This article presents a fairness principle for evaluating decision-making based on predictions: a decision rule is unfair when the individuals directly impacted by the decisions who are equal with respect to the features that justify inequalities in outcomes do not have the same statistical prospects of being benefited or harmed by them, irrespective of their socially salient morally arbitrary traits. The principle can be used to evaluate prediction-based decision-making from the point of view of a wide range of antecedently specified (...) substantive views about justice in outcome distributions. (shrink)

In this paper, I argue that sufficientarian principles are indispensable in the set of principles that have bearing on issues in distributive ethics. I provide two arguments in favor of this claim. First, I argue that sufficientarianism is the only framework that allows us to appropriately analyze what sort of obligations we have toward individuals who are badly off due to their own faults and choices. Second, I argue that sufficientarianism is the only theory that provides an adequate framework for (...) thinking about the desperately badly off. (shrink)

This article analyzes approaches to nondeterminacy that suggest that one can make justified choices when primary criteria fail to fully determine a best alternative by introducing a secondary criterion. It is shown that these approaches risk violating Basic Contraction Consistency. Some ways of adjusting two-step models in order to protect against this are addressed, and it is suggested that proponents of two-step models should adopt formal conditions which qualify what counts as a permissible secondary criterion that resemble supervaluationist conditions that (...) qualify what counts as admissible precisifications of vague terms. (shrink)

A notorious problem that has recently received increased attention in axiology, normative theory and population ethics is the apparent ubiquity of what can be generally called nondeterminacy. This paper illustrates how nondeterminacy can spawn cyclical rankings. So, accepting that practical reasons can admit of nondeterminacy challenges the widely held idea that ‘better than’ is transitive. As a result, standard approaches to rational choice under nondeterminacy fail to be action-guiding, since in some situations all options are dominated, that is, impermissible according (...) to standard rational choice criteria. (shrink)

How should one understand comparisons in which neither of two alternatives is at least as good as the other? Much recent literature on comparability problems focuses on what the appropriate explanation of the phenomenon is. Is it due to vagueness or the possibility of non-conventional comparative relations such as parity? This paper argues that the discussions on how to best explain comparability problems has reached an impasse at which it is hard to make any progress. To advance the discussion we (...) suggest a new classification of comparability problems that focuses on the problems they cause for practical reasoning. (shrink)

Parker’s article is a welcome attempt to address the importance of environmental sustainability in the realm of clinical ethics.1 We support the recent movement to seriously consider the environmental impact of healthcare institutions in bioethics.2 3 Still, we find two partly linked weaknesses of Parker’s analysis and guideline suggestion. These relate to a need in ‘green’ bioethics to see beyond the normal healthcare ethical focus on health-related values related to individual patients, and to primarily adopt institutional ways of framing central (...) decision problems. Traditional bioethics applies a restricted scope of values to assess clinical decisions: primarily health-related patient well-being (including life) and patient autonomy. If a decision improves (or, as in Parker’s inhaler case, maintains) a patient’s health-related well-being, this supports it. However, if a decision improves a patient’s non health-related well-being, say, winning a beauty contest or securing a job by having cosmetic surgery, it is not supported. And so on. This idea of healthcare as, in Michael Walzer’s classic terminology, a separate ‘sphere of justice’ has two interrelated limitations: it reflects a bias towards individual patients over other people, and it restricts the scope of values allowed to influence healthcare ethical judgements. These limitations appear once we see that the issue addressed by Parker can be framed either as prescription decisions taken by individual doctors against the background of …. (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)

Incommensurability is the impossibility to determine how two options relate to each other in terms of conventional comparative relations. This book features new research on incommensurability from philosophers who have shaped the field into what it is today, including John Broome, Ruth Chang and Wlodek Rabinowicz. The book covers four aspects relating to incommensurability. In the first part, the contributors synthesize research on the competing views of how to best explain incommensurability. Part II illustrates how incommensurability can help us deal (...) with seemingly insurmountable problems in ethical theory and population ethics. The contributors address the Repugnant Conclusion, the Mere Addition Paradox and so-called Spectrum Arguments. The chapters in Part III outline and summarize problems caused by incommensurability for decision theory. Finally, Part IV tackles topics related to risk, uncertainty and incommensurability. Value Incommensurability: Ethics, Risk, and Decision-Making will be of interest to researchers and advanced students working in ethical theory, decision theory, action theory, and philosophy of economics. (shrink)

