Previous edition, 1st, published in 1971.

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

In this paper, I argue for the counter-intuitive conclusion that the same adaptive preference can be both prudentially good and prudentially bad for its holder: that is, it can be prudentially objectionable from one temporal perspective, but prudentially unobjectionable from another. Given the possibility of transformative experiences, there is an important sense in which even worrisome adaptive preferences can be prudentially good for us. That is, if transformative experiences lead us to develop adaptive preferences, then their objects can become prudentially (...) better for our actual selves than the objects of their non-adaptive alternatives would now be. I also argue, however, that the same worrisome adaptive preferences might still be prospectively prudentially objectionable: that is, our pre-transformation selves might be prudentially better off undergoing a non-adaptive alternative transformative experience instead. I argue that both claims hold across the range of the most broadly-defended accounts of well-being in the literature. (shrink)

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that all (...) are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

Perfectionism, the view that well-being is a matter of developing characteristically human capacities, has relatively few defenders in the literature, but plenty of critics. This paper defends perfectionism against some recent formulations of classic objections, namely, the objection that perfectionism ignores the relevance of pleasure or preference for well-being, and a sophisticated version of the ‘wrong properties’ objection, according to which the intuitive plausibility of the perfectionist ideal is threatened by an absence of theoretical pressure to accept putative wrong properties (...) cases. The paper argues these objections are unsuccessful, but introduce a new worry, the Deep Problem: Perfectionism fails to offer a satisfying foundational justification for why developing the human essence is valuable. The paper responds to the deep problem, ultimately arguing that it is a puzzle put to all theories of well-being to provide a justification for their normative significance. (shrink)

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.

This chapter is divided into three parts. First I outline what makes something an objective list theory of well-being. I then go on to look at the motivations for holding such a view before turning to objections to these theories of well-being.

Explains the desire-fulfillment theory of well-being, its history, its development, its varieties, its advantages, and its challenges.

And in this book the distinguished scholar Amartya Sen offers a powerful critique of the theory of social justice that, in its grip on social and political ...

abstract In this paper I develop a characterization of disability according to which disability is in no way a sub-optimal feature. I argue, however, that this conception of disability is compatible with the idea that having a disability is, at least in a restricted sense, a harm. I then go on to argue that construing disability in this way avoids many of the common objections levelled at accounts which claim that disability is not a negative feature.

With much of the world's population facing restricted access to adequate medical care, how to allocate scarce health-care resources is a pressing question for governments, hospitals, and individuals. How do we decide where funding for health-care programs should go? Tannsjo here approaches the subject from a philosophical perspective, balancing theoretical treatments of distributive ethics with real-world examples of how health-care is administered around the world today. Tannsjo begins by laying out several popular ethical theories-utilitarianism, which recommends maximizing the best overall (...) outcome; egalitarianism, which recommends smoothing out the differences between people as much as possible; and the maximin/leximin theory, which urges people to give absolute priority to those who are worst off. Tannsjo shows how, in abstract thought experiments, these theories come into conflict with each other and reveal puzzling implications. He goes on to argue, however, that when we consider health-care in the real-world, these theories all agree on a central point: in a well-ordered welfare state, more resources should be directed to the care and cure of people suffering from mental illness, and less to the marginal life extension of elderly patients. Tannsjo's book thus recommends a shift in spending to increase fairness and overall utility-while also recognizing that this kind of dispassionate suggestion, with its purely economic foundation, is unlikely to take hold in policy. Tannsjo's analysis is a case study in how ethical theories can sometimes lead to rational conclusions and recommendations that we are not prepared to accept. (shrink)

Illness severity is a priority setting criterion in several countries. Age seems to matter when considering severity, but perhaps not small age differences. In the following article we consider Small Differences : small differences in age are not relevant when considering differential illness severity. We show that SD cannot be accommodated within utilitarian, prioritarian or egalitarian theories. Attempting to accommodate SD by postulating a threshold model becomes exceedingly complex and self-defeating. The only way to accommodate SD seems to be to (...) accept some form of relevance view, where some age differences are irrelevant. This view can accommodate SD, but at the expense of consistent priority orderings. Severity thus becomes unsuitable for systematic decision-making. We argue that SD should be dismissed and that we should accept a continuous relationship between severity of illness and age. (shrink)

Perfectionism, broadly speaking, is the view that the development of certain characteristically human capacities is good. The view gains motivation in part from the intuitive pull of an objective approach to wellbeing, but dissatisfaction with objective list theory. According to objective list theory, goods such as knowledge, achievement, and friendship constitute good in a life. The objective list has terrific intuitive appeal – after all, it’s a list generated by reflecting on the good life. But as a theory, some find (...) it unsatisfying. What justifies presence on the list? On the traditional conception it is just a list and not much of a theory at all. Perfectionism captures the intuitive pull of the objective list and provides a unifying justification: the entries on the list share in common a special relationship to human nature. This essay gives an overview of perfectionism. (shrink)

Adaptive preference formation is the unconscious altering of our preferences in light of the options we have available. Jon Elster has argued that this is bad because it undermines our autonomy. I agree, but think that Elster's explanation of why is lacking. So, I draw on a richer account of autonomy to give the following answer. Preferences formed through adaptation are characterized by covert influence (that is, explanations of which an agent herself is necessarily unaware), and covert influence undermines our (...) autonomy because it undermines the extent to which an agent's preferences are ones that she has decided upon for herself. This answer fills the lacuna in Elster's argument. It also allows us to draw a principled distinction between adaptive preference formation and the closely related phenomenon of character planning. (shrink)

