In virtue of what is something a reason for action? That is, what makes a consideration a reason to act? This is a metaphysical or meta-normative question about the grounding of reasons for action. The answer to the grounding question has been traditionally given in ‘pure’, univocal terms. This paper argues that there is good reason to understand the ground of practical normativity as a hybrid of traditional ‘pure’ views. The paper 1) surveys the three leading ‘pure’ answers to the (...) question of a normative ground, 2) examines one or two of the most difficult problems for each, proposing along the way a new objection to one, and 3) argues that a particular hybrid view about normative grounds –‘hybrid voluntarism’ – avoids each of the main problems faced by the three leading ‘pure’ views. (shrink)

Temkin's book is a very original and deeply unsettling work of skeptical philosophy that mounts an important new challenge to contemporary ethics.

Agency and identity -- Necessitation -- Acts and actions -- Aristotle and Kant -- Agency and practical identity -- The metaphysics of normativity -- Constitutive standards -- The constitution of life -- In defense of teleology -- The paradox of self-constitution -- Formal and substantive principles of reason -- Formal versus substantive -- Testing versus weighing -- Maximizing and prudence -- Practical reason and the unity of the will -- The empiricist account of normativity -- The rationalist account of normativity (...) -- Kant on the hypothetical imperative -- Against particularistic willing -- Deciding and predicting -- Autonomy and efficacy -- The function of action -- The possibility of agency -- Non-rational action -- Action -- Attribution -- The psychology of action -- Expulsion from the garden : the transition to humanity -- Instinct, emotion, intelligence, and reason -- The parts of the soul -- Inside or outside -- Pull yourself together -- The constitutional model -- Models of the soul -- The city and the soul -- Platonic virtues -- Justice : substantive, procedural, and platonic -- Kant and the constitutional model -- Defective action -- The problem of bad action -- Being governed by the wrong law -- Or five bad constitutions -- Conceptions of evil -- Degrees of action -- Integrity and interaction -- Deciding to be bad -- The ordinary cases -- Dealing with the disunified -- Kant's theory of interaction -- My reasons -- Deciding to treat someone as an end in himself -- Interacting with yourself -- How to be a person -- What's left of me? (shrink)

Winner of the 1975 National Book Award, this brilliant and widely acclaimed book is a powerful philosophical challenge to the most widely held political and social positions of our age--liberal, socialist, and conservative.

We are often faced with choices that involve the weighing of people's lives against each other, or the weighing of lives against other good things. These are choices both for individuals and for societies. A person who is terminally ill may have to choose between palliative care and more aggressive treatment, which will give her a longer life but at some cost in suffering. We have to choose between the convenience to ourselves of road and air travel, and the lives (...) of the future people who will be killed by the global warming we cause, through violent weather, tropical disease, and heat waves. We also make choices that affect how many lives there will be in the future: as individuals we choose how many children to have, and societies choose tax policies that influence people's choices about having children. These are all problems of weighing lives. How should we weigh lives? Weighing Lives develops a theoretical basis for answering this practical question. It extends the work and methods of Broome's earlier book Weighing Goods to cover the questions of life and death. Difficult problems come up in the process. In particular, Weighing Lives tackles the well-recognized, awkward problems of the ethics of population. It carefully examines the common intuition that adding people to the population is ethically neutral - neither a good nor a bad thing - but eventually concludes this intuition cannot be fitted into a coherent theory of value. In the course of its argument, Weighing Lives examines many of the issues of contemporary moral theory: the nature of consequentialism and teleology; the transitivity, continuity, and vagueness of betterness; the quantitative conception of wellbeing; the notion of a life worth living; the badness of death; and others. This is a work of philosophy, but one of its distinctive features is that it adopts some of the precise methods of economic theory (without introducing complex mathematics). Not only philosophers, but also economists and political theorists concerned with the practical question of valuing life, should find the book's conclusions highly significant to their work. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the (...) relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

Challenging, with several powerful arguments, some of our deepest beliefs about rationality, morality, and personal identity, Parfit claims that we have a false view about our own nature. It is often rational to act against our own best interersts, he argues, and most of us have moral views that are self-defeating. We often act wrongly, although we know there will be no one with serious grounds for complaint, and when we consider future generations it is very hard to avoid conclusions (...) that most of us will find very disturbing. (shrink)

