I agree that a good pensions system should embody some form of collective risk pooling and that this would be to the advantage of everyone. There are some difficult issues of adverse selection to be solved, however. Moreover, egalitarian concerns are of crucial importance in most countries and they require to go further than collective risk pooling and to take into account that society is more than a system of self-interested monetary transfers between and within cohorts.

What follows is a sketch of three of the main claims of How to Pool Risks across Generations: The Case for Collective Pensions (Otsuka 2023) with which my symposium commentators critically engage: namely, that (1) by efficiently pooling risks across as well as within generations, (2) collective pensions can realize a form of Rawlsian reciprocity involving fair terms of cooperation for mutual advantage, (3) through the voluntary binding agreements of individuals to join a mutual association that provides social insurance. I (...) respond to their challenges to these claims in my replies that follow their contributions. (shrink)

Despite a significant amount of literature debating the efficiency of high-risk pools in health insurance, dramatically less has been written about their normative implications. The present article takes the route less traveled by setting aside the question of efficiency to argue that the use of high-risk pools creates some serious normative concerns. The article explores these concerns by dividing them on two fronts. First, as regards the social-recognitional status of those who are forced into the high-risk pool. Second, as regards (...) a general concern of distributive justice, namely fairness in access to resources. The author argues that regardless of the veracity of arguments which laud the efficiency of high-risk pools, their use in health insurance is unjust because of the herein explained implications for social recognition and distributive justice. (shrink)

In this paper, I propose and defend a distinct and novel approach to compensation for risk impositions. I call it the Risk-Pooling System of compensation. This system suggests that when X performs an action that imposes a risk of harm to Y, then X is liable to Y, and is therefore obliged to make an ex ante compensation that is roughly equivalent to the expected cost of potential harm to a social- risk pool. If and when Y suffers harm as (...) a result of the risk imposed by X, they then receive an ex post compensation roughly equivalent to the cost of actual harm suffered. This system of compensation creates a social buffer between the risk imposer – the one who has the duty to pay compensation into the pool – and the victim – the one who has the right to receive compensation from the social pool. I contend that the Risk-Pooling System is an improvement over its alternatives due to its capacity to produce the best social utilities, particularly, in terms of reducing information costs, obtaining optimal deterrence in the society and creating incentives for people to be engaged in social activities. (shrink)

In 2006, the Centers for Disease Control and Prevention launched an initiative to address the health of women of childbearing age in the United States—a preconception care campaign to improve fetal and maternal health in the country by targeting interventions on parents, and largely women, before conception occurs. In The Zero Trimester: Pre-Pregnancy Care and the Politics of Reproductive Risk, sociologist Miranda Waggoner uses this campaign as an entry point to address the emergence and widespread acceptance of preconception care and (...) its political consequences in the United States. Throughout the book, Waggoner interrogates how preconception care extends assumptions that the onus for children’s health falls... (shrink)

"This economic system cannot do without the ultima ratio of the complete destruction of those existences which are irretrievably associated with the hopelessly unadapted." "Joseph Schumpeter, The Theory of Economic Development1"Slavoj Žižek poses more than a few heavy-gauge questions in his In Defense of Lost Causes . Foremost among them, at the beginning of chapter nine: “The only true question today is: do we endorse this ‘naturalization’ of capitalism, or does contemporary global capitalism contain antagonisms which are sufficiently strong to (...) prevent its indefinite reproduction?”2 This vast question—as well as its possible answers—develops in Žižek's…. (shrink)

