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.

Greg Bognar has recently offered a prioritarian justification for ‘fair innings’ distributive principles that would ration access to healthcare on the basis of patients' age. In this article, I agree that Bognar's principle is among the strongest arguments for age-based rationing. However, I argue that this position is incomplete because of the possibility of ‘time-relative' egalitarian principles that could complement the kind of lifetime egalitarianism that Bognar adopts. After outlining Bognar's position, and explaining the attraction of time-relative egalitarianism, I suggest (...) various ways in which these two kinds of principle could interact. Since various options have very different implications for age-based rationing, proponents of such a rationing scheme must take a position on time-relative egalitarianism to complement a lifetime prioritarian view like Bognar's. (shrink)

In a world of limited resources, competition between the young and old prompt difficult questions of justice. In countries with public pension and health care systems, or with aging populations, there is often a concern that members of different generations are not always treated fairly. Dennis McKerlie's monograph examines justice between age-groups with the ultimate goal of a new theory of justice that effectively grapples with those questions. In the realm of public policy and medical ethics this is an important (...) and timely topic, but surprisingly one that has received relatively little attention from moral philosophers. McKerlie develops a comprehensive view of fairness between age groups that applies the egalitarian values of equality, or priority for the badly off, to temporal parts of lives -- not just to complete lives. (shrink)

Equality is a key concept in our moral and political vocabulary. There is wide agreement on its instrumental value and its favourable impact on many aspects of society, but less certainty over whether it has a non-instrumental or intrinsic value that can be demonstrated. In this project, Shlomi Segall explores and defends the view that it does. He argues that the value of equality is not reducible to a concern we might have for the worse off, or to ensuring that (...) individuals do not fall into poverty and destitution; instead he claims that undeserved inequalities, wherever and whenever we might find them, are bad in themselves. Assessing the strength of competing accounts, such as sufficientarianism and prioritarianism, he brings together for the first time discussions of the moral value of equality with luck- or responsibility-sensitive accounts of distributive justice. His book will interest readers in political and moral philosophy. (shrink)

This paper considers the simple two-person two-period case of distributive judgement, and argues (a) that sensible intertemporal distributive principle should consider both the distribution of people's life time well-being and the distribution of people's well-being at each period and (b) that, if (a) is correct, Egalitarianism is more acceptable than Prioritarianism since the latter must choose either one.

Universal health coverage (UHC) is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services. This document is the final report of the WHO Consultative Group on Equity and Universal Health Coverage. The report addresses the key issues of fairness and equity that arise on the path to UHC. As such, the report is relevant for every actor that affects that path and governments in particular, as they are in (...) charge of overseeing and guiding the progress toward UHC. (shrink)

In this book Larry Temkin examines the concepts of equality and inequality, and addresses one particular question in depth: how can we judge between different sorts of inequality? When is one inequality worse than another? Temkin shows that there are many different factors underlying and influencing our egalitarian judgments and that the notion of inequality is surprisingly complex. He looks at inequality as applied to individuals and to groups, and at the standard measures of inequality employed by economists and others, (...) and considers whether inequality matters more in a poor society than a rich one. The arguments of non-egalitarians are also examined. Temkin's book presents a new way of thinking about equality and inequality which challenges the assumptions of philosophers, welfare economists, and others concerned with these notions on a practical as well as a theoretical level. (shrink)

This study uses techniques from economics to illuminate fundamental questions in ethics, particularly in the foundations of utilitarianism. Topics considered include the nature of teleological ethics, the foundations of decision theory, the value of equality and the moral significance of a person's continuing identity through time.

This report by the WHO Consultative Group on Equity and Universal Health Coverage addresses how countries can make fair progress towards the goal of universal coverage. It explains the relevant tradeoffs between different desirable ends and offers guidance on how to make these tradeoffs.

This book addresses a range of relevant theoretical issues, including the possibility of an interpersonally comparable measure of well-being, or “utility” metric; the moral value of equality, and how that bears on the form of the social welfare function; social choice under uncertainty; and the possibility of integrating considerations of individual choice and responsibility into the social-welfare-function framework. This book also deals with issues of implementation, and explores how survey data and other sources of evidence might be used to calibrate (...) both a utility metric and a social welfare function, and whether distributive goals are ever best pursued through regulation rather than the tax system. In working through this range of theoretical and practical issues, the book draws from a wide variety of literatures, including philosophical scholarship on equality, responsibility, the nature of well-being, and personal identity over time; the social choice literature within economics; applied economic literatures concerning the measurement of inequality and poverty; legal and policy-analysis scholarship on cost-benefit analysis, environmental justice, and the choice between regulation and taxation; and the burgeoning field of “happiness studies”. (shrink)

This is the text of The Lindley Lecture for 1996, given by T.M. Scanlon, an American philosopher.

