critique targets mainly Tännsjö’s method, but also several unjustified conclusions and some implicit assumptions.

This paper argues that the Repugnant Conclusion which the Mere Addition Paradox generates is not the same as the one which a sum-aggregative view like impersonal total utilitarianism leads to, but a slightly more moderate version of it. Given a spectrum of outcomes {A, B, C, …, X, Y, Z} such that in each of them there is a population that is twice as large as the previous one and has a level of wellbeing that is just barely lower than (...) the previous one, the Mere Addition Paradox implies that while almost all the outcomes of the spectrum are better than A, the last ones, such as Y and Z, will not, lest we accept that adding lives at a negative level is positive or neutral. This affects the way the Mere Addition Paradox should be presented. (shrink)

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We (...) demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose. (shrink)

The present paper constitutes an introduction to a special issue of Diametros devoted to Setting Health-Care Priorities. What Ethical Theories Tell Us by Torbjörn Tännsjö. The book in question states that there are three moral theories which have valid implications in the field of the distribution of medical resources in a healthcare system: utilitarianism, the maximin/leximin view, and egalitarianism. A number of authors have contributed to this special issue with papers which challenge this thesis. Robert E. Goodin argues that, besides (...) general moral theories, some local principles of justice might be valid. Quinn Hiroshi Gibson states that Tännsjö should have considered the Rawlsian view on justice in its contractualist reading. Jay A. Zameska argues that his “revised lexical sufficientarianism” constitutes a more reliable moral view than prioritarianism. Finally, Lasse Nielsen points out that there is more to say about distributive justice than consequentialist theories can grasp. Moreover, he puts forward an argument in defense of prioritarianism. The final article in this issue constitutes Tännsjö’s replies to his critics. (shrink)

Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this analysis, the (...) paper arrives at the following three conclusions: that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case. (shrink)

In this commentary on Torbjörn Tännsjö’s Setting Health-Care Priorities, I argue that sufficientarianism provides a valuable perspective in considering how to set health care priorities. I claim that pace Tännsjö, sufficientarianism does offer a distinct alternative to prioritarianism. To demonstrate this, I introduce sufficientarianism and distinguish two forms: Tännsjö’s “weak sufficientarianism” and an alternative strong form of sufficientarianism that I call “revised lexical sufficientarianism.” I raise a problem for Tännsjö’s sufficientarianism, and advocate for the revised view on this basis. I (...) then demonstrate that in the area of population ethics, the revised view outperforms the other views Tännsjö considers. As such, I aim to demonstrate that sufficientarianism — understood as its own theory and not just as a form of prioritarianism — offers unique advantages in population ethics, and would have been a valuable complement to the other theories Tännsjö considers. (shrink)

This paper firstly distinguishes between principles of “global justice” that apply the same anywhere and everywhere – Tännsjö’s utilitarianism, egalitarianism, prioritarianism and such like – and principles of “local justice” that apply within the specific sphere of health-care. Sometimes the latter might just be a special case of the former – but not always. Secondly, it discusses reasons, many psychological in nature, why physicians might devote excessive resources to prolonging life pointlessly, showing once again that those reasons might themselves be (...) morally significant. (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)

Torbjörn Tännsjö has written a clear and thought-provoking book on healthcare priority setting. He argues that different branches of ethical theory—utilitarianism, egalitarianism, and prioritarianism—are in general agreement on real-world healthcare priorities, and that it is human irrationality that stands in the way of complying with their recommendations. While I am generally sympathetic to the overall project and line of argumentation taken by the book, this paper raises two concerns with Tännsjö’s argument. First, that he is wrong to set aside deontic (...) constraints as irrelevant or as pointing in the same direction as consequentialism. Secondly, that his argument against prioritarianism in favor of utilitarianism is insufficient and under-developed. Given these problems, I conclude that we should welcome Tännsjö’s contribution but with these qualifications in mind. (shrink)

