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 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)

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)

In Norway, priority for health interventions is assigned on the basis of three official criteria: health benefit, resources, and severity. Responses to the COVID-19 pandemic have mainly happened through intersectoral public health efforts such as lockdowns, quarantines, information campaigns, social distancing and, more recently, vaccine distribution. The aim of this article is to evaluate potential priority setting criteria for public health interventions. We argue in favour of the following three criteria for public health priority setting: benefit, resources (...) and improving the well-being of the worse off. We argue that benefits and priority to the worse off may reasonably be understood in terms of individual well-being, rather than only health, for public health priority setting. We argue that lessons from the COVID-19 pandemic support our conclusions. Keywords: COVID-19, Prioritarianism, Priority Setting, Public Health, Severity. (shrink)

Egalitarian theories of justice hold that equality should be promoted. Typically, perfect equality will not be achievable, and it will be necessary to determine which of various unequal distributions is the most equal. All plausible conceptions of equality hold that, where perfect equality does not obtain, (1) any benefit (no matter how small) to a worst-off person that leaves him/her still a worst-off person has priority (with respect to equality promotion) over any benefit (no matter how large) to a (...) best-off person, and (2) any benefit to a worse-off person (even if not a worst-off person) has priority over a benefit of the same size to a better off person (even if not a best-off person). Beyond that there is much disagreement. (shrink)

We shall focus on moral theories that are solely concerned with promoting the benefits (e.g., wellbeing) of individuals and explore the possibility of such theories ascribing some priority to benefits to those who are worse off—without this priority being absolute. Utilitarianism (which evaluates alternatives on the basis of total or average benefits) ascribes no priority to the worse off, and leximin (which evaluates alternatives by giving lexical priority to the worst off, and then the (...) second worst off, and so on) ascribes absolute priority to the worse off (i.e., favors even a very small benefit to a worse off person over very large benefits to large numbers of better off people). Neither extreme view, we assume, is plausible. (shrink)

We argue that there is a marked shift in the moral weight of an increment in a person's well-being when one moves from a case involving only intra-personal trade-offs to a case involving only inter-personal trads-offs. This shift, we propose, is required by the separateness of persons. We also argue that the Priority View put forward by Parfit cannot account for such a shift. We also outline two alternative views, an egalitarian view and a claims-based view, that can account (...) for this shift. (shrink)

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)

I begin, in section 1, with a presentation of the Interpersonal Addition Theorem. The theorem, due to John Broome (1991), is a re-formulation of the classical result by Harsanyi (1955). It implies that, given some seemingly mild assumptions, the overall utility of an uncertain prospect can be seen as the sum of its individual utilities. In sections 1 and 2, I discuss the theorem's connection with utilitarianism and in particular consider its implications for the Priority View, according to which (...) benefits to the worse off count for more, in terms of overall utility, than comparable benefits to the better off (cf. Parfit 1995 [1991]). Broome (1991) and Klint Jensen (1996) have argued that, in view of the Interpersonal Addition Theorem, the Priority View should be rejected for measurement-theoretical reasons. Therefore, it cannot be seen as a plausible competitor to utilitarianism (cf. section 1). I will suggest, however, that a proponent of the Priority View would be well-advised, on independent grounds, to reject one of the basic assumptions on which the Addition Theorem is based. I have in mind the so-called Principle of Personal Good for uncertain prospects (cf. sections 4 and 5). If the theorem is disarmed in this way, then, as a side benefit, the Priority View will avoid the afore-mentioned problems with measurement. (shrink)

In this article we argue that the social value of health research should be conceptualized as a function of both the expected benefits of the research and the priority that the beneficiaries deserve. People deserve greater priority the worse off they are. This conception of social value can be applied for at least two important purposes: in health research priority setting when research funders, policy-makers, or researchers decide between alternative research projects; and in evaluating the ethics (...) of proposed research proposals when research ethics committees assess whether the social value of the research is sufficient to justify the risks and burdens to research participants and others. In assessing how far a proposed research project will advance the interests of people who are more disadvantaged, research priority setters and RECs should examine the diseases that the research targets and the type of research. Just as certain diseases impose a greater burden on people who are more disadvantaged, so certain types of intervention and forms of research are more likely to benefit people who are more disadvantaged. We outline which populations are likely to be representative of the global worst off and identify what types of health research, and which disease categories, are priorities for these populations. (shrink)