It is common to allocate scarce health care resources by maximizing QALYs per dollar. This approach has been attacked by disability-rights advocates, policy-makers, and ethicists on the grounds that it unjustly discriminates against the disabled. The main complaint is that the QALY-maximizing approach implies a seemingly unsatisfactory conclusion: other things being equal, we should direct life-saving treatment to the healthy rather than the disabled. This argument pays insufficient attention to the downsides of the potential alternatives. We show that this sort (...) of discrimination is one of four unpalatable consequences that any approach to priority setting in health care must face. We argue that, given the alternatives, it is far from clear that we should revise the QALY-maximizing approach in response to this objection. (shrink)

Since it appeared in 1971, John Rawls's A Theory of Justice has become a classic. The author has now revised the original edition to clear up a number of difficulties he and others have found in the original book. Rawls aims to express an essential part of the common core of the democratic tradition--justice as fairness--and to provide an alternative to utilitarianism, which had dominated the Anglo-Saxon tradition of political thought since the nineteenth century. Rawls substitutes the ideal of the (...) social contract as a more satisfactory account of the basic rights and liberties of citizens as free and equal persons. "Each person," writes Rawls, "possesses an inviolability founded on justice that even the welfare of society as a whole cannot override." Advancing the ideas of Rousseau, Kant, Emerson, and Lincoln, Rawls's theory is as powerful today as it was when first published. (shrink)

Though the revised edition of A Theory of Justice, published in 1999, is the definitive statement of Rawls's view, so much of the extensive literature on Rawls's theory refers to the first edition. This reissue makes the first edition once again available for scholars and serious students of Rawls's work.

An argument against the bias towards the near; how a defence of temporal neutrality is not a defence of S; an appeal to inconsistency; why we should reject S and accept CP.

In this book by the award-winning author of Just Healthcare, Norman Daniels develops a comprehensive theory of justice for health that answers three key questions: what is the special moral importance of health? When are health inequalities unjust? How can we meet health needs fairly when we cannot meet them all? Daniels' theory has implications for national and global health policy: can we meet health needs fairly in ageing societies? Or protect health in the workplace while respecting individual liberty? Or (...) meet professional obligations and obligations of justice without conflict? When is an effort to reduce health disparities, or to set priorities in realising a human right to health, fair? What do richer, healthier societies owe poorer, sicker societies? Just Health: Meeting Health Needs Fairly explores the many ways that social justice is good for the health of populations in developed and developing countries. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

Ethicists and economists commonly assume that if A is all things considered better than B, and B is all things considered better than C, then A is all things considered better than C. Call this principle Transitivity. Although it has great conceptual, intuitive, and empirical appeal, I argue against it. Larry S. Temkin explains how three types of ethical principle, which cannot be dismissed a priori, threaten Transitivity: (a) principles implying that in some cases different factors are relevant to comparing (...) A to C than to comparing A to B or B to C; (b) principles of limited scope; (c) principles implying that morally relevant differences in degree can amount to differences in kind. My counterexamples employ a principle of type (c): pleasures and pains enormously different in intensity differ in kind. Temkin has also endorsed this type of counterexample, using arguments based on earlier drafts of this paper. (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)

This chapter presents examples of the practical problem of weighing lives, from medicine, global warming and elsewhere. It also sets out in general terms the theoretical problem that the book will tackle. The problem is to evaluate distributions of wellbeing, in which wellbeing is distributed across people, across time, and across states of nature.

This volume presents a comprehensive statement in defense of the doctrine known as classical, hedonistic utilitarianism. It is presented as a viable alternative in the search for a moral theory and the claim is defended that we need such a theory. The book offers a distinctive approach and some quite controversial conclusions. Torbjorn Tannsjo challenges the assumption that hedonistic utilitarianism is at variance with common sense morality particularly as viewed through the perspective of the modern feminist moral critique.