We reflect, using a vignette, on conceptual tensions and the value judgements that lie behind difficult decisions about whether or not the older person with dementia should return home or move into long-term care following hospital admission. The paper seeks, first, to expose some of the difficulties arising from the assessment of residence capacity, particularly around the nature of evaluative judgements and conceptual tensions inherent in the legal approach to capacity. Secondly, we consider the assessment of best interests around place (...) of residence, which demonstrates significant conceptual tensions. In addition, ‘best interests’ raise issues around the perception of risk and the perceptions of the family and crucially involve the notions of autonomy and trust. Finally, we not only gesture at some practical considerations based on insights from values-based medicine, but also make the suggestion that we require tighter functional assessments of residence capacity coupled with broader judgements about best interests. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Language, Thought, and LogicGabriele PooleLanguage, Thought, and Logic, by John M. Ellis; x & 163 pp. Evanston: Northwestern University Press, 1993, $29.95.It is John Ellis’s contention that notwithstanding the enormous amount of energy that has gone into language studies not very much progress has been achieved and our theory of language remains vastly fragmented and contradictory. Language, Thought, and Logic is presented as an effort to overcome this (...) impasse. Many ideas are discussed, but the fundamental themes are the following four: the priority of categorization over communication, the functional nature of most categories, the attack on the severance of grammar from meaning which characterizes generative grammarians, and the dismissal of the debate on the relationship between language and thought as a meaningless issue.In chapters two and three, Ellis—after having convincingly argued for the logical priority of (language induced) categorization over communication—proceeds to illustrate the difference between “real” and “functional” categories. He states that a few categories, such as chemical classes, have their base in “reality.” Most categories, however, (Ellis uses the example of poison) are not based on intrinsic characteristics of its members (poisons differ widely in chemical structure) but on the collective purposes of the speakers (identifying dangerous substances). The former are “real” categories, the latter functional ones, and on the basis of this opposition Ellis attacks “naive realists” who claim that most linguistic categories are grounded in the extra-linguistic world. Ellis’s dichotomy however is not fully convincing: reality, of course, includes human beings and their interactions with the world. Once we concede that the chemical structure of a given substance is a real fact, then we have to admit that the interaction of a given substance with the human body is equally “real,” and [End Page 142] that a category based on a given type of interaction is grounded in “reality” just as one based on a given type of chemical structure.Chapter five instead is devoted to the traditional question of the relationship between thought and language. Ellis’s contention is that this discussion is in itself logically absurd, since language is an essential part of thought. This “initial logical misstep” inevitably leads thinkers such as John Lyons, Max Black, Eric Lenneberg, and no doubt countless others, to “astonishing” and “bewildering” statements, pseudoproblems,” and “comic” errors (pp. 56–58). In this case, too, Ellis’s position is not particularly convincing, and one wishes that he had devoted some of his unforgiving examination of the logical integrity of other people’s positions to his own arguments. For readers are bound to ask themselves why on earth does the fact that language is part of thought make it “not possible” to speak of the relationship between the two. Is it logically “not possible” to speak of the relationship of the part to the whole? Is it “not possible,” for example, to speak of the relationship of the heart to the rest of the human body?In general, by denying the possibility of discussing the relationship of thought and language, Ellis ends up completely ignoring the tension between the more standardized and collective aspects of language (grammar, and denotation, in particular) and the various ways it becomes articulated within individuals, through its inevitable enmeshment in their different experiences. This is a pity, because in many ways Ellis is trying to carve a commendable path between the Scylla of “deep structures” and the Charybdis of “linguistic determinism,” between the severance of language from meaning, and their absolute identification. It is perhaps inevitable that in shying away from the latter peril he ends up contradicting himself. After having declared the logical impossibility of speaking of the influence of the structure of language on thought, he subsequently states that it is certainly not true that everything in our mental life is completely determined by the structure of our language” (p. 61).Ultimately one is left with the impression that what would have best been offered as a refinement and integration of other positions has been polemically presented as a radical alternative, with the risk of helping to perpetuate the fragmentation of linguistic studies it was meant to overcome. Thus, as far as... (shrink)