In this dissertation, I discuss two distributive principles in moral philosophy: Derek Parfit's Prioritarianism and Egalitarianism. I attempt to defend a version of Egalitarianism, which I call Weighted Egalitarianism. Although Parfit claims that Egalitarianism is subject to what he calls the Levelling Down Objection, I show that my proposed Weighted Egalitarianism is not subject to the Objection, and that it gives priority to the worse off people. The real difference between the two principles lies in how the weight (...) of each person's well-being is determined. Prioritarianism assumes that there is a moral scale of the goodness of well-being, independently of distributions of people's well-being. I raise two objections to this claim: firstly, it is hard to believe that the choice of the level of well-being affects our distributive judgement; secondly, it is hard to believe that there is such a moral scale independently of distributions of people's well-being. On the other hand, Weighted Egalitarianism claims that the weight is given by the rank order position of the person in the ranking by well-being level. This means that, in Weighted Egalitarianism, the goodness of a distribution is an increasing, linear function of people's well-being. Weighted Egalitarianism is not affected by the choice of the level of people's well-being. Nor does it require require the moral scale of the goodness of well-being independently of distributions of people's well-being. Leximin, which might be a version of Prioritarianism, avoids my objections. But it is hard to support Leximin, because it rules out the trade off between the better off and the worse off. I conclude that Weighted Egalitarianism is more acceptable than Prioritarianism. (shrink)

The most influential egalitarian perspective is undoubtedly Rawls's (1971, 1993), which assigns absolute priority to the least advantaged in society (the difference principle). However, many have claimed that even though an egalitarian perspective should imply some priority to the worst off, the Rawlsian perspective is too demanding. One response to this criticism is to argue in favour of an egalitarian perspective that never assigns absolute priority to the worse off, but which still includes limited priority (...) to those members of society in distributive conflicts. A different response to the demandingness criticism is to agree that the worse off should not always be given absolute priority, but to argue that there are some cases where they should be. In this paper, we elaborate on this view, and look at the possibility of deviating from the leximin approach within this category of egalitarian principles. (shrink)

Progress towards Universal Health Coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the WHO Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases and how should one adjudicate between them when their demands conflict? This paper (...) by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three principal dimensions of progress towards UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to pre-payment with pooling of funds. Our cases are simplified to highlight common trade-offs. While we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC. (shrink)

I develop the recent claim that prioritarianism, and not only its egalitarian competitors, must be committed to an impersonal outcome value (i. e. a value that makes a distribution better even if this does not affect anyone’s welfare). This value, that I label telic priority and that consists in the goodness of benefits going to the worst off recipients, implies implausible judgments that more than compete with ‘pure’ (Parfit) egalitarianism’s applause in leveling down scenarios. ‘Pure prioritarianism’, an axiological theory (...) that would consist in an unqualified commitment to telic priority only, must therefore be developed into a pluralist version of the priority view. Contra Parfit, prioritarianism and egalitarianism are on a par concerning the relationship between their pure (and implausible) formulations and their pluralist (and plausible) versions. The final section explains why telic priority always assigns preference to the worst-off (and not merely to the worse-off). (shrink)

When thinking about population level healthcare priority setting decisions, such as those made by the National Institute for Health and Care Excellence, good medical ethics requires attention to three main principles of health justice: (1) cost-effectiveness, an aspect of beneficence, (2) non-discrimination, and (3) priority to the worse off in terms of both current severity of illness and lifetime health. Applying these principles requires consideration of the identified patients who benefit from decisions and the unidentified patients who (...) bear the opportunity costs. (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)

This essay examines several possible rationales for the egalitarian judgment that justice requires better-off individuals to help those who are worse off even in the absence of social interaction. These rationales include equality (everyone should enjoy the same level of benefits), moral meritocracy (each should get benefits according to her responsibility or deservingness), the threshold of sufficiency (each should be assured a minimally decent quality of life), prioritarianism (a function of benefits to individuals should be maximized that gives (...) class='Hi'>priority to the worse off), and mixed views. A case is made for adopting either prioritarianism or a mixed view that gives priority both to the worse off and to the more responsible and deserving. (shrink)