Much research aimed at developing measures for normative criteria to guide the assessment of healthcare resource allocation decisions has focused on health maximization, equity concerns and more recently approaches based on health capabilities. However, a widely embraced idea is that health resources should be allocated to meet health needs. Little attention has been given to the principle of need which is often mentioned as an alternative independent criteria that could be used to guide healthcare evaluations. This paper develops a model (...) and indicator of need satisfaction that aggregates the health needs of a population in a particular time period into a single measure that weights individual health needs by the severity of their ill health. The paper provides a first step towards formalizing the principle of need as a measurable objective for healthcare policy and we discuss some challenges for future research, including incorporating the duration of time into need-based health evaluations. (shrink)

A notorious debate in the ethics of healthcare rationing concerns whether to address rationing decisions with substantial principles or with a procedural approach. One major argument in favour of procedural approaches is that substantial principles are indeterminate so that we can reasonably disagree about how to apply them. To deal with indeterminacy, we need a just decision process. In this paper I argue that it is a mistake to abandon substantial principles just because they are indeterminate. It is true that (...) reasonable substantial principles designed to deal with healthcare rationing can be expected to be indeterminate. Yet, the indeterminacy is only partial. In some situations we can fully determine what to do in light of the principles, in some situations we cannot. The conclusion to draw from this fact is not that we need to develop procedural approaches to healthcare rationing, but rather that we need a more complex theory in which both substantial principles and procedural approaches are needed. (shrink)

This article presents an approach to how to make reasonable social choices when independent criteria (e.g., prioritarianism, religious freedom) fail to fully determine what to do. The article outlines different explanations of why independent criteria sometimes fail to fully determine what to do and illustrates how they can still be used to eliminate ineligible alternatives, but it is argued that the independent criteria cannot ground a reasonable social choice in these situations. To complement independent criteria when they fail to fully (...) determine what to do, it is suggested that society must engage in public deliberation by way of generating new reasons that can determine how to rank the alternatives. It is suggested that the approach to social choice presented here reveals a way of accepting the relevance of independent criteria for social choice without letting go of the idea that the attitudes of affected parties matter. (shrink)

This paper argues that decision problems and money-pump arguments should not be a deciding factor against accepting non-transitive better than relations. If the reasons to accept normative standpoints that entail a non-transitive better than relation are compelling enough, we ought to revise our decision method rather than the normative standpoints. The paper introduces the most common argument in favor of non-transitive better than relations. It then illustrates that there are different ways to reconceptualize rational choice so that rational choice is (...) possible also when the relevant better than relation is non-transitive. (shrink)

How should scarce health-related resources be allocated? This paper argues that values that apply to these decisions fail to always fully determine what we should do. Health maximization and allocation-according-to-need are suggested as two values that should be part of a general theory of how to allocate health-related resources. The “small improvement argument” is used to argue that it is implausible that one alternative is always better, worse, or equal to another alternative with respect to these values. Approaches that rely (...) on these values are thus incomplete. To deal with this, it is suggested that we ought to use incomplete theories in a two-step process. Such a process first discards ineligible alternatives, and, second, uses reasons grounded in collective commitments to identify a unique, best alternative in the remaining set. (shrink)

In 1997 John Broome presented the Collapsing Argument that was meant to establish that non-conventional comparative relations cannot exist. Broome's argument has faced a lot of scrutiny and a certain type of counterexample has been used to undermine it. Most of the counterexamples focus on the Collapsing Principle which plays a central role in Broome's argument. In this article we will take a closer look at the most common type of counterexample and propose how to adjust the Collapsing Principle in (...) order to avoid objections based on these counterexamples. We argue that a weaker version of the Collapsing Principle is not susceptible to the classical counterexamples. Furthermore, after an explorative discussion about the intuitions behind the original principle, we show that this weaker formulation is at least as intuitive as the principle suggested by Broome. (shrink)

Distributive theories evaluate distributions of goods based on candidate recipients’ characteristics, e.g. how well off candidates are, how deserving they are, and whether they fare below sufficiency. But such characteristics vary across possible worlds, so distributive theories may differ in terms of the world which for them settles candidates’ characteristics. This paper examines how distributive theories differ in terms of whether candidate recipients’ relevant characteristics are grounded in the possible world that would take place if the distributor does not intervene (...) (call it the “input” world) or if they are grounded in each possible world that the distributor can bring about through different decisions (call each an “output” world). We illustrate the importance of this distinction in relation to one distributive theory, prioritarianism. As we show, both input and output versions of prioritarianism are plausible interpretations of the literature, and there are good reasons to take input prioritarianism seriously. Ultimately, however, we argue that input prioritarianism should be rejected. (shrink)