Abstract Normative criteria for evaluations of economic and social outcomes are often formulated in terms of social welfare functions which are essentially and importantly non-satiable. However, there are good reasons to consider certain normative criteria and many policy objectives to be capped, i.e. bounded, and thus satiable provided sufficient resources are made available for their satisfaction. Inspired by the Foster–Greer–Thorbecke class of indicators, this paper uses an interdisciplinary approach to develop a model for assessing outcomes in terms of capped objectives (...) based on an understanding of individual shortfalls from the objective, denoted needs. We present an indicator to measure need satisfaction in a population of individuals with heterogeneous needs and highlight an aggregation problem under scarcity. For such situations, we develop three ways in which the indicator can be weighted that reflect respectively concerns over the frequency, depth and severity of the need shortfalls and show that normative evaluations based on these weighting schemes can conflict, yielding mutually inconsistent outcome rankings. The indicator can be adapted to measure a wide variety of phenomena, e.g. health needs, education shortfalls, deprivation, etc., and it is suited for targeting exercises and other policy implementations. In particular, it allows for exogenous weighting schemes, i.e. weights that can incorporate non-shortfall characteristics relevant for the evaluation, e.g. age, gender, ethnicity, etc. The indicator thus enables new ways for researchers to promote and study satiable objectives in a wide variety of contexts relevant to economic and social policy, e.g. human development programs, poverty reduction, healthcare policies, etc. (shrink)

Much research aimed at developing measures for normative criteria to guide the assessment of healthcare resource allocation decisions has focused on health maximization, equity concerns and more recently approaches based on health capabilities. However, a widely embraced idea is that health resources should be allocated to meet health needs. Little attention has been given to the principle of need which is often mentioned as an alternative independent criteria that could be used to guide healthcare evaluations. This paper develops a model (...) and indicator of need satisfaction that aggregates the health needs of a population in a particular time period into a single measure that weights individual health needs by the severity of their ill health. The paper provides a first step towards formalizing the principle of need as a measurable objective for healthcare policy and we discuss some challenges for future research, including incorporating the duration of time into need-based health evaluations. (shrink)

This article discusses many issues raised by Munoz-Dardé, Katz, Ross, and Kagan. In doing this, I accept many of their claims, but reject others. I contend that the Essentially Comparative View can make genuine comparisons, deny that a contractualist approach helps with my book’s puzzles, and grant that my book’s central results are difficult to comprehend. I note important differences between economists’s impossibility results and my own, but accept that they may illuminate each other, using Sen’s Paradox of the Paretian (...) Liberal to illustrate this. I consider my work’s implications for the Sorites Paradox, as well as famous deontological cases. I also significantly reassess the Narrow Person-Affecting View, and some of my responses to Parfit and Broome. Finally, I stress my book’s many arguments challenging the Axioms of Transitivity, the high costs of retaining such axioms, and the importance of not prematurely choosing between highly plausible views that are inconsistent. (shrink)

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear and much-needed introduction to (...) this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two (...) distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

This paper presents an argument to the effect that the relation of exact similarity with respect to properties that are supervenient cannot be transitive. The point of departure is that, while a difference in respect of supervenient properties entails a difference in respect of subvenient properties, exact similiarity in respect of supervenient properties is compatible with differences in respect of subvenient properties. It is logically possible that two such sets of differences that each individually is insufficient for a difference as (...) regards the supervenient property together are sufficient for such a supervenient difference. This possibility claim is incompatible with the necessity claim entailed by the transitivity of exact similarity. Several objections to this argument are then considered. (shrink)

This is a wide-ranging defense of a distinctive version of hedonistic act utilitarianism. It is plainly written, forthright, and stimulating. Also, it is replete with disputable assertions and arguments. I shall pursue one issue here, after sketching the project of each substantial chapter.

Recent research indicates that there is a gap in life expectancy between the rich and the poor. This raises the question: should we on egalitarian grounds use income-based equity weights when we assess benefits of alternative benevolent interventions, so that health benefits to the poor count for more? This article provides three egalitarian arguments for using income-based equity weights under certain circumstances. If income inequality correlates with inequality in health, we have reason to use income-based equity weights on the ground (...) that health inequality is bad. If income inequality correlates with inequality in opportunity for health, we have reason to use such weights on the ground that inequality in opportunity for health is bad. If income inequality correlates with inequality in well-being, income-based equity weights should be used to mitigate inequality in well-being. Three different ways in which to construe income-based equity weights are introduced and discussed. They can be based on relative income inequality, on income rankings and on capped absolute income. The article does not defend any of these types of weighting schemes, but argues that in order to settle which of these types of weighting scheme to choose, more empirical research is needed. (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)