This paper takes its departure from the Interpersonal Addition Theorem. The theorem, by John Broome, is a re-formulation of the classical result by Harsanyi. It implies that, given some seemingly mild assumptions, the overall utility of an uncertain prospect can be seen as the sum of its individual utilities. In sections 1 and 2, I discuss the theorem’s connection with utilitarianism and in particular the extent to which this theorem still leaves room for the Priority View. According to the (...) latter, the utilitarian approach needs to be modified: Benefits to the worse off should count for more, overall, than the comparable benefits to the better off.Broome and Jensen have argued that the Priority View cannot be seen as a plausible competitor to utilitarianism: Given the addition theorem, prioritarianism should be rejected for measurement-theoretical reasons. I suggest that this difficulty is spurious: The proponents of the Priority View would be well advised, on independent grounds, to reject one of the basic assumptions on which the addition theorem is based, the so-called Principle of Personal Good for uncertain prospects.According to the Principle of Personal Good, one prospect is better than another if it is better for everyone or at least better for some and worse for none. That the Priority View, as I read it, rejects this welfarist intuition may be surprising. Isn’t welfarism a common ground for prioritarians and utilitarians? Still, as I argue, this welfarist common ground is better captured by a restricted Principle of Personal Good that is valid for *outcomes*, but not necessarily for uncertain prospects. We obtain this surprising result if we take the priority weights imposed by prioritarians to be relevant only to *moral*, but not to *prudential*, evaluations of prospects. This makes it possible for a prospect to be morally better even though it is worse for everyone concerned. The proposed interpretation of the Priority View thus drives a sharp wedge between prudence and morality. (shrink)

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies (...) show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for the worse off, and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting. (shrink)

IntroductionHigh healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.MethodsUsing a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting (...) treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.ResultsGiving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms.ConclusionIn settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty. (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)

In the philosophical literature, prioritarianism is generally given either a teleological or contractualist rendering. Both forms of prioritarianism, I argue, are unsatisfactory, which creates a need for an alternative conception of prioritarianism. I develop a noncontractualist version of deontic prioritarianism that is superior to both teleological and contractualist prioritarianism with respect to grounding the normativity of absolute levels of well-being and explaining our moral thinking about priority to the worse off. Some objections to this view are addressed, and (...) the possibility of a mixed or hybrid view is briefly considered. Noncontractualist deontic prioritarianism might apply to both whole lives and parts of lives, a position that is consistent with a person-centered approach to distributive ethics, I contend. Finally, noncontractualist deontic prioritarianism seems to apply to one-person cases in which there are not competing claims to our aid, but I argue that this result is not an embarrassment for the view. (shrink)

The definition and measurement of social welfare have been a vexed issue for the past century. This book makes a constructive, easily applicable proposal and suggests how to evaluate the economic situation of a society in a way that gives priority to the worse-off and that respects each individual's preferences over his or her own consumption, work, leisure and so on. This approach resonates with the current concern to go 'beyond the GDP' in the measurement of social progress. (...) Compared to technical studies in welfare economics, this book emphasizes constructive results rather than paradoxes and impossibilities, and shows how one can start from basic principles of efficiency and fairness and end up with concrete evaluations of policies. Compared to more philosophical treatments of social justice, this book is more precise about the definition of social welfare and reaches conclusions about concrete policies and institutions only after a rigorous derivation from clearly stated principles. (shrink)

Derek Parfit has argued that (Teleological) Egalitarianism is objectionable by breaking a person-affecting claim to the effect that an outcome cannot be better in any respect - such as that of equality - if it is better for nobody. So, he presents the Priorty View, i.e., the policy of giving priority to benefiting the worse-off, which avoids this objection. But it is here argued, first, that there is another person-affecting claim that this view violates. Secondly, Egalitarianism can be (...) construed as person-affecting in a weaker sense. Thirdly, it is possible to construct a Relational version of the Priority View which incorporates the Egalitarian value of just equality in this sense. Two reasons are given for why this Relational View and Egalitarianism are superior to the Parfitian Absolute Priority View. However, no attempt is made to abjudicate between the first two views, the main point being that they both accept the value of just equality in the same sense. (shrink)

Egalitarians think that equality in the distribution of goods somehow matters. But what exactly is egalitarianism? This article argues for a characterization based on novel principles essentially involving risk. The characterization is then used to resolve disputed questions about egalitarianism. These include: the way egalitarianism is concerned with patterns, in particular its relationship to strong separability; the relationship between egalitarianism and other distributive views, such as concerns with fairness and with giving priority to the worse off; and the (...) relationship between egalitarianism and evaluative measurement. But egalitarianism is subject to a particularly severe form of the levelling-down objection, and is claimed to be false. (shrink)