The point of departure for this article is a review of the discussion between Twaddle and Nordenfelt on the concepts of disease, illness, and sickness, and the objective is to investigate the fruitfulness of these concepts. It is argued that disease, illness, and sickness represent different perspectives on human ailment and that they can be applied to analyze both epistemic and normative challenges to modern medicine. In particular the analysis reveals epistemic and normative differences between the concepts. Furthermore, the article (...) demonstrates, against Nordenfelt's claim, that the concepts of disease, illness, and sickness can exist without a general theory of health. Additionally, the complexity of different perspectives on human ailment also explains why it is so difficult to give strict definitions of basic concepts within modern health care. (shrink)

People who have not experienced diseases and health conditions tend to judge them to be worse than they are reported to be by people who have experienced them. This phenomenon, known as the disability paradox, presents a challenge for health policy, and in particular, healthcare resource distribution. This divergence between patient and public preferences is most plausibly explained as a result of hedonic adaptation, a widespread phenomenon in which people tend to adapt fairly quickly to the state they are in, (...) good or bad, and adjust their baseline utility accordingly.If patient utilities can be shown to be inappropriate for use in public policy decision making, the disability paradox fades away. This paper offers a critique of one such attempt: the idea that adaptation leads to adaptive preferences. I argue that none of the main accounts of adaptive preferences in fact characterise adapted patient preferences as irrational. Adapted preferences should not, therefore, be treated as synonymous with adaptive preferences. I suggest that much patient adaptation should be understood as a form of the ubiquitous human ability to respond to environmental change. Consequently, we ought not to discount patient preferences. (shrink)

Critics argue that adaptive preference theorists misrepresent oppressed people's reasons for perpetuating their oppression. According to critics, AP theorists assume that people who adapt their preferences to unjust conditions lack the psychic capacities that would allow them to develop their own normative perspectives and/or form appropriate values. The misrepresentation is morally problematic, because it promotes unjustified paternalism and perpetuates colonial stereotypes of third‐world women. I argue that we can imagine a conception of AP that is consistent with acknowledging agency in (...) people who perpetuate their oppression. I offer a weak perfectionist conception of AP that is consistent with recognising agentic capacities in the oppressed. On my conception, APs are preferences incompatible with an agent's basic wellbeing that formed under unjust conditions — and that an agent would reverse upon exposure to better conditions. My conception encourages respectful treatment of the oppressed without requiring us to abandon the feminist political goals the notion of AP is meant to serve. It helps us identify real‐world preferences that are problematically adapted to oppressive conditions and offers an account of why they seem not to be women's ‘true preferences’. (shrink)

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

ABSTRACT:Current literature in moral and political philosophy is rife with discussion of adaptive preferences. This is no accident: while preferences are generally thought to play an important role in a number of normative domains, adaptive preferences seem exceptions to this general rule—they seem problematic in a way that preference-respecting theories of these domains cannot adequately capture. Thus, adaptive preferences are often taken to be theoretically explanatory: a reason for adjusting our theories of the relevant normative domains. However, as I shall (...) argue here, the relentless focus on the phenomenon of preference adaptation is a mistake. While I do not take a stand on whether typical examples of adaptive preferences are or are not problematic, I argue here that if they are problematic, it cannot be because they are adaptive. (shrink)

Although the problem of adaptiveness plays an important motivating role in her work on human capabilities, Martha Nussbaum never gives a clear account of the controversial concept of adaptive preferences on which she relies. In this paper, I aim both to reconstruct the most plausible account of the concept that may be attributed to Nussbaum and to provide a critical appraisal of that account. Although her broader work on the capabilities approach moves progressively towards political liberalism as time passes, I (...) aim to show that her account of adaptive preferences continues to maintain her earlier commitment to perfectionism about the good. I then distinguish between two obligatory kinds of respect for persons, which I call, respectively, primary and secondary recognition respect. This distinction allows us to see that her perfectionist account of adaptive preferences allows her to show persons primary but not secondary recognition respect. Ultimately, I claim that an acceptable account of adaptive prefer.. (shrink)

Accounts of adaptive preferences are of two kinds: well-being accounts fully theorized for their own sake and political accounts theorized to facilitate the political project of reducing oppression and marginalization. Given their practical role, the latter are often less fully theorized, and are therefore less robust to theoretical criticism. In this paper, I first draw on well-being accounts to identify the well-theorized elements that political accounts should want to adopt in order to strengthen their project and avoid common criticisms. Second, (...) I appeal to the political project to show the shortcomings of the well-being accounts on which I draw. (shrink)

There is little agreement among moral and political philosophers when it comes to determining what it is that makes adaptive preferences problematic. The large number of competing explanations offered by philosophers illustrates the absence of any consensus. The most prominent versions of these explanations have recently come under attack by Dale Dorsey, who argues that adaptive preferences are a red herring: the problematic nature of adaptive preferences is not explained by the fact of adaptation but by an appeal to some (...) other normative consideration. In this article I offer an account of adaptive preferences that both accommodates the thought that only some of our adaptive preferences are problematic and responds to the skeptical challenge pressed by Dorsey. I argue that some adaptive preferences are prima facie irrational as they exhibit a peculiar error in reasoning where individuals change the semantic content of the reasons underpinning the new preference. (shrink)