In this article, I first compare positions I have taken in the past and those taken by Peter Singer on how the allocation of life-saving resources should be affected by the aggregation of expected quality of life, quantity of life, and need, both within the life of a person and across persons . I then reexamine the specific issue of whether and why differences in expected years of life and quality of life that a scarce resource can provide a disabled (...) and a nondisabled person should affect our allocation decisions. I attend to how the use of the veil of ignorance bears on this issue and also how the conclusions I reach differ in certain ways from my past positions. (shrink)

This paper deals with the truth-Conditions and the logic for vague languages. The use of supervaluations and of classical logic is defended; and other approaches are criticized. The truth-Conditions are extended to a language that contains a definitely-Operator and that is subject to higher order vagueness.

A notorious problem that has recently received increased attention in axiology, normative theory and population ethics is the apparent ubiquity of what can be generally called nondeterminacy. This paper illustrates how nondeterminacy can spawn cyclical rankings. So, accepting that practical reasons can admit of nondeterminacy challenges the widely held idea that ‘better than’ is transitive. As a result, standard approaches to rational choice under nondeterminacy fail to be action-guiding, since in some situations all options are dominated, that is, impermissible according (...) to standard rational choice criteria. (shrink)

The principle of need—the idea that resources should be allocated according to need—is often invoked in priority setting in the health care sector. In this article, I argue that a reasonable principle of need must be indeterminate, and examine three different ways that this can be dealt with: appendicizing the principle with further principles, imposing determinacy, or empowering decision makers. I argue that need must be conceptualized as a composite property composed of at least two factors: health shortfall and capacity (...) to benefit. When one examines how the different factors relate to each other, one discovers that this is sometimes indeterminate. I illustrate this indeterminacy in this article by applying the small improvement argument. If the relation between the factors are always determinate, the comparative relation changes by a small adjustment. Yet, if two needs are dissimilar but of seemingly equal magnitude, the comparative relation does not change by a small adjustment of one of the factors. I then outline arguments in favor of each of the three strategies for dealing with indeterminacy, but also point out that all strategies have significant shortcomings. More research is needed concerning how to deal with this indeterminacy, and the most promising path seems to be to scrutinize the position of the principle of need among a plurality of relevant principles for priority setting in the health care sector. (shrink)

In this paper, I argue that sufficientarian principles are indispensable in the set of principles that have bearing on issues in distributive ethics. I provide two arguments in favor of this claim. First, I argue that sufficientarianism is the only framework that allows us to appropriately analyze what sort of obligations we have toward individuals who are badly off due to their own faults and choices. Second, I argue that sufficientarianism is the only theory that provides an adequate framework for (...) thinking about the desperately badly off. (shrink)

Derek Parfit’s mere addition paradox has generated a large literature. This paper articulates one response to this paradox—which Parfit himself suggested—in terms of a formal account of the relation of parity. I term this response the ‘parity view’. It is consistent with transitivity of ‘at least as good as’, but implies incompleteness of this relation. The parity view is compatible with critical‐band utilitarianism if this is adjusted to allow for vagueness. John Broome argues against accounts which involve incompleteness. He thinks (...) they are based on an intuition of ‘neutrality’, which is most naturally understood in terms of equality. There is no rationale, on Broome’s view, for seeing it as ‘incommensurateness’ which leads to incompleteness. Parity provides one. Broome’s worries that ‘incommensurateness’ makes neutrality implausibly ‘greedy’, and that ‘incommensurateness’ and vagueness are incompatible do not constitute a knock‐down case against the parity view. Similar worries arise for his preferred vagueness view. (shrink)

Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the (...) fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications. (shrink)

Derek Parfit’s mere addition paradox has generated a large literature. This paper articulates one response to this paradox - which Parfit hirnself suggested - in terms of a formal account of the relation of parity. I term this response the ‘parity view’. It is consistent with transitivity of ‘at least as good as’, but implies incompleteness of this relation. The parity view is compatible with critical-band utilitarianism if this is adjusted to allow for vagueness. John Broome argues against accounts which (...) involve incompleteness. He thinks they are based on an intuition of ‘neutrality’, which is most naturally understood in terms of equality. There is no rationale, on Broome’s view, for seeing it as ‘incommensurateness’ which leads to incompleteness. Parity provides one. Broome’s worries that ‘incommensurateness’ makes neutrality implausibly ‘greedy’, and that ‘incommensurateness’ and vagueness are incompatible do not constitute a knock-down case against the parity view. Similar worries arise for his preferred vagueness view. (shrink)

When thinking about population level healthcare priority setting decisions, such as those made by the National Institute for Health and Care Excellence, good medical ethics requires attention to three main principles of health justice: (1) cost-effectiveness, an aspect of beneficence, (2) non-discrimination, and (3) priority to the worse off in terms of both current severity of illness and lifetime health. Applying these principles requires consideration of the identified patients who benefit from decisions and the unidentified patients who bear the opportunity (...) costs. (shrink)

A notorious debate in the ethics of healthcare rationing concerns whether to address rationing decisions with substantial principles or with a procedural approach. One major argument in favour of procedural approaches is that substantial principles are indeterminate so that we can reasonably disagree about how to apply them. To deal with indeterminacy, we need a just decision process. In this paper I argue that it is a mistake to abandon substantial principles just because they are indeterminate. It is true that (...) reasonable substantial principles designed to deal with healthcare rationing can be expected to be indeterminate. Yet, the indeterminacy is only partial. In some situations we can fully determine what to do in light of the principles, in some situations we cannot. The conclusion to draw from this fact is not that we need to develop procedural approaches to healthcare rationing, but rather that we need a more complex theory in which both substantial principles and procedural approaches are needed. (shrink)

This article analyzes approaches to nondeterminacy that suggest that one can make justified choices when primary criteria fail to fully determine a best alternative by introducing a secondary criterion. It is shown that these approaches risk violating Basic Contraction Consistency. Some ways of adjusting two-step models in order to protect against this are addressed, and it is suggested that proponents of two-step models should adopt formal conditions which qualify what counts as a permissible secondary criterion that resemble supervaluationist conditions that (...) qualify what counts as admissible precisifications of vague terms. (shrink)