Michael Otsuka, Alex Voorhoeve and Marc Fleurbaey have challenged the priority view in favour of a theory based on competing claims. The present paper shows how their argument can be used to recast the priority view. All desert claims in distributive justice are comparative. The stronger a party’s claims to a given benefit, the greater is the value of her receiving it. Ceteris paribus, the worse-off have stronger claims on welfare, and benefits to them matter more. This (...) can account for intuitions that at first appear egalitarian, as the analysis of an example of Larry Temkin’s shows. The priority view, properly understood, is desert-adjusted utilitarianism under the assumption that no other claims pertain. (shrink)

The article is a plea for ethicists to regard probability as one of their most important concerns. It outlines a series of topics of central importance in ethical theory in which probability is implicated, often in a surprisingly deep way, and lists a number of open problems. Topics covered include: interpretations of probability in ethical contexts; the evaluative and normative significance of risk or uncertainty; uses and abuses of expected utility theory; veils of ignorance; Harsanyi’s aggregation theorem; population size problems; (...) equality; fairness; giving priority to the worse off; continuity; incommensurability; nonexpected utility theory; evaluative measurement; aggregation; causal and evidential decision theory; act consequentialism; rule consequentialism; and deontology. (shrink)

Does disability make a person worse off? I argue that the best answer is yes AND no, because we can be worse off in two conceptually distinct ways. Disabilities usually make us worse off in one way (typified by facing hassles) but not in the other (typified by facing loneliness). Acknowledging two conceptually distinct ways to be worse off has fundamental implications for philosophical theories of well-being. (This paper won the APA’s Routledge, Taylor & Francis Prize (...) in 2017.). (shrink)

Positional goods are goods whose relative amount determines their absolute value. Many goods appear to have positional aspects. For example, one’s relative standing in the distribution of education and wealth may determine one’s absolute condition with respect to goods like employment opportunities, self-respect, and social inclusion. Positional goods feature in recent arguments from T.M. Scanlon, Brian Barry, and Harry Brighouse and Adam Swift that assert that we should favor egalitarian distributions of positional goods even if we reject equality as a (...) fundamental principle of distributive justice. With respect to positional goods, worsening the better off is required to better the worse off. Thus, we have reason to “level down” goods such as education and wealth in order to benefit those worse off with respect to the value of those goods. I argue that the allegedly positional aspects of the goods in question are not actually positional. Moreover, leveling down these goods risks self-defeat: it may produce a net decrease in the value of the shares of individuals with less of such goods. If so, leveling down measures would fail on their own terms. (shrink)

Application of egalitarian and prioritarian accounts of health resource allocation in low‐income countries have both been criticized for implying distribution outcomes that allow decreasing/undermining health gains and for tolerating unacceptable standards of health care and health status that result from such allocation schemes. Insufficient health care and severe deprivation of health resources are difficult to accept even when justified by aggregative efficiency or legitimized by fair deliberative process in pursuing equality and priority oriented outcomes. I affirm the sufficientarian argument (...) that, given extreme scarcity of public health resources in low‐income countries, neither health status equality between populations nor priority for the worse off is normatively adequate. Nevertheless, the threshold norm alone need not be the sole consideration when a country's total health budget is extremely scarce. Threshold considerations are necessary in developing a theory of fair distribution of health resources that is sensitive to the lexically prior norm of sufficiency. Based on the intuition that shares must not be taken away from those who barely achieve a minimal level of health, I argue that assessments based on standards of minimal physical/mental health must be developed to evaluate the sufficiency of the total resources of health systems in low‐income countries prior to pursuing equality, priority, and efficiency based resource allocation. I also begin to examine how threshold sensitive health resource assessment could be used in the Philippines. (shrink)

The lifetime equality view has recently been met with the objection that it does not rule out simultaneous inequality: two persons may lead equally good lives on the whole and yet there may at any time be great differences in their level of well-being. And simultaneous inequality, it is held, ought to be a concern of egalitarians. The paper discusses this and related objections to the lifetime equality view. It is argued that rather than leading to a revision of the (...) lifetime equality view, these objections, if taken seriously, should make us account for our egalitarian concerns in terms of the priority view rather than the equality view. The priority view claims that there is a greater moral value to benefiting the worse off. Several versions of the priority view are also distinguished. (shrink)

