The available resources for global health assistance are far outstripped by need. In the face of such scarcity, many people endorse a principle according to which highest priority should be given to the worst off. However, in order for this prioritarian principle to be useful for allocation decisions, policy-makers need to know what it means to be badly off. In this article, we outline a conception of disadvantage suitable for identifying the worst off for the purpose of making health resource (...) allocation decisions. According to our total advantage view: the worst off are those who have the greatest total lifetime disadvantage; advantage foregone due to premature death should be treated in the same way as other ways of being disadvantaged at a time; how badly off someone is depends on the actual outcomes that will befall her without intervention, not her prospects at a time; and all significant forms of disadvantage count for determining who is worst off, not just disadvantage relating to health. We conclude by noting two important implications of the total advantage view: first, that those who die young are among the globally worst off, and second, that the epidemiological shift in the global burden of disease from communicable to non-communicable diseases should not lead to a corresponding shift in global health spending priorities. (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)

The moral philosopher Dan Brock has argued that equality of health outcomes “even if achievable” is problematic as a goal in its own right—because it is open to the levelling down objection. The levelling down objection to egalitarianism has received surprisingly little attention in the bioethics literature on distribution of health and healthcare and deserves more attention. This paper discusses and accepts an example given by Brock showing that prioritarianism and egalitarianism may judge distributions of health outcomes differently. We should (...) accept that levelling down is never a good thing, all things considered, but that equality often is. By discussing variants of Brock’s example, it is demonstrated that if equality, prioritarianism and aggregation are combined, as in a population-wide summary measure of health, such as the health achievement index, this combined set of principles is not open to levelling down. The paper suggests—although a more thorough investigation of the properties of the achievement index is needed—that this measure is always sensitive to inequality in health, is always sensitive to average health, can assign priority to those with lowest health outcomes and is not sensitive to levelling down. Levelling down is not an embarrassment for egalitarians if they adopt a pluralist theory that integrates fairness with goodness. Equality is not the only value egalitarians promote. But equality is so important that we should not reject it. (shrink)

Department of Political Studies, Queen's University, 99 University Avenue, Kingston, Ontario, Canada, K7L 3N6. Email: farrelly{at}queensu.ca ' + u + '@' + d + ' '//--> Abstract Should we invest more public funding in basic aging research that could lead to medical interventions that permit us to safely and effectively retard human aging? In this paper I make the case for answering in the affirmative. I examine, and critique, what I call the Fairness Objection to making aging research a greater (...) priority than it currently is. The Fairness Objection presumes that support for aging research is limited to a simplistic utilitarian justification. That is, a mode of justification that is aggregative and permits imposing high costs on a few so that small benefits could be enjoyed by numerous recipients. I develop two arguments to refute the Fairness Objection. The Fairness Objection mischaracterizes the utilitarian argument for retarding human aging. It does so by invoking the fallacious conceptual distinction between "saving lives" and "extending lives", as well as making a number of mistaken assumptions concerning the likely benefits of retarding human aging. Secondly, I argue that the case for tackling aging can be made on contractualist , in addition to utilitarian, grounds. Because the harms of senescence are "morally relevant" to the harms of disease, contractualists can permit aggregation within lives. And thus no one could reasonably reject, I contend, a principle that makes the aspiration to tackle human aging more of a priority than it currently is. CiteULike Connotea Del.icio.us What's this? (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)

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)

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)

Age rationing is a central issue in the health care priority‐setting literature, but it has become ever more salient in the light of the Covid‐19 outbreak, where health authorities in several countries have given higher priority to younger over older patients. But how is age rationing different under outbreak circumstances than under normal circumstances, and what does this difference imply for ethical theories? This is the topic of this paper. The paper argues that outbreaks such as that of Covid‐19 involve (...) special circumstances that change how age should influence our prioritization decisions, and that while this shift in circumstances poses a problem for consequentialist views such as utilitarianism and age‐weighted consequentialism, contractualism is better equipped to cope with it. The paper then offers a contractualist prudential account of age rationing under outbreak circumstances. (shrink)

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being (...) worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity). (shrink)

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)

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)

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)

This article explores the problem of justice between age-groups. Specifically, it presents a challenge to a leading theory in this field, Norman Daniels' Prudential Lifespan Account. The challenge relates to a key assumption that underlies this theory, namely the assumption that all individuals live complete lives of equal length. Having identified the roles that this assumption plays, the article argues that the justifications Daniels offers for it are unsatisfactory and that this threatens the foundation of his position, undermining his claim (...) that ‘the fact that we all age’ makes age a special problem of distributive justice. This shows that the problem of justice between age-groups is not special in the way Daniels proposes; rather it involves the same irreducibly interpersonal distributive decisions as other problems of justice. The consequences of this argument are several-fold. Most importantly, it shows that the Rawlsian account of justice to which Daniels hopes to attach his theory to requires significantly greater benefits to be conferred on those in earlier age-groups relative to those in later age-group, not a distribution similar to simultaneous equality as Daniels proposes. (shrink)

This essay considers whether permitting the cost-effectiveness of healthcare to govern its allocation is ethically objectionable on the grounds that it fails to give sufficient weight to the severity of people’s health states. After documenting the popular sentiment that appears to support this criticism, the essay considers how to implement prioritising severity, focusing on Erik Nord’s work. The remainder of the essay scrutinises the ethical arguments supporting policies prioritising severity and challenges those who would prioritise severity to define a notion (...) of severity whose prioritisation they can defend. (shrink)