This article argues that values that apply to health care allocation entail the possibility of “spectrum arguments,” and that it is plausible that they often fail to determine a best alternative. In order to deal with this problem, a two-step process is suggested. First, we should identify the Strongly Uncovered Set that excludes all alternatives that are worse than some alternatives and not better in any relevant dimension from the set of eligible alternatives. Because the remaining set of alternatives often (...) contain more than one element, we need some complementary method of selecting a unique alternative. In order to address this issue, I suggest that we must invoke caps on the values that are used to evaluate alternatives, and that these caps must be grounded in collective commitments. (shrink)

This paper shows that versions of prioritarianism that focus at least partially on well-being levels at certain times conflict with conventional views of prudential value and prudential rationality. So-called timeslice prioritarianism, and pluralist views that ascribe importance to timeslices, hold that a benefit matters more, the worse off the beneficiary is at the time of receiving it. We show that views that evaluate outcomes in accordance with this idea entail that an agent who delays gratification makes an outcome worse, even (...) if it is better for the agent and worse for no one else. We take this to show that timeslice prioritarianism and some pluralist views violate Weak Pareto, and we argue that these versions of prioritarianism are implausible. (shrink)

This article addresses the prioritization questions that arise when people attempt to institutionalize reasonable ethical principles and create guidelines for microlevel decisions. I propose that this instantiates an incommensurability problem, and suggest two different kinds of practical solutions for dealing with this issue.

This article shows that introducing the positive comparative relation parity only helps one block so‐called “Spectrum Arguments” in order to avoid their unsavoury implications if one specifies parity in a specific way with respect to its persistence. The article illustrates how parity must both admit of persistency and be weakly non‐persistent for parity to block Spectrum Arguments, and identifies some consequences of that discovery for the general debate on Spectrum Arguments, value theory and comparability problems.

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, whims, and prejudices, (...) which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers. (shrink)

Abstract Normative criteria for evaluations of economic and social outcomes are often formulated in terms of social welfare functions which are essentially and importantly non-satiable. However, there are good reasons to consider certain normative criteria and many policy objectives to be capped, i.e. bounded, and thus satiable provided sufficient resources are made available for their satisfaction. Inspired by the Foster–Greer–Thorbecke class of indicators, this paper uses an interdisciplinary approach to develop a model for assessing outcomes in terms of capped objectives (...) based on an understanding of individual shortfalls from the objective, denoted needs. We present an indicator to measure need satisfaction in a population of individuals with heterogeneous needs and highlight an aggregation problem under scarcity. For such situations, we develop three ways in which the indicator can be weighted that reflect respectively concerns over the frequency, depth and severity of the need shortfalls and show that normative evaluations based on these weighting schemes can conflict, yielding mutually inconsistent outcome rankings. The indicator can be adapted to measure a wide variety of phenomena, e.g. health needs, education shortfalls, deprivation, etc., and it is suited for targeting exercises and other policy implementations. In particular, it allows for exogenous weighting schemes, i.e. weights that can incorporate non-shortfall characteristics relevant for the evaluation, e.g. age, gender, ethnicity, etc. The indicator thus enables new ways for researchers to promote and study satiable objectives in a wide variety of contexts relevant to economic and social policy, e.g. human development programs, poverty reduction, healthcare policies, etc. (shrink)

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support (...) the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy. (shrink)

This paper addresses how to think about the permissibility of introducing deadweight costs on candidate recipients of goods in order to attain better outcomes. The paper introduces some distinctions between different kinds of value dimensions that should be taken into account when such judgements are made and draws from the literature on comparisons across different value dimensions in order to canvas what sort of situations one might arguably face when evaluating ordeals. In light of the distinctions drawn and the possibilities (...) canvassed, the paper proceeds to outline what circumstances indicate which of the possible situations one is in. (shrink)

This article provides a new argument and a new value-theoretical ground for person-centered care and shared decision making that ascribes to it the role of enabling rational choice in situations involving clinical choice. Rather than referring to good health outcomes and/or ethical grounds such as patient autonomy, it argues that a plausible justification and ground for person-centered care and shared decision making is preservation of rationality in the face of comparative non-determinacy in clinical settings. Often, no alternative treatment will be (...) better than or equal to every other alternative. In the face of such comparative non-determinacy, Ruth Chang has argued that we can make rational decisions by invoking reasons that are created through acts of willing. This article transfers this view to clinical decision making and argues that shared decision making provides a solution to non-determinacy problems in clinical settings. This view of the role of shared decision making provides a new understanding of its nature, and it also allows us to better understand when caregivers should engage in shared decision making and when they should not. (shrink)