Background HIV prevention trials conducted among disadvantaged vulnerable at-risk populations in developing countries present unique ethical dilemmas. A key concern in bioethics is the validity of informed consent for trial participation obtained from research subjects in such settings. The purpose of this study was to investigate the effectiveness of a continuous informed consent process adopted during the MDP301 phase III vaginal microbicide trial in Mwanza, Tanzania. Methods A total of 1146 women at increased risk of HIV acquisition working as alcohol (...) and food vendors or in bars, restaurants, hotels and guesthouses have been recruited into the MDP301 phase III efficacy and safety trial in Mwanza. During preparations for the trial, participatory community research methods were used to develop a locally-appropriate pictorial flipchart in order to convey key messages about the trial to potential participants. Pre-recorded audio tapes were also developed to facilitate understanding and compliance with gel-use instructions. A comprehension checklist is administered by clinical staff to all participants at screening, enrolment, 12, 24, 40 and 50 week follow-up visits during the trial. To investigate women's perceptions and experiences of the trial, including how well participants internalize and retain key messages provided through a continuous informed consent process, a random sub-sample of 102 women were invited to participate in in-depth interviews conducted immediately after their 4, 24 and 52 week follow-up visits. Results 99 women completed interviews at 4-weeks, 83 at 24-weeks, and 74 at 52 weeks. In all interviews there was evidence of good comprehension and retention of key trial messages including that the gel is not currently know to be effective against HIV; that this is the key reason for conducting the trial; and that women should stop using gel in the event of pregnancy. Conclusions Providing information to trial participants in a focussed, locally-appropriate manner, using methods developed in consultation with the community, and within a continuous informed-consent framework resulted in high levels of comprehension and message retention in this setting. This approach may represent a model for researchers conducting HIV prevention trials among other vulnerable populations in resource-poor settings. Trial registration Current Controlled Trials ISRCTN64716212. (shrink)

How to Pool Risks across Generations makes the case for the collective provision of pensions, on fair terms of social cooperation. Through the insurance of a mutual association which extends across society and over multiple generations, we share one another's fates by pooling risks across both space and time. Resources are transferred, not simply between different people, but also within the possible future lives of each person: from one's more fortunate to one's less fortunate future selves. The book opens with (...) an investigation of the longevity and investment risk that even a single individual on a desert island would face in providing for her old age. From this atomistic starting point, it builds up, within and across the chapters, to increasingly collective forms of pension provision. By joining together, it is possible to tame the risks we would face as individuals each with our own private pension pot. A collective pension can be justified as a 'social union of social unions': an enduring corporate body, which is formed by agreements to pool risks, in a manner that involves reciprocity between the various individuals that constitute the collective. Even though all individuals age and die, a collective pension scheme remains evergreen, as the average age of members remains relatively unchanged, through the influx of new members to replace those who retire. It is therefore possible to smooth risks indefinitely across as well as within generations, to the mutual advantage of each. (shrink)

The use of algorithmic prediction in insurance is regarded as the beginning of a new era, because it promises to personalise insurance policies and premiums on the basis of individual behaviour and level of risk. The core idea is that the price of the policy would no longer refer to the calculated uncertainty of a pool of policyholders, with the consequence that everyone would have to pay only for her real exposure to risk. For insurance, however, uncertainty is not only (...) a problem – shared uncertainty is a resource. The availability of individual risk information could undermine the principle of risk-pooling and risk-spreading on which insurance is based. The article examines this disruptive change first by exploring the possible consequences of the use of predictive algorithms to set insurance premiums. Will it endanger the principle of mutualisation of risks, producing new forms of discrimination and exclusion from coverage? In a second step, we analyse how the relationship between the insurer and the policyholder changes when the customer knows that the company has voluminous, and continuously updated, data about her real behaviour. (shrink)

The question of how the probabilistic opinions of different individuals should be aggregated to form a group opinion is controversial. But one assumption seems to be pretty much common ground: for a group of Bayesians, the representation of group opinion should itself be a unique probability distribution, 410–414, [45]; Bordley Management Science, 28, 1137–1148, [5]; Genest et al. The Annals of Statistics, 487–501, [21]; Genest and Zidek Statistical Science, 114–135, [23]; Mongin Journal of Economic Theory, 66, 313–351, [46]; Clemen and (...) Winkler Risk Analysis, 19, 187–203, [7]; Dietrich and List [14]; Herzberg Theory and Decision, 1–19, [28]). We argue that this assumption is not always in order. We show how to extend the canonical mathematical framework for pooling to cover pooling with imprecise probabilities by employing set-valued pooling functions and generalizing common pooling axioms accordingly. As a proof of concept, we then show that one IP construction satisfies a number of central pooling axioms that are not jointly satisfied by any of the standard pooling recipes on pain of triviality. Following Levi, 3–11, [39]), we also argue that IP models admit of a much better philosophical motivation as a model of rational consensus. (shrink)