The article provides answers to comments in this journal on my recent book, Setting Health-Care Priorities. What Ethical Theories Tell Us. Did I address all of the relevant theories? Yes, I did. Was my argument underdeveloped in any respects? Yes, at least in one as I should perhaps have discussed contractual ethical thinking more carefully. I do so in this response. Moreover, the critical comments raised have helped me to clarify my argument in many ways, for which I thank my (...) critics. (shrink)

The consideration of the problem of healthcare allocation as a special case of distributive justice is especially alluring when we only consider consequentialist theories. I articulate here an alternative Rawlsian non-consequentialist theory which prioritizes the fairness of healthcare allocation procedures rather than directly setting distributive parameters. The theory in question stems from Rawlsian commitments that, it is argued, have a better Rawlsian pedigree than those considered as such by Tännsjö. The alternative framework is worthy of consideration on its own merits, (...) but it also casts light on two related difficulties with Tännsjö’s approach: (i) the limits of his supposedly ecumenical methodology, which is revealed to be dialectically suspect and (ii) issues with the type of abstraction and idealization from actual judgements and preferences which the approach requires. (shrink)

Ageism is the view that it is of greater moral value to allocate health care resources to younger people than to older people. In medical ethics, it is well-known that standard interpretations of distributive principles such as utilitarianism and egalitarianism imply some form of ageism. At times, ethicists argue as if practical complications are the only or main reason for not abiding to ageism. In this article, we argue that inferences to ageism from such distributive principles tend to commit what (...) we call the anticipation-blindness fallacy: A much too narrow focus on life quality benefits of health care treatments inclines us to overlook the importance of life quality benefits of health care safety, that is the mere trust in and expectation of being treated and cared for as one grows old. This is a key omission because health safety has value for a much larger population and for much longer time. Taking health safety into account therefore has important implications as for how ageist we ought to be. (shrink)

_The purpose _of this article is to find out whether philosophical and anthropological studies of human nature affect the legitimization of decisions about human life and death, using the example of a philosophical analysis of the problem of euthanasia. _Theoretical__ basis._ Philosophically and anthropologically based situational analysis in bioethics is chosen as the research methodology, which reveals the legitimation of euthanasia as a complex and highly responsible moral decision, which should be based on both the consideration of all the patient’s (...) special circumstances and the competent and adequate application of fundamental knowledge about the human being. _Originality._ From a philosophical point of view, it would be correct to legalize euthanasia, but under the condition of significantly limiting the cases of its application, clearly defining the conditions for its provision and strict control over its implementation. It is morally unacceptable to justify either murder or torture, so euthanasia appears as an attempt to avoid both at the same time. _Conclusions._ Specific solutions to practical problems often indicate the necessary direction for solving theoretical difficulties. Thus, making proper moral decisions about euthanasia requires reliance on fundamental knowledge about human beings, but at the same time it provides arguments "for" and "against" artificial termination of life. The basic principles of bioethics – autonomy, nonmaleficence, beneficence and respect for the dignity of human life – serve as criteria for making balanced ethical decisions both in theory and in practice. These principles should be complemented by a coherent ethical, legal and philosophical position on euthanasia, which is achieved through legitimation procedures. Decisive for making a decision on euthanasia should be the strong desire of the patient himself. (shrink)

Total views imply what Derek Parfit has called ‘the repugnant conclusion’. There are several strategies aimed at debunking the intuition that this implication is repugnant. In particular, it goes away when we consider the principle of unrestricted instantiation, according to which any instantiation of the repugnant conclusion must appear repugnant if we should be warranted in relying on it as evidence against total theories. However, there are instantiations of the conclusion where it doesn't seem to be at all repugnant. Hence (...) there is nothing repugnant about the repugnant conclusion as such. The faults with total views have nothing to do with large numbers or with the conclusion as such. It is possible, if you like, to correct these putative faults even if you adopt some total view (different from utilitarianism). (shrink)