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)

Health, Luck, and Justice is the first attempt to systematically apply luck egalitarianism to the just distribution of health and health care.

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)

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)

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)

In recent works, Shlomi Segall suggests and defends a luck egalitarian approach to justice in health. Concurring with G. A. Cohen’s mature position he defends the idea that people should be compensated for “brute luck”, i.e. the outcome of actions that it would be unreasonable to expect them to avoid. In his defense of the luck egalitarian approach he seeks to rebut the criticism raised by Norman Daniels that luck egalitarianism is in some way too narrow and in another too (...) wide to uphold justice in health and health care distribution. He points out that a pluralistic outline of luck egalitarianism taking into account the moral requirement of meeting everyone’s basic needs can avoid this line of criticism. In this article I argue against the application of such pluralistic luck egalitarianism in matters of health distribution. First of all, Segall has not shown that luck egalitarianism handles well health distributions above a threshold of basic needs. Secondly, his way of avoiding Elizabeth Anderson’s abandonment objection is theoretically problematic. Finally, I argue that luck egalitarianism in general fails to acknowledge the moral foundation of health and health care as a basic human entitlement. Thus I conclude that luck egalitarianism fails to take health needs seriously and that it cannot therefore uphold justice in health. (shrink)

Ruth Chang has defended a concept of "parity", implying that two items may be evaluatively comparable even though neither item is better than or equally good as the other. This article takes no stand on whether there actually are cases of parity. Its aim is only to make the hitherto somewhat obscure notion of parity more precise, by defining it in terms of the standard value relations. Given certain plausible assumptions, the suggested definiens is shown to state a necessary and (...) sufficient condition for parity, as this relation is envisaged by Chang. (shrink)

Abstract: The paper provides a general account of value relations. It takes its departure in a special type of value relation, parity, which according to Ruth Chang is a form of evaluative comparability that differs from the three standard forms of comparability: betterness, worseness and equal goodness. Recently, Joshua Gert has suggested that the notion of parity can be accounted for if value comparisons are interpreted as normative assessments of preference. While Gert's basic idea is attractive, the way he develops (...) it is flawed: His modeling of values by intervals of permissible preference strengths is inadequate. Instead, I provide an alternative modeling in terms of intersections of rationally permissible preference orderings. This yields a general taxonomy of all binary value relations. The paper concludes with some implications of this approach for rational choice. (shrink)

The idea that there is such an analytic connection will hardly come as news. It amounts to no more and no less than an endorsement of the claim that all reasons are 'internal', as opposed to 'external', to use Bernard Williams's terms (Williams 1980). Or, to put things in the way Christine Korsgaard favours, it amounts to an endorsement of the 'internalism requirement' on reasons (Korsgaard 1986). But how exactly is the internalism requirement to be understood? What does it tell (...) us about the nature of reasons? And where-in lies its appeal? My aim in this paper is to answer these ques- tions. (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)

This paper argues for the existence of a fourth positive generic value relation that can hold between two items beyond ‘better than’, ‘worse than’, and ‘equally good’: namely ‘on a par’.

This article presents an approach to how to make reasonable social choices when independent criteria (e.g., prioritarianism, religious freedom) fail to fully determine what to do. The article outlines different explanations of why independent criteria sometimes fail to fully determine what to do and illustrates how they can still be used to eliminate ineligible alternatives, but it is argued that the independent criteria cannot ground a reasonable social choice in these situations. To complement independent criteria when they fail to fully (...) determine what to do, it is suggested that society must engage in public deliberation by way of generating new reasons that can determine how to rank the alternatives. It is suggested that the approach to social choice presented here reveals a way of accepting the relevance of independent criteria for social choice without letting go of the idea that the attitudes of affected parties matter. (shrink)

How should one understand comparisons in which neither of two alternatives is at least as good as the other? Much recent literature on comparability problems focuses on what the appropriate explanation of the phenomenon is. Is it due to vagueness or the possibility of non-conventional comparative relations such as parity? This paper argues that the discussions on how to best explain comparability problems has reached an impasse at which it is hard to make any progress. To advance the discussion we (...) suggest a new classification of comparability problems that focuses on the problems they cause for practical reasoning. (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)

This article argues that values that apply to health care allocation entail the possibility of “spectrum arguments,” and that it is plausible that they often fail to determine a best alternative. In order to deal with this problem, a two-step process is suggested. First, we should identify the Strongly Uncovered Set that excludes all alternatives that are worse than some alternatives and not better in any relevant dimension from the set of eligible alternatives. Because the remaining set of alternatives often (...) contain more than one element, we need some complementary method of selecting a unique alternative. In order to address this issue, I suggest that we must invoke caps on the values that are used to evaluate alternatives, and that these caps must be grounded in collective commitments. (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)

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)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

This paper is a revised version of the Royal Institute of Philosophy’s Annual Lecture, 2016. It discusses the demands of critical reasoning in ethical arguments, and focuses in particular on the assessment of justice. It disputes the belief that reasoning about choice remains unfinished until an optimal alternative has been identified. A successful closure of a reasoning may identify a maximal alternative, which is not judged to be worse than any other available option. A maximal alternative need not be optimal (...) in the sense of being ‘best’. Critically sound reasoning can lead us to a partial ordering yielding a maximal alternative that is not optimal. The compulsive search for an optimal alternative needlessly limits the reach of reasoning in ethics. (shrink)

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, whims, and prejudices, (...) which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers. (shrink)

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)