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)

This paper examines explore the issues of intergenerational equity raised by climate change. A number of different reasons have been suggested as to why current generations may legitimately favor devoting resources to contemporaries rather than to future generations. These - either individually or jointly - challenge the case for combating climate change. In this paper, I distinguish between three different kinds of reason for favoring contemporaries. I argue that none of these arguments is persuasive. My answer in each case appeals (...) to the concept of human rights. It maintains that a human rights-centered perspective to climate change enables us to address each of these reasons. (shrink)

Some people contend that fetuses have moral status but less than that of paradigm persons. Many people hold views implying that sentient animals have moral status but less than that of persons. These positions suggest that moral status admits of degrees. Does it? To address this question, we must first clarify what it means to speak of degrees of moral status. The paper begins by clarifying the more basic concept of moral status and presenting two models of degrees of moral (...) status. It then sketches several significant considerations in favor of, and several against, the assertion of degrees of moral status. The paper concludes by drawing lessons from the discussion. (shrink)

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We (...) demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose. (shrink)

Initial vaccine allocations for the coronavirus disease 2019 (COVID-19) will be limited. It is crucial to assess the ethical values associated with different methods of allocation, as well as important scientific and practical questions. This Viewpoint identifies three ethical values, benefiting people and limiting harm; prioritizing disadvantaged populations; and equal concern for all. It then explains why these values support prioritizing three groups: health care workers; other essential workers and people in high-transmission settings; and people with medical vulnerabilities associated with (...) poorer COVID-19 outcomes. In contrast, two other groups, people over 65 without medical vulnerabilities and participants in clinical research, present more complex ethical questions. This prioritization also encompasses valuing direct benefits to vaccinated individuals, indirect benefits to individuals protected from spread of infection, and indirect health and socioeconomic benefits to those protected from harm as health system and societal functioning improve. Vaccine allocation that recognizes important ethical values and avoids arbitrariness, waste, and corruption can ensure that the distribution of a COVID-19 vaccine is both fair and perceived as fair. (shrink)

This paper firstly distinguishes between principles of “global justice” that apply the same anywhere and everywhere – Tännsjö’s utilitarianism, egalitarianism, prioritarianism and such like – and principles of “local justice” that apply within the specific sphere of health-care. Sometimes the latter might just be a special case of the former – but not always. Secondly, it discusses reasons, many psychological in nature, why physicians might devote excessive resources to prolonging life pointlessly, showing once again that those reasons might themselves be (...) morally significant. (shrink)

Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, focusing on (...) discrimination and on fundamental egalitarian and social justice concerns. (shrink)

This article is a critical survey of the debate over the value of the social discount rate, with a particular focus on climate change. The ma- jority of the material surveyed is from the economics rather than from the philosophy literature, but the emphasis of the survey itself is on founda- tions in ethical and other normative theory rather than highly technical details. I begin by locating the standard approach to discounting within the overall landscape of ethical theory, and explaining (...) the assumptions and simplifications that are needed in order to arrive at the model that is standard in the discounting literature. The article then covers the general theory of the Ramsey equation and its relationship to observed interest rates, arguments for and against a positive rate of pure time preference, the consumption elasticity of utility, and the effect of various sorts of uncertainty on the discount rate. Finally, it turns specifically to the ap- plication of this debate to the case of climate change, focussing on the recent controversy over the low discount rate used in the Stern Review of the Economics of Climate Change. (shrink)

I argue that the use of a social discount rate to assess the consequences of climate policy is unhelpful and misleading. I consider two lines of justification for discounting: (i) ethical arguments for a "pure rate of time preference" and (ii) economic arguments that take time as a proxy for economic growth and the diminishing marginal utility of consumption. In both cases I conclude that, given the long time horizons, distinctive uncertainties, and particular costs and benefits at stake in the (...) climate context, discount rates are at best a poor proxy for the normative considerations they are meant to represent. (shrink)