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)

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)

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.

I argue that T.M. Scanlon's contractualist account of morality has difficulty accommodating our intuitions about the moral relevance of the number of people affected by an action. I first consider the "Complaint Model" of reasonable rejection, which restricts the grounds for an individual's rejection of a principle to its effects upon herself. I argue that it can accommodate our intuitions about numbers only if we assume that, whenever we do not know who will be affected, each individual may appeal only (...) to the _expected effects on her. This assumption, I suggest, leads to counterintuitive results in cases where, although we do not know who will be affected, we do know that _someone will be. I then consider two proposals to supplement the complaint model with a direct appeal to aggregation. I argue that both are open to serious objections. (shrink)

It is a common view that benefits to the worse off should be given priority when health benefits are distributed. This paper addresses how to understand who is worse off in this context when individuals are differently well off at different times. The paper argues that the view that this judgment about who is worse off should be based solely on how well off individuals are when their complete lives are considered (i.e. 'the complete lives view') is implausible in this (...) context. Instead, it is argued that a pluralistic stance toward this issue should be accepted. This pluralistic stance recognizes that also the view that only focuses on how well off individuals are now and in the future (i.e. 'the forward-looking view') is relevant. The argument is based on appeals to intuitive judgments concerning who is worse off in different cases and reference to various underlying reasons why priority to benefits to the worse off is justified. (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)