According to standard comparativist views, death is bad insofar as it deprives someone of goods she would otherwise have had. In The Ethics of Killing, Jeff McMahan argues against such views and in favor of a gradualist account according to which how bad it is to die is a function of both the future goods of which the decedent is deprived and her cognitive development when she dies. Comparativists and gradualists therefore disagree about how bad it is to die at (...) different ages. In this paper I examine two prominent criticisms of gradualism and show that both misconstrue McMahan. I develop a related criticism that seems to show that a gradualist cannot coherently relate morbidity and mortality. This criticism also fails, but has an instructive implication for how policy-makers setting priorities for health care investments should regard choices between life-saving interventions and interventions against non-fatal diseases in the very young. (shrink)

The Canadian province of Quebec recently amended its Health Insurance Act to cover the costs of In Vitro Fertilization . The province of Ontario recently de-insured IVF. Both provinces cited cost-effectiveness as their grounds, but the question as to whether a public health insurance system ought to cover IVF raises the deeper question of how we should understand reproduction at the social level, and whether its costs should be a matter of individual or collective responsibility. In this article I examine (...) three strategies for justifying collective provisions in a liberal society and assess whether public reproductive assistance can be defended on any of these accounts. I begin by considering, and rejecting, rights-based and needs-based approaches. I go on to argue that instead we ought to address assisted reproduction from the perspective of the contractarian insurance-based model for public health coverage, according to which we select items for inclusion based on their unpredictability in nature and cost. I argue that infertility qualifies as an unpredictable incident against which rational agents would choose to insure under ideal conditions and that assisted reproduction is thereby a matter of collective responsibility, but only in cases of medical necessity or inability to pay. The policy I endorse by appeal to this approach is a means-tested system of coverage resembling neither Ontario nor Quebec's, and I conclude that it constitutes a promising alternative worthy of serious consideration by bioethicists, political philosophers, and policy-makers alike. (shrink)

ABSTRACT In a recent paper published in this journal, Thomas S. Petersen makes a qualified defense of what he calls ‘the Claim from Adoption’, according to which, ‘instead of expending resources on bringing new children [in developed countries] into the world using reproductive technology and caring for these children, we ought to devote these resources to the adoption and care of existing destitute children’. My purpose in this paper is not to discuss Petersen’s argument in favor of that claim. Rather, (...) I want to show that, even if the Claim from Adoption might be, other things being equal, true, it is not true all things considered. What is, all things considered, true is a much more complex set of statements, including a general prima facie obligation to adopt, as well as an obligation by the state of developed countries to discourage procreation and promote adoption of destitute children. (shrink)

Philippe Van Parijs suggests that in culturally divided societies health care systems (and perhaps other welfare services) should be divided along regional lines. He argues that since members of homogenous societies have relatively similar needs and tastes, it is easier for them to agree on a rather comprehensive distributive scheme. This proposed reform of health care, Van Parijs argues, would be consistent with distributive justice rather than undermine it. Against Van Parijs, the paper demonstrates that this policy of devolution upsets (...) distributive justice. Devolution does so by shifting the pattern of distribution (across communities) from distribution according to need, to distribution of equal shares. The paper also argues that devolution is likely to weaken solidarity across the polity as a whole, which further undermines the attainment of distributive justice. The paper concludes that far from catering to culturally driven differences in medical preferences, distributive justice (in fact) permits disregard of such differences, and warrants enforcing a unitary pattern of consumption of medical goods (and other welfare services) across the citizenry, thus retaining a unified health care (and correspondingly, welfare) system. Key Words: devolution • health care • justice • solidarity • Van Parijs. (shrink)

Following Rawls, many political liberals hold reasonableness in high regard. Reasonable citizens can disagree, however, and some may find their arguments routinely ignored in elections and legislatures. Should we be troubled by such failures of institutional responsiveness as a matter of justice? The author argues that the expectation of such failures would lead parties in an original position to favor certain classes of institutions over others: A Theory of Justice and Political Liberalism together suggest a particular federal structure to a (...) republic of reasons. (shrink)

Federal political orders often exhibit a conflict between the ideals of equality and political autonomy, since individuals in different subunits often enjoy systematically different standards of living conditions. While federal arrangements may be theoretically attractive to avoid despotism, such federal inequality would appear to conflict with the principles of egalitarian cosmopolitanism. The paper argues that individuals' interest in equal shares of income and wealth may legitimately be weighed against their interest in political control enjoyed by their subunit, as long as (...) the inequalities do not engender misery, domination, or unfair procedures. The reasons for subunit autonomy include reducing the risk of domination, increasing the responsiveness to local preferences, and reducing the burdens of decision making. These arguments also suggest that states may not always be the appropriate subunits in legitimate federal orders. (shrink)

It is widely recognized that prioritizing health care resources by their relative cost-effectiveness can result in lower priority for the treatment of disabled persons than otherwise similar non-disabled persons. I distinguish six different ways in which this discrimination against the disabled can occur. I then spell out and evaluate the following moral objections to this discrimination, most of which capture an aspect of its unethical character: it implies that disabled persons' lives are of lesser value than those of non-disabled persons; (...) it constitutes “double jeopardy” or violates Frances Kamm's non-linkage principle; it conflicts with equality of opportunity; it conflicts with fairness, which requires ignoring (some/most) differential impacts of treatment; it wrongly gives lower priority to disabled persons for equally effective treatment; it conflicts with giving all persons an equal chance to reach their full potential; and, it is in conflict with giving priority to the worse off. (shrink)

At what stage of life is death worst for its victim? I hold that, typically, death is worse the earlier it occurs. Others, including Jeff McMahan and Christopher Belshaw, have argued that it is worst to die in early adulthood. In this paper I show that McMahan and Belshaw are wrong; I show that views that entail that Student’s death is worse face fatal objections. I focus in particular on McMahan’s time-relative interest account (TRIA) of the badness of death. Manuscript (...) in progress. (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)