What is the relation between desert and other values such as equality, priority for the worse off, and utility? According to the common (pluralist) view, desert and these other values reflect distinct concerns: some are about distributive justice, some about retributive justice, and some (most clearly, utility) are not concerned with justice at all. However, another (monistic) view holds that while desert is a basic value, other values are merely derived from it. This controversy is relevant, for instance, (...) to allocative decisions and criminal punishment, where we need to know if other values should be balanced against desert. Yet, despite its theoretical significance and practical importance, this topic is underexplored. Aiming to fill this gap, we consider the arguments for and against the competing views. We demonstrate that the interaction between desert and other values raises a difficult dilemma: there are powerful arguments for and against both the pluralistic and the monistic accounts of desert. Indeed, we suggest that this dilemma is due to the unique nature of desert. Unlike other values, desert, especially its more robust forms, does not only sometimes conflict with competing considerations that favor different courses of actions, but rather seems to dispel other values even as pro tanto ones. (shrink)

: When reflecting on arguments in the debate about genetic technologies, decision makers must try to be empathetic to those who are worse off. Disparities in health and health care in the U.S. pale when global facts are considered. Although U.S. citizens ought to be concerned about the worse off in the U.S., such concern ultimately must be balanced against the urgent imperative to address the plight of those in poor countries. It is a matter of fairness that (...) care and concern be directed to those who are truly worse off in global terms. (shrink)

The Interpersonal Addition Theorem, due to John Broome, states that, given certain seemingly innocuous assumptions, the overall utility of an uncertain prospect can be represented as the sum of its individual utilities. Given ‘Bernoulli's hypothesis’ according to which individual utility coincides with individual welfare, this result appears to be incompatible with the Priority View. On that view, due to Derek Parfit, the benefits to the worse off should count for more, in the overall evaluation, than the comparable benefits (...) to the better off. Pace Broome, the paper argues that prioritarians should meet this challenge not by denying Bernoulli's hypothesis, but by rejecting one of the basic assumptions behind the addition theorem: that a prospect is better overall if it is better for everyone. This conclusion follows if one interprets the priority weights that are imposed by prioritarians as relevant only to moral, but not to prudential, evaluations of prospects. (shrink)

-/- I start from three premises, roughly as follows: (1) that if possible world x is better than world y for every individual who exists in either world, then x is better than y; (2) that if x has a higher average utility, a higher total utility, and no more inequality than y, then x is better than y; (3) that better than is transitive. From these premises, it follows that benefits given to the worse off contribute no more (...) to the world’s value than equal-sized benefits given to the better off. (shrink)

In their paper ‘Why It Matters That Some Are Worse Off Than Others: An Argument against the Priority View’, Michael Otsuka and Alex Voorhoeve argue that prioritarianism is mistaken. I argue that their case against prioritarianism has much weaker foundations than it might at first seem. Their key argument is based on the claim that prioritarianism ignores the fact of the ‘separateness of persons’. However, prioritarianism, far from ignoring that fact, is a plausible response to it. It may (...) be that prioritarianism disregards the fact of the ‘unity of the individual’. But even if this is true, that doesn’t straightforwardly tell against prioritarianism as a view about distributive justice. In the end, Otsuka and Voorhoeve’s argument relies on a non-decisive intuition that they appeal to early in their paper. Their conclusion, as a result, is not compelling. (shrink)

In this article, I firstly discuss why a prioritarian clause can rescue the utilitarian doctrine from the risk of exacerbating inequality in the distribution of resources in those cases in which utility of income does not decline at the margin. Nonetheless, when in the presence of adaptive preferences, classic prioritarianism is more likely than utilitarianism to increase the inequality of resources under all circumstances, independently of the diminishing trend of utility. Hence, I propose to shift the informational focus of prioritarianism (...) from welfare to either social income or capabilities in order to safeguard those who are worse off. Following this, I argue that we may have reasons to limit the aggregative logic of priority-amended utilitarianism through one or more sufficiency thresholds, and that we can partially defuse the negative-thesis objection that is usually levelled against sufficientarianism, provided we interpret the threshold(s) as valid only as long as everyone is led above it. (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)