Scarce healthcare resources can be allocated in many ways. The National Institute for Health and Clinical Excellence in the UK focuses on the size of the benefit relative to costs, yet we know that there is support among clinicians and the general public for reducing inequalities in health. This paper shows how the UK general public trade-off these sometimes competing objectives, and the data we gather allow us to show the weight given to different population groups, for example, 1 extra (...) year of life in full health to someone who would otherwise die at the age of 60 years is worth more than twice as much as an additional year of life to someone who would otherwise die at the age of 70 years. Such data can help inform the rationing decisions faced by all healthcare systems around the world. (shrink)

In our lives, we aim to achieve welfare for ourselves, that is, to live good lives. But we also have another, more impartial perspective, where we aim to balance our concern for our own welfare against a concern for the welfare of others. This is a perspective of justice. Nils Holtug examines these two perspectives and the relations between them.

This book originated as lectures for a course on political philosophy that Rawls taught regularly at Harvard in the 1980s.

We shall focus on moral theories that are solely concerned with promoting the benefits (e.g., wellbeing) of individuals and explore the possibility of such theories ascribing some priority to benefits to those who are worse off—without this priority being absolute. Utilitarianism (which evaluates alternatives on the basis of total or average benefits) ascribes no priority to the worse off, and leximin (which evaluates alternatives by giving lexical priority to the worst off, and then the second worst off, and so on) (...) ascribes absolute priority to the worse off (i.e., favors even a very small benefit to a worse off person over very large benefits to large numbers of better off people). Neither extreme view, we assume, is plausible. (shrink)

Temkin presents a new way of thinking about equality and inequality that challenges the assumptions of philosophers, welfare economists, and others, and has significant implications on both a practical and theoretical level.

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)

Suppose that A and B are two kinds of goods such that more of each is better than less. A is strongly superior to B if any amount of A is better than any amount of B. It is weakly superior to B if some amount of A is better than any amount of B. There are many examples of these relations in the literature, sometimes under the labels “higher goods” and “discontinuity.” The chapter gives a precise and generalized statement (...) of Strong and Weak Superiority and discusses different ways in which these relations can be relevant to the aggregation of welfare. It also proves a number of general results. One of the results gives rise to a dilemma: It can be used as an argument against the existence of value superiority or, alternatively, as an argument against the view that superiority entails a radical difference in value. (shrink)

In a world of limited resources, competition between the young and old prompt difficult questions of justice. In countries with public pension and health care systems, or with aging populations, there is often a concern that members of different generations are not always treated fairly. Dennis McKerlie's monograph examines justice between age-groups with the ultimate goal of a new theory of justice that effectively grapples with those questions. In the realm of public policy and medical ethics this is an important (...) and timely topic, but surprisingly one that has received relatively little attention from moral philosophers. McKerlie develops a comprehensive view of fairness between age groups that applies the egalitarian values of equality, or priority for the badly off, to temporal parts of lives -- not just to complete lives. (shrink)

In many societies, the aging of the population is becoming a major problem. This raises difficult issues for ethics and public policy. On what is known as the fair innings view, it is not impermissible to give lower priority to policies that primarily benefit the elderly. Philosophers have tried to justify this view on various grounds. In this article, I look at a consequentialist, a fairness-based, and a contractarian justification. I argue that all of them have implausible implications and fail (...) to correspond to our moral intuitions. I end by outlining a different kind of consequentialist justification that avoids those implications and corresponds better to our considered moral judgments. (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)

The lifetime equality view has recently been met with the objection that it does not rule out simultaneous inequality: two persons may lead equally good lives on the whole and yet there may at any time be great differences in their level of well-being. And simultaneous inequality, it is held, ought to be a concern of egalitarians. The paper discusses this and related objections to the lifetime equality view. It is argued that rather than leading to a revision of the (...) lifetime equality view, these objections, if taken seriously, should make us account for our egalitarian concerns in terms of the priority view rather than the equality view. The priority view claims that there is a greater moral value to benefiting the worse off. Several versions of the priority view are also distinguished. (shrink)

In "Equality, Priority, and Compassion," Roger Crisp rejects both egalitarianism and prioritarianism. Crisp contends that our concern for those who are badly off is best accounted for by appealing to "a sufficiency principle" based -- indirectly, via the notion of an impartial spectator -- on compassion for those who are badly off" (p. 745). A key example of Crisp's is the Beverly Hills case (discussed below). This example is directed against prioritarianism, but it also threatens egalitarianism. In this article, I (...) respond to the Beverly Hills case. I also challenge the wide person-affecting principle and Crisp's welfarist restriction, which some believe underlie the Levelling Down Objection against egalitarianism. My aim in this article is to defend egalitarianism by illuminating both its nature and appeal. (shrink)