We provide an overview of the characteristics of those who have gained insurance coverage due to the ACA as well as the characteristics of the remaining uninsured. We also describe the implications for the broader sharing of health care risks required under the law, and how they vary by individuals' health status. Finally, we assess the implications of state decisions to expand or not expand Medicaid eligibility under the law, how those decisions affect state finances, health care providers, residents, and (...) how the effects may vary for those states using waivers to expand eligibility using strategies designed to be more broadly politically acceptable. (shrink)

Are risk preferences stable over time? To address this question we elicit risk preferences from the same pool of subjects at two different moments in time. To interpret the results, we use a Fechner stochastic choice model in which the revealed preference of individuals is governed by some underlying preference, together with a random error. We take cumulative prospect theory as the underlying preference model (Kahneman and Tversky, Econometrica 47:263–292, 1979; Tversky and Kahneman, Journal of Risk and Uncertainty 5:297–323, 1992). (...) We observe that the aggregate pattern of preferences is very similar in both sessions, and it matches the results reported in the literature. Most subjects are risk averse for gains, and risk seeking for losses. However, the subjects that jointly agree with the reflection effect of prospect theory are around 50%. The percentage of individuals that change their responses across sessions is quite high, 63%. Estimating the stochastic choice model we find that 72% of the subjects have an underlying preference which agrees with the reflection effect of prospect theory. The remaining 28% are mainly classified as risk averse for both gains and losses. The results reinforce the empirical validity of the reflection effect. Deviations from the reflection effect can be attributed to noise, as well as to the existence of a fraction of risk averse subjects. (shrink)

101 real couples participated in a controlled experimental risk-taking task involving variations in household and individual income risks, while controlling for ex-ante income inequality. Our design disentangles the effects of household risk, intra-household risk inequality, and ex-post payoff inequality. We find that most couples (about 79%) pooled their risk at the household level when risks were borne symmetrically, but a significant proportion of couples (about 36%) failed to do so when individual risks were borne asymmetrically. Additionally, within the scope of (...) the control variables we have utilized, we find that intra-household risk inequality has a larger impact on non-married couples compared to married ones. These results remain robust when the analysis is limited to couples in which both spouses are risk-averse. Lastly, we find that preferences for household efficiency are significantly correlated across both certain and risky situations. However, couples consisting of two income-maximizing spouses do not show greater aversion to risk inequality compared to couples with other compositions. (shrink)

Algorithmic predictions are promising for insurance companies to develop personalized risk models for determining premiums. In this context, issues of fairness, discrimination, and social injustice might arise: Algorithms for estimating the risk based on personal data may be biased towards specific social groups, leading to systematic disadvantages for those groups. Personalized premiums may thus lead to discrimination and social injustice. It is well known from many application fields that such biases occur frequently and naturally when prediction models are applied to (...) people unless special efforts are made to avoid them. Insurance is no exception. In this paper, we provide a thorough analysis of algorithmic fairness in the case of insurance premiums. We ask what “fairness” might mean in this context and how the fairness of a premium system can be measured. For this, we apply the established fairness frameworks of the fair machine learning literature to the case of insurance premiums and show which of the existing fairness criteria can be applied to assess the fairness of insurance premiums. We argue that two of the often-discussed group fairness criteria, independence (also called statistical parity or demographic parity) and separation (also known as equalized odds), are not normatively appropriate for insurance premiums. Instead, we propose the sufficiency criterion (also known as well-calibration) as a morally defensible alternative that allows us to test for systematic biases in premiums towards certain groups based on the risk they bring to the pool. In addition, we clarify the connection between group fairness and different degrees of personalization. Our findings enable insurers to assess the fairness properties of their risk models, helping them avoid reputation damage resulting from potentially unfair and discriminatory premium systems. (shrink)

The AIDS crisis poses a special challenge for American health care, which depends heavily on private insurance to pay medical bills. Can we provide adequate health care to all who need it and still meet the financial requirements of the private health insurance industry? More insurance carriers are turning to antibody testing in order to eliminate poor risks from non‐group, direct‐pay pools. Some cost‐conscious employers have attempted to fire AIDS patients summarily or to exclude AIDS coverage from group insurance policies. (...) Various remedies are available for spreading the financial risks of the epidemic, such as covering persons with AIDS under Medicare or in state‐sponsored health insurance pools. Ethical questions about cost and access may also rekindle the debate about the need for national health insurance. (shrink)