Recent research indicates that there is a gap in life expectancy between the rich and the poor. This raises the question: should we on egalitarian grounds use income-based equity weights when we assess benefits of alternative benevolent interventions, so that health benefits to the poor count for more? This article provides three egalitarian arguments for using income-based equity weights under certain circumstances. If income inequality correlates with inequality in health, we have reason to use income-based equity weights on the ground (...) that health inequality is bad. If income inequality correlates with inequality in opportunity for health, we have reason to use such weights on the ground that inequality in opportunity for health is bad. If income inequality correlates with inequality in well-being, income-based equity weights should be used to mitigate inequality in well-being. Three different ways in which to construe income-based equity weights are introduced and discussed. They can be based on relative income inequality, on income rankings and on capped absolute income. The article does not defend any of these types of weighting schemes, but argues that in order to settle which of these types of weighting scheme to choose, more empirical research is needed. (shrink)

There is a mistake in the definition of the covering criterion on page 6.

This paper introduces a condition for rational choice that states that accepting decision methods and normative theories that sometimes entail that the act of choosing a maximal alternative renders this alternative non-maximal is irrational. The paper illustrates how certain distributive theories that ascribe importance to what the status quo is violate this condition and argues that they thereby should be rejected.

How should states and international organizations allocate global health resources? This paper examines proposals for distributing these resources in the literature. First, we look at the literature on the metrics for measuring what matters and consider how they might be modified to avoid some common objections—e.g., that these measures discriminate against the disabled or fail to give due weight to helping the young (or old) or those in present (or future) generations. Second, we canvas existing approaches to evaluating allocations of (...) health‐related resources utilizing such measures and advance a new way of doing so. We suggest that it is important to provide substantive arguments for directly evaluating alternative allocations, but there is also room for deliberation about fair procedures for selecting allocation criteria and securing just outcomes. (shrink)

It is a common view that benefits to the worse off should be given priority when health benefits are distributed. This paper addresses how to understand who is worse off in this context when individuals are differently well off at different times. The paper argues that the view that this judgment about who is worse off should be based solely on how well off individuals are when their complete lives are considered (i.e. 'the complete lives view') is implausible in this (...) context. Instead, it is argued that a pluralistic stance toward this issue should be accepted. This pluralistic stance recognizes that also the view that only focuses on how well off individuals are now and in the future (i.e. 'the forward-looking view') is relevant. The argument is based on appeals to intuitive judgments concerning who is worse off in different cases and reference to various underlying reasons why priority to benefits to the worse off is justified. (shrink)

This paper argues that accepting incommensurability can be a useful step for developing attractive hybrid theories to how to distribute scarce health-related resources. If one provides opportunity for distributive options to be incommensurable with respect to substantive criteria, one can hold on to substantive criteria while also providing room for decision processes to play a significant role. The paper also argues that the strategy of accepting incommensurability is preferable to the strategy of having substantive criteria establish sets of options that (...) are equally, explains why incommensurability gives us reason to go hybrid, and argues that reasons grounded in decision processes have properties that make them appropriate as “tiebreakers” in choice situations characterized by incommensurability. (shrink)

This paper addresses normative issues that arise in relation to indicators and measures of health impact. With inspiration from Nicole Hassoun's recent proposal, the paper argues and illustrates that those interested in measuring global health impact face questions about how to prioritize among those with ill-health, how to weigh benefits to those who cannot lead minimally good lives against benefits to the better off, and how to think about whether someone is badly off.

Why should we care about global health? What obligations do we have to improve global health? How can we work towards establishing a health industry that is better equipped to deal with the most significant global health challenges? In her impressive and ambitious book, Global Health Impact: Extending Access to Essential Medicine (Hassoun, 2020), Nicole Hassoun attempts to answer these questions, by drawing on contemporary research in political philosophy, global justice, health economics and business ethics. In this symposium, Timothy Campbell, (...) Yukiko Asada and Andreas Albertsen explore three dimensions of Hassoun’s proposal: the relation between measuring global health impact and conceptions of the minimally good life, different metrics used to measure the global health burden and democratic consumption and social justice. In a response paper, Hassoun responds to the critical remarks.In her book, Hassoun presents a theoretical framework that explains why we ought to care about global health, develops a way of measuring the global health impact of health technologies and argues that individuals should be guided by this in their consumption. The book presents an ambitious proposal for how one in a very practical way can use the measuring tool in order to promote global health by labeling and certifying different market products so that consumers and investors get incentivizing information that can change their behavior in a way that promotes global health. (shrink)