Prioritarianism is the view that we ought to give priority to benefiting those who are worse off. Sufficientism, on the other hand, is the view that we ought to give priority to benefiting those who are not sufficiently well off. This paper concerns the relative merits of these two views; in particular, it examines an argument advanced by Roger Crisp to the effect that sufficientism is the superior of the two. My aim is to show that Crisp's (...) argument is unsound. While I concede his objections against the particular prioritarian views that he considers, I propose a different version of prioritarianism that is invulnerable to those objections. (shrink)

What justifies differences in the acceptance of paternalism towards competent minors and older people? I propose two arguments. The first argument draws on the widely accepted view that paternalism is easier to justify the more good it promotes for the paternalizee. It argues that paternalism targeting young people generally promotes more good for the people interfered with than similar paternalism targeting older people. While promoting people's interests or well-being is essential to the justification of paternalism, the first argument has certain (...) unfair implications in that it disfavours paternalism towards the worse off. The second argument caters to such fairness concerns. It argues that priority or inequality aversion supports age-differentiated paternalism because young people, who act imprudently and thereby risk their interests or well-being, are worse off than older people who act in similar ways. I suggest that both arguments are pertinent in evaluating specific paternalistic acts and policies. (shrink)

Several liberal philosophers and penal theorists have argued that the state has a reason to prohibit acts that harm individuals. But what is harm? According to one specification of harm, a person P is harmed by an act (or an event) a iff, as a result of a, P is made worse off in terms of well-being. One central question here involves the baseline against which we assess whether someone is ‘worse off’. In other words, when a person (...) is harmed he is worse off, certainly—but what is worse off a variation from? A central part of the paper critically discusses different answers to this question based on versions of what we can call: the temporal baseline, the baseline from mankind and the counterfactual baseline. Essentially, it will be argued that the counterfactual baseline leaves us with a better understanding of harming than the other baselines discussed. The final part of the paper will describe some of the implications of our investigation for the application and evaluation of the view that harm matters in the justification of which type of acts should be criminalized by the state. The overall conclusion of the paper is that adherents of a view like the harm principle face a dilemma. Either they can accept the counterfactual baseline but then, they can do without the harm principle. Or they can reject the counterfactual baseline—but then they will have to formulate an alternative baseline which, as will be shown in the paper, is no easy task. (shrink)

Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this (...) analysis, the paper arrives at the following three conclusions: that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case. (shrink)

According to luck egalitarianism it is bad or unjust if someone is worse off than another through no fault or choice of her own. This article argues that there is a tension in standard luck egalitarian theory between justifying absolute and comparative welfare levels. If a person responsibly acts in a way that brings her welfare level below that of others, this is justified according to the theory. However, even if we can say that the person's new welfare level (...) is justified in absolute terms, it is less clear that her now being worse off than others, is justified. The reason is that while she has in one sense chosen her welfare level, she has not chosen to be worse off than others. Her relative standing, something with which egalitarians ought to be concerned, is determined by her choices in conjunction with the choices of all others. But no individual controls the choices of all others. Hence, for any one individual it is the case that her relative standing is beyond her control. Some responses to this problem are available. It is doubtful, however, that these are entirely successful. (shrink)

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)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

Prioritarianism is a family of views comparing distributions of well-being. What unites prioritarians is the thought that when deciding whether a distribution is overall better than another, the worse off have priority. There are different ways of making this idea more precise. However, some of these views have extreme aggregative implications and others have extreme anti-aggregative implications. This raises the question: can prioritarians accommodate partial aggregation (aggregating in some but not all cases) and avoid both extremes? In this (...) paper, I explore and focus on a neglected anti-aggregation condition. I identify a family of views I call ‘bounded prioritarianism’ that meet this condition by placing an upper bound on the moral significance of benefits. I argue that anyone sympathetic to partial aggregation ought to opt for a version of bounded prioritarianism. (shrink)

The good of those who are worse off matters more to the overall good than the good of those who are better off does. But being worse off than one’s fellows is not itself bad; nor is inequality itself bad; nor do differences in well-being matter more when well-being is lower in an absolute sense. Instead, the good of the relatively worse-off weighs more heavily in the overall good than the good of the relatively better-off does, in (...) virtue of the fact that the former are relatively worse off. This paper articulates and defends the view just described. (shrink)