Understanding the clinical significance of variants associated with hereditary cancer risk requires access to a pooled data resource or network of resources—a “cancer gene variant commons”—incorporating representative, well-characterized genetic data, metadata, and, for some purposes, pathways to case-level data. Several initiatives have invested significant resources into collecting and sharing cancer gene variant data, but further progress hinges on identifying and addressing unresolved policy issues. This commentary provides insights from a modified policy Delphi process involving experts from a range of stakeholder (...) groups involved in the data-sharing ecosystem. In particular, we describe policy issues and options generated by Delphi participants in five domains critical to the development of an effective cancer gene variant commons: incentives, financial sustainability, privacy and security, equity, and data quality. Our intention is to stimulate wider discussion and lay a foundation for further work evaluating policy options more in-depth and mapping them to those who have the power to bring about change. Addressing issues in these five domains will contribute to a cancer gene variant commons that supports better care for at-risk and affected patients, empowers patient communities, and advances research on hereditary cancers. (shrink)

ABSTRACT:Many ethicists argue that contract theory offers the most promising strategy for regulating risks. I challenge the adequacy of the contractualist approach for evaluating the complicated, novel risks associated with some structured financial products, particularly focusing on risks to third parties. Structured financial products like collateralized debt obligations (CDOs) divide a pool of financial assets into risk “tranches” organized from least to most risky. Investors purchase various tranches based on their individual risk-and-return preferences. Whereas contract theory holds that investment risks (...) are ethically permitted (roughly) when everyone—including both parties directly involved in the investments and third parties—consents to them, structured financial products like CDOs show that even risks to which everyone consents are ethically problematic when they involve systemic risks of ruin. (shrink)

Does asking about trauma history create participant distress? If so, how does it compare with reactions to other personal questions? Do participants consider trauma questions important compared to other personal questions? Using 2 undergraduate samples (Ns = 240 and 277), the authors compared participants' reactions to trauma questions with their reactions to other possibly invasive questions through a self-report survey. Trauma questions caused relatively minimal distress and were perceived as having greater importance and greater cost-benefit ratings compared to other kinds (...) of psychological research in an undergraduate human subjects pool population. These findings suggest that at least some kinds of trauma research appear to pose minimal risk when compared to other minimal risk research topics, and that participants recognize the importance of research about trauma. (shrink)

Generalisation, universal knowledge claims, and recommendations within disaster studies are problematic because they lead to miscommunication and the misapplication of actionable knowledge. The consequences and impacts thereof are not often considered by experts; forgone as irrelevant to the academic division of labour. There is a disconnect between expert assertions for disaster risk reduction (DRR) and their practical suitability for laypersons. Experts currently assert independently of the context within which protective action measures (PAMs) are to be used, measures unconnected to the (...) people for whom they are developed. This has knock-on effects for DRR: much expert-generated science and policy remains unused, unimplemented, and sometimes misapplied. I use philosophical accounts of assertion and epistemic blame to highlight the epistemic relationship between experts and laypersons. This relationship includes responsibilities and agreements between epistemic agents. Since multilevel DRR knowledge still transfers top-down from experts to laypersons, if experts impair the epistemic relationship, they can be held epistemically blameworthy. To address the pervasiveness of top-down systems, I analyse the epistemic framings and narratives currently shaping DRR, and more specifically PAMs and campaigns. I deconstruct universal perspectives that dominate the epistemic processes of generating, disseminating, and implementing DRR knowledge and specifically for co-seismic landslide PAMs for Nepal. I argue for more inclusive, contextual, and epistemically responsible DRR. Co-production of knowledge should begin from the standpoints of marginalised persons who may have an epistemic advantage due to their socio-politically marginalised positions. Often these epistemic contributions are left out of DRR efforts because marginalised persons are rarely afforded equal, if any, epistemic agency, which results in epistemic gaps and a large pool of relevant knowledge remaining unincorporated and unused in DRR research and policy. (shrink)