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

In recent years there has been a good deal of discussion of equality’s place in the best account of distribution or distributive justice. One central question has been whether egalitarianism should give way to a principle requiring us to give priority to the worse off. In this article, I shall begin by arguing that the grounding of equality is indeed insecure and that the priority principle appears to have certain advantages over egalitarianism. But I shall then claim that the priority (...) principle itself is ungrounded and that the priority principle should itself give way to a sufficiency principle based — indirectly, via the notion of an impartial spectator — on compassion for those who are badly off. (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)

Some of us believe in giving priority to people who are badly off in designing social policies and in acting ourselves to help others. As Thomas Nagel puts it, the badly off should be first in the queue when benefits are distributed. This idea is one way of explaining moral views that are called ‘egalitarian.’ Egalitarian moral views can depend either on the idea of valuing equality itself or on the idea of giving priority to the interests of the badly (...) off. This paper is concerned with the second kind of egalitarianism.The purest form of the idea explains the priority in this way: a benefit for someone badly off can be more important morally, or can have more value, than a benefit of the same size for someone better off. This is to suppose that the priority in question cannot be explained by thinking in utilitarian terms and accepting the principle of diminishing marginal utility. (shrink)

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they (...) can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII). (shrink)

This article brings together two debates in contemporary political philosophy: on the one hand, the dispute between the distributive and relational approaches to equality and, on the other hand, the field of intergenerational equality. I offer an original contribution to the second domain and by doing so, I inform the first. The aim of this article is thus twofold: (1) shedding some light on an under-researched and yet crucial question – ‘which inequalities between generations matter?’ and (2) contributing to a (...) far-reaching debate that touches upon the nature of egalitarianism. After showing that there are two key problems that fall within the scope of intergenerational equality – questions of justice between age groups and questions of equality between birth cohorts – I argue that, contrary to what the default distributive view (complete lives egalitarianism) states, some inequalities between age groups matter independently of their diachronic impact, and so partly for relational reasons. I argue that, even if we are distributive egalitarians, we must endorse the relational egalitarian conception to successfully make sense of some inequalities between age groups. I infer from this both that the putative view that the ‘relational’ conception of equality can be redescribed as distributive must be rejected and that the distributive view requires supplementation (but not necessarily displacement) by the relational 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)

Lifetime quality-adjusted life-year (QALY) prioritarianism has recently been defended as a reasonable specification of the prioritarian view that benefits to the worse off should be given priority in health-related priority setting. This paper argues against this view with reference to how it relies on implausible assumptions. By referring to lifetime QALY as the basis for judgments about who is worse off lifetime QALY prioritarianism relies on assumptions of strict additivity, atomism and intertemporal separability of sublifetime attributes. These assumptions entail that (...) a health state at some period in time contributes with the same amount to how well off someone is regardless of intrapersonal and interpersonal distributions of health states. The paper argues that this is implausible and that prioritarians should take both intrapersonal and interpersonal distributions of goods into account when they establish who is worse off. They should therefore not accept that lifetime QALY is a reasonable ground for ascribing priority and reject lifetime QALY prioritarianism. (shrink)

This is a reprint of Amartya Sen’s 1973 book on the measurement of inequality, plus an updated bibliography and index, and an annex by James Foster and Sen that summarizes and comments on the main developments since 1973. The book is superbly written and focuses on verbal discussion of the plausibility and significance of the conditions, theorems, and measures.

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)

In recent years, there has been a growing groundswell of support for the idea that universal health coverage should be provided even in the developing world. While I wholeheartedly agree with the eventual goal of attaining universal health coverage globally, and the sooner the better, I have worries as to whether the world's rich countries, or institutions like the World Health Organization, should be pushing the world's poorest countries to take whatever steps are necessary to achieve that goal. My fear (...) is that universal health coverage in the developing world is an intoxicating, but potentially dangerous, idea whose time may not yet have come. This article's aim is not to settle the question of whether the developing world should be urged, or pushed, to adopt policies of universal health coverage. It is merely to explore some worries about the wisdom of such a tack. The article is divided into eight sections. In Section 1, I give a brief introduction. In Section 2, I provide some background for my topic. In Section 3, I discuss the notion of universal health coverage, and what the push for such a goal in the developing world seemingly involves. In Section 4, I raise some general worries I have about the push for universal health coverage in the developing world. In Section 5, I present a wide range of possible justifications for universal health coverage in the developing world. In Section 6, I discuss whether any of the purported justifications of universal health coverage in the developing world actually do so. In Section 7, I consider some comments, objections, and responses. Finally, in Section 8, I offer a brief conclusion. (shrink)