Purpose: Explore public attitudes towards the trade-offs between justice and medical outcome inherent in organ allocation decisions.Background: The US Task Force on Organ Transplantation recommended that considerations of justice, autonomy and medical outcome be part of all organ allocation decisions. Justice in this context may be modeled as a function of three types of need, related to age, clinical urgency, and quality of life.Methods: A web-based survey was conducted in which respondents were asked to choose between two hypothetical patients who (...) differed in clinical urgency , age, pretransplant and post-transplant quality of life, and life expectancy.Results: A pool of 1600 people were notified via email about the survey; 623 responded. Respondents preferred giving organs to younger people up to an age difference of <15.4 years and more clinically urgent people up to a difference in urgency of <2.54 months . Priority varied with the quality of life of the worst-off patient and the relative status of the patients. If both had worse than average quality of life, respondents preferred the better-off patient. When both had better than average quality of life, they preferred the worse-off patient. In analysis according to age versus clinical urgency, the older the patient, the more urgency needed to receive priority. In quality of life versus clinical urgency, the better the control’s quality of life, the more urgency the competing patient required. The worse the patient’s post-transplant outcome, the more urgency needed to receive priority.Conclusions: It appears that clinical urgency is only one of many factors influencing attitudes about allocation decisions and that respondents may invoke different principles of fairness depending the relative clinical status of patients. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