This paper performs a critical analysis of Irving Gottesman’s 1991 “Figure 10,” which lists the lifetime risks of developing schizophrenia among the relatives of people diagnosed with schizophrenia. Figure 10, which has been cited in numerous psychiatry and abnormal psychology textbooks, is almost always discussed in support of important genetic influences on schizophrenia. However, the pooled results in Figure 10 can also be explained by environmental factors. Moreover, the risk percentages Gottesman reported are derived from biased research designs, some of (...) which are based on implausible theoretical assumptions, while some results are not included. It is concluded that a closer look at the studies used to compile Figure 10 might lead psychiatrists, psychologists, and genetic researchers to decide that, in addition to problems in schizophrenia adoption research and the ongoing failure to find postulated “schizophrenia genes,” the evidence supporting a genetic basis for schizophrenia is far weaker than is currently believed. (shrink)

The objective of this research paper is to examine the impact of monetary policy conditions on bank risk-taking in the Western Balkan countries. The paper tries to identify if monetary policy conditions, especially money interest rates, may induce a greater appetite for bank risk-taking in the Western Balkan countries. The impact of macroeconomic and banking indicators on bank risk-taking will be examined, too. For this purpose, we apply pooled OLS techniques, Fixed and Random effects panel, and Hausman-Taylor Instrumental IV model. (...) The econometric results show a negative correlation between the monetary policy rate and bank risk-taking, rejecting the hypothesis that monetary policy rates indicate bank risk increase. However, expansive credit policies or loan portfolio growth have a positive impact on bank risk-taking in the Western Balkans. The study is original, and its findings will be of value to Central Banks and other policymakers in the Western Balkan countries. (shrink)

As schizotypal personality disorder increasingly prevails in the general population, a rapid and comprehensive measurement instrument is imperative to screen individuals at risk for SPD. To address this issue, we aimed to develop a computerized adaptive testing for SPD using a non-clinical Chinese sample, consisting of a calibration sample and a validation sample. The item pool of SPD was constructed from several widely used SPD scales and statistical analyses based on the item response theory via a calibration sample using a (...) graded response model. Finally, 90 items, which measured at least one symptom of diagnostic criteria of SPD in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and had local independence, good item fit, high slope, and no differential item functioning, composed the final item pool for the CAT-SPD. In addition, a simulated CAT was conducted in an independent validation sample to assess the performance of the CAT-SPD. Results showed that the CAT-SPD not only had acceptable reliability, validity, and predictive utility but also had shorter but efficient assessment of SPD which can save significant time and reduce the test burden of individuals with less information loss. (shrink)

Cultural comparisons enjoy increasing popularity in economics. Since cultural comparison must abandon random allocation to treatments, it is unclear whether differences found between countries can be attributed to country characteristics or are merely driven by differences in subject pools. In experiments in two Chinese cities and at two campuses in Ethiopia, we show that within-country differences are negligible. Differences between the two countries, on the other hand, are large.

What makes insurance special among risk technologies is the particular way in which it links solidarity and technical rationality. On one hand, within insurance practices ‘risk’ is always defined in technical terms. It is related to monetary measurement of value and to statistical probability calculated for a limited population. On the other hand, and at the same time, insurance has an inherent connection to solidarity. When taking out an insurance, one participates in the risk pool within which each member is (...) reciprocally responsible for others’ risks. The combination of technical controllability and solidarity has made insurance a successful tool for governing welfare societies during the twentieth century. From the point of view of business ethics, it is interesting that, as we argue in this article, the connection between insurance and solidarity is not limited to social welfare assemblages, but is evident in relation to private insurance as well. At the same time, however, it is important to understand that insurance does not advance all forms of solidarity. Hence, this theoretical article analyzes the specific conceptions of solidarity that the different forms of insurance practice produce. Particular emphasis is put on the distinction between ‘chance solidarity’ and ‘subsidizing solidarity’. The main questions of the article are: What kinds of conceptions of solidarity are built in the insurance technology? And how are the limits of solidarity defined and justified in different forms of insurance? (shrink)

Rawlsian justice as fairness is neither fundamentally luck egalitarian nor relational egalitarian. Rather, the most fundamental idea is that of society as a fair system of cooperation. Collective pensions provide a case study which illustrates the fruitfulness of conceiving justice in these latter terms. Those who have recently reached the age of majority do not now know how long they will live in retirement or how well any investments they try to save up for their retirement would fare. From the (...) perspective of the beginning of their working lives, it is therefore rational for each to enter into an agreement with others, who also do not yet know their fates, that, if one turns out to be among the unfortunate whose private pension pots would not have yielded enough for one’s retirement, one will receive much more in retirement, whereas those whose pension pots would have overflowed their retirements will receive somewhat less. These terms are to each person’s expected advantage, which is made possible by a fair sharing of the fruits of social cooperation which arise through the efficiencies reaped by the pooling of the risk of outliving what one could save for one’s retirement on one’s own. It is rational for each to agree to share one another’s fates by pooling risks across both space and time, on fair terms of social cooperation for mutual advantage. Even when collective pensions arise from, and are proportional to, a baseline of unequal income, they can be defended on grounds of reciprocity involving regard for one another as equals. (shrink)

No provision of the Patient Protection and Affordable Care Act has proven to be more contentious than the so-called “individual mandate.” Starting in 2014, the mandate will impose a penalty on non-exempt individuals who lack health insurance. According to Congress, the mandate is essential to ensuring near universal coverage. Without it, PPACA’s insurance reforms will lead healthy individuals to delay purchasing health insurance until they require medical care, resulting in risk pools with a disproportionate share of high-risk people. The price (...) of insurance will then climb, causing more and more not-so-sick people to forego health insurance. The resulting “death spiral” will make insurance unaffordable to many more Americans. (shrink)

Insurance is pervasive in many social settings. As a cooperative device based on risk pooling, it serves to attenuate the adverse consequences of various risks by offering policyholders coverage against the losses implied by adverse events in exchange for the payment of premiums. In the insurance industry, the concept of actuarial fairness serves to establish what could be adequate, fair premiums. Accordingly, premiums paid by policyholders should match as closely as possible their risk exposure. Such premiums are the product of (...) the probabilities of losses and the expected losses. This article presents a discussion of the fairness of actuarial fairness through three steps: defining the concept based on its formulation within the insurance industry; determining in which sense it may be about fairness; and raising some objections to the actual fairness of actuarial fairness. The necessity of a normative evaluation of actuarial fairness is justified by the influence of the concept on the current reforms of public insurance systems and the fact that it highlights the question of the repartition of the gains and burdens of social cooperation. (shrink)

Until recently, climate scientists were unable to link the occurrence of extreme weather events to anthropogenic climate change. In recent years, however, climate science has made considerable advancements, making it possible to assess the influence of anthropogenic climate change on single weather events. Using a new technique called ‘probabilistic event attribution’, scientists are able to assess whether anthropogenic climate change has changed the likelihood of the occurrence of a recorded extreme weather event. These advancements raise the expectation that this branch (...) of climate science can contribute to climate adaptation efforts. This paper examines the normative underpinnings of these policy discussions. To date, the debates revolve around whether the findings of attribution science can be used to establish moral liability for harms resulting from climate change. On close analysis, this normative framework has serious shortcomings. The paper rejects the moral liability framework and suggests, through a review of the international climate negotiations under the UNFCCC, that the science of event attribution can inform adaptation policy within a risk-pooling and climate risk insurance framework. The proposed framework is defended both on normative grounds and on the basis of its potential application within the Warsaw International Mechanism for Loss and Damage under the Cancun Adaptation Framework. (shrink)

This paper explores how the widely acknowledged conception of tort law as corrective justice is to be applied to the law of negligence. Corrective justice is an ordering of transactions between two parties which restores them to an antecedent equality. It is thus incompatible with the comprehensive aggregation of utilitarianism, and it stands in easy harmony with Kantian moral notions. This conception of negligence law excludes both maximizing theories, such as Holmes' and Posner's, and Fried's risk pool, which combines Kantianism (...) with distributive rather than corrective justice.Central to the Kantian approach is the impermissibility of self-preference. The two types of self-preference, self-preference in conception and self-preference in action can respectively account for the objective standard and the Learned Hand test, which are the two most characteristic features of negligence and which are generally (and wrongly) considered to be inescapably aggregative. This corrective justice conception of the negligence standard can then be compared to Epstein's corrective justice conception of strict liability, and arguments can be offered in favour of the superiority of the former. (shrink)

Many countries have imposed strict regulations on the genetic information to which insurers have access. