In recent years there has been a good deal of discussion of equality’s place in the best account of distribution or distributive justice. One central question has been whether egalitarianism should give way to a principle requiring us to give priority to the worse off. In this article, I shall begin by arguing that the grounding of equality is indeed insecure and that the priority principle appears to have certain advantages over egalitarianism. But I shall then claim that the priority (...) principle itself is ungrounded and that the priority principle should itself give way to a sufficiency principle based — indirectly, via the notion of an impartial spectator — on compassion for those who are badly off. (shrink)

Challenging, with several powerful arguments, some of our deepest beliefs about rationality, morality, and personal identity, Parfit claims that we have a false view about our own nature. It is often rational to act against our own best interersts, he argues, and most of us have moral views that are self-defeating. We often act wrongly, although we know there will be no one with serious grounds for complaint, and when we consider future generations it is very hard to avoid conclusions (...) that most of us will find very disturbing. (shrink)

The contributors to the volume are: Richard Arneson, Linda Barclay, Thomas Christiano, Nils Holtug, Susan Hurley, Kasper Lippert-Rasmussen, Dennis McKerlie, ...

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same (...) way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications. (shrink)

In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out and discuss a number of queries which seem to (...) arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

Greg Bognar has recently offered a prioritarian justification for ‘fair innings’ distributive principles that would ration access to healthcare on the basis of patients' age. In this article, I agree that Bognar's principle is among the strongest arguments for age-based rationing. However, I argue that this position is incomplete because of the possibility of ‘time-relative' egalitarian principles that could complement the kind of lifetime egalitarianism that Bognar adopts. After outlining Bognar's position, and explaining the attraction of time-relative egalitarianism, I suggest (...) various ways in which these two kinds of principle could interact. Since various options have very different implications for age-based rationing, proponents of such a rationing scheme must take a position on time-relative egalitarianism to complement a lifetime prioritarian view like Bognar's. (shrink)

This book elucidates the theoretical structure and scope of interpersonal and intra-personal aggregation--a trade-off between benefits to a group of individuals and losses to another group of individuals--and defends a form of aggregation -- formal aggregation -- that resolves a variety of outstanding problems arising from the conventional understanding of aggregation, including the Number Problem concerning the moral relevance of the number of individuals.

This chapter examines whether an individual’s being worse off than others should be a relevant consideration in the allocation of limited medical resources. It reviews arguments pressed by proponents of different theories of justice about whether being worse off than others makes special demands on health care resource prioritization. Even if there is good reason to restrict the concern for the worse off to those with worse health in the prioritization and allocation of health care resources, additional issues remain. One (...) is how to determine who has worse health, and whether the worse off are those with the worse overall health or those with the most serious medical condition now in need of treatment. Another issue is whether only individuals’ present health, or instead their lifetime health, including past and expected future health, is relevant. (shrink)

Soft regulatory measures are often promoted as an alternative for existing regulatory regimes for nanotechnologies. The call for new regulatory approaches stems from several challenges that traditional approaches have difficulties dealing with. These challenges relate to general problems of governability, tensions between public interests, but also (and maybe particularly) to almost complete lack of certainty about the implications of nanotechnologies. At the same time, the field of nanotechnology can be characterized by a high level of diversity. In this paper, we (...) discuss and compare two models for framing public policy in relation to technology regulation: the first is a deliberative model based on foresight knowledge and the second the wide reflective equilibrium model, developed by political philosopher John Rawls. In both models, the aim is to find consensus on (a framework for) policy measures and regulation. On the basis of a critical discussion of the strengths and weaknesses of both models, some tentative conclusions are drawn for effective policy making and implementation based on soft law. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting (...) point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

Is it fair to leave the next generation a public debt? Is it defensible to impose legal rules on them through constitutional constraints? From combating climate change to ensuring proper funding for future pensions, concerns about ethics between generations are everywhere. In this volume sixteen philosophers explore intergenerational justice. Part One examines the ways in which various theories of justice look at the matter. These include libertarian, Rawlsian, sufficientarian, contractarian, communitarian, Marxian and reciprocity-based approaches. In Part Two, the authors look (...) more specifically at issues relevant to each of these theories, such as motivation to act fairly towards future generations, the population dimension, the formation of preferences through education and how they impact on our intergenerational obligations, and whether it is fair to rely on constitutional devices. (shrink)

We all have beliefs, even strong convictions, about what is just and fair in our social arrangements. How should these beliefs and the theories of justice that incorporate them guide our thinking about practical matters of justice? This wide-ranging collection of essays by one of the foremost medical ethicists in the USA explores the claim that justification in ethics, whether of matters of theory or practice, involves achieving coherence between our moral and non-moral beliefs. Amongst the practical issues addressed in (...) the volume are the design of health-care institutions, the distribution of goods between the old and the young, and fairness in hiring and firing. In combining ethical theory and practical ethics this volume will prove especially valuable to philosophers concerned with ethics and applied ethics, political theorists, bioethicists, and others involved in the study of public policy. (shrink)

This book is a collection of essays on various problems arising in connection with John Rawls's theory of justice. Its focus is the method of wide reflective equilibrium. The first half of the book begins with Daniels's well-known essay "Wide Reflective Equilibrium and Theory Acceptance in Ethics" and ends with an excellent discussion of the role of reflective equilibrium in Rawls's Political Liberalism. The essays in the second part discuss justice in health care. They are of interest in their own (...) right, and also as illustrating Daniels's view that for those practicing the method of reflective equilibrium, applied moral philosophy is integral to the process of moral theorizing. Daniels says that the essays do not constitute a systematic treatment of wide reflective equilibrium. But they display a much higher degree of thematic coherence than is usual in a collection, and they read much like the chapters of a monograph. (shrink)

All definitions of mental disorder are backed up by arguments that rely on general criteria (e.g., that a definition should be consistent with ordinary language). These desiderata are rarely explicitly stated, and there has been no systematic discussion of how different definitions should be assessed. To arrive at a well-founded list of desiderata, we need to know the purpose of a definition. I argue that this purpose must be practical; it should, for example, help us determine who is entitled to (...) publicly funded health care. I then propose eight conditions of adequacy that can be used to assess competing definitions (e.g., the ordinary language condition, the coherence condition, and the condition of normative adequacy). These conditions pull in different directions, however, and we must decide which are most important. I also suggest that there is no single definition that can help us deal with all the relevant practical issues. (shrink)

How to handle orphan drugs for rare diseases is a pressing problem in current health-care. Due to the group size of patients affecting the cost of treatment, they risk being disadvantaged in relation to existing cost-effectiveness thresholds. In an article by Niklas Juth it has been argued that it is irrelevant to take indirectly operative factors like group size into account since such a compensation would risk discounting the use of cost, a relevant factor, altogether. In this article we analyze (...) Juth’s argument and observe that we already do compensate for indirectly operative factors, both outside and within cost-effectiveness evaluations, for formal equality reasons. Based on this we argue that we have reason to set cost-effectiveness thresholds to integrate equity concerns also including formal equality considerations. We find no reason not to compensate for group size to the extent we already compensate for other factors. Moreover, groups size implying a systematic disadvantage also on a global scale, i.e. taking different aspects of the health condition of patients suffering from rare diseases into account, will provide strong reason for why group size is indeed relevant to compensate for. (shrink)

Disease prioritarianism is a principle that is often implicitly or explicitly employed in the realm of healthcare prioritization. This principle states that the healthcare system ought to prioritize the treatment of disease before any other problem. This article argues that disease prioritarianism ought to be rejected. Instead, we should adopt ‘the problem-oriented heuristic’ when making prioritizations in the healthcare system. According to this idea, we ought to focus on specific problems and whether or not it is possible and efficient to (...) address them with medical means. This has radical implications for the extension of the healthcare system. First, getting rid of the binary disease/no-disease dichotomy implicit in disease prioritarianism would improve the ability of the healthcare system to address chronic conditions and disabilities that often defy easy classification. Second, the problem-oriented heuristic could empower medical practitioners to address social problems without the need to pathologize these conditions. Third, the problem-oriented heuristic clearly states that what we choose to treat is a normative consideration. Under this assumption, we can engage in a discussion on de-medicalization without distorting preconceptions. Fourth, this pragmatic and de-compartmentalizing approach should allow us to reconsider the term ‘efficiency’. (shrink)