Equal Justice explores the role of the idea of equality in liberal theories of justice. The title indicates the book’s two-part thesis: first, I claim that justice is the central moral category in the socio-political domain; second, I argue for a specific conceptual and normative connection between the ideas of justice and equality. This pertains to the age-old question concerning the normative significance of equality in a theory of justice. The book develops an independent, systematic, and comprehensive theory of equality (...) and egalitarianism. The principal question is about the importance of equality in a theory of justice. More precisely, we should pose questions in four contracting circles: 1. Is justice the supreme value guiding our setup of the basic structure of society, or are there other, equally important values, such as recognition, care, communal belonging? 2. If justice is the highest guiding principle, which competing ideals—especially equality and freedom—ought to have precedence in a policy oriented toward justice? What status does the ideal of equality have in that framework? 3. If equality is a basic ideal of just policy, how should it be practically realized? What sort of equality (equal opportunity, equality of welfare, resource equality) should be demanded? 4. What patterned distribution of which specific goods does the ideal of equality demand? Which principles of distribution can be justified according to our justice ideal? To conclude and summarize: 5. What is the essential core of an egalitarian theory of justice, as opposed to an inegalitarian theory? These five questions structure the work’s order of argumentation. Part A elaborates the conceptual foundations and basic moral principles of justice and equality. Chapter I sets out to install justice as the central moral category in the socio-political domain. At the beginning of the first chapter, the conceptual foundations of justice are clarified. While not eliminating the classical distinctions between different forms of justice, I argue that the distributive paradigm is of primary importance. The primacy of justice in the socio-political domain is developed out of a confrontation with alternative positions, those which maintain either that justice generally, or distributive justice in particular, are subsidiary virtues. At the end of Chapter I, the first of the questions mentioned above is answered in a way that establishes justice as the guiding normative concept for the foundation and evaluation of any social order. To clarify the role of equality in a theory of justice, Chapter II separates the idea of equality into four different principles. They are organized in a way that begins with the most general and uncontroversial principle of equality, and progresses towards increasingly detailed and contested principles. There are two theses that articulate and defend the significance of equality for justice: First there is a conceptual connection between justice and equality, in that principles of formal and proportional equality are necessary in order to explicate the concept of justice. These two principles establish an unbreakable bond between justice and equality. Justice can only be explained—or so I argue—by reference to these and other (normative) principles of equality. The second thesis posits a normative relationship between justice and equality, which is disclosed by three substantive principles of equality: moral equality, the presumption of equality, and the principle of responsibility. I argue that the normative core of an egalitarian theory of justice is expressed by the latter two principles, which are themselves based on the first principle, that of moral equality. When we view one another as persons, what form of equality or equal treatment is normatively demanded? I argue that the answer to this question is given by the procedural principle of the presumption of equality: regardless of their apparent differences, all persons deserve strictly equal treatment, unless certain kinds of differences have whatever particular relevance would justify, on generally acceptable grounds, unequal treatment or unequal distribution. The justification of the presumption of equality is central to this work and has considerable importance. If the presumption principle’s validity can be justified by enlisting the principle of general justification, then the primacy of equality, and the essential argument for an egalitarian theory of justice, is established. This would likewise provide a procedure for the construction of a material theory of justice. The second question is answered thereby at the end of Chapter II: Equality should have primacy over competing ideals within a justice-oriented policy. The presumption of equality establishes this primacy and, at the same time, offers an appropriate metric and guideline for the construction of a material theory of distributive justice. The presumption of equality in Part B offers an elegant procedure for the development of a theory of distributive justice. Chapter III clearly sets out the necessary prerequisites that a theory of distribution must satisfy in order to determine a liberal-egalitarian distributional framework. We need to specify in which situation the distribution takes place; which goods are and are not to be distributed; in which respect the presumptive equality is to be produced; and by and to whom, and for what period, the relevant goods are to be distributed. The distribution is based on resources understood as general-purpose means. It is necessary to divide goods into different categories, since the justification for unequal treatment in one domain will not carry over into another. This makes presumptive equality necessarily complex. To that end, four spheres of justice are distinguished: (1) the political sphere, which involves allocating rights through the distribution of civil liberties; (2) the democratic sphere, in which political power and the rights of political participation are regulated; (3) the economic sphere, in which income and property are distributed; (4) the social sphere, in which social positions and opportunities are distributed. This framework of distributive justice answers the third of our guiding questions, about the nature of equality, in terms of equality of resources. Chapters IV and V set out the egalitarian distributive criteria for each sphere. I argue that the generally accepted, fundamental rights of classical liberalism are more effectively reconstructed by reference to the equal resource distribution presumptively required in those spheres. Chapter IV shows that when it comes to the first two spheres, those involving basic rights and freedoms and entitlement political participation, there can be no justified exceptions to the equal distribution of the relevant goods. That section argues, contrary to what we commonly find in theories of freedom or popular sovereignty, that the value of freedom and self-determination as the political basis of autonomy is best realized through the presumption of equal distribution. Chapter V deals with the other two spheres, those of economic goods and social positions, and argues for justified exceptions to equal distribution. In the economic sphere we find one principal reason favouring unequal distribution of resources, and three restrictions and compensations limiting that inequality. The basic exception to equal economic distribution arises from the unequal consequences of personal responsibility. From a suitably egalitarian standpoint, the principle of responsibility is the normative principle that determines which reasons justify economic inequality. Here the basic idea is that unequal shares of social goods are fair if they result from the choices and deliberate actions of the relevant parties. That individuals have to bear the costs of their own choices is a condition of autonomy. However, benefits or disadvantages arising from arbitrary and unmerited differences in social circumstances or natural endowments is unfair. The unequal consequences of independent decision-making and action must therefore be limited by compensating first for preferences, secondly for disadvantages, and thirdly by redistributing wealth in aid of the worse-off. I situations of emergency, compensating for disadvantages has priority over all other claims, owing to the urgency of the situation. Social inequalities go beyond the permissible limit if it is possible to improve the long-term social or economic situation of the worse-off by redistributing wealth to them. These exceptions lead to a complex system of free economic action within a framework of compensatory tax and transfer mechanisms. Finally, in the social sphere, the distribution of social positions, offices and opportunities must be structured to ensure that equally talented and motivated citizens have roughly equal chances of obtaining those offices or positions, irrespective of their economic or social class backgrounds. This compromise is permissible for reasons of freedom and prudence, and it makes a certain measure of inequality acceptable. The fourth of our guiding questions is answered accordingly. There are five principles of justice for the basic structure of society, and five legal principles that govern the special distribution of goods in the respective spheres—all are ranked according to their most defensible grounds of priority, ensuring that everyone is accorded equal justice. Chapter VI recapitulates the initial question of equality’s value. The conception of equal justice developed in this work postulates five principles of equality and five principles of law; these constitute an egalitarian framework because they support and promote social justice. Equality has value with respect to them, but is not given any independent, intrinsic value. That is why I call the account developed here a form of constitutive egalitarianism: justice is realized through the realization of equality, itself accomplished by applying the five postulates of equality and five distributive principles of law. This is an egalitarianism on two levels. The first level is involves the claim that morality or justice is conceptually connected with equality. The second level gives equality a substantial weight in what is conceptually validated at the first level, namely the presumption of equality, and constructs an appropriate interpretation and conception of distributive justice through principles of distribution for the individual spheres. The weight and importance of equality is shown by the distributive criteria applied to those spheres. This answers our final guiding question about the nature of an egalitarian theory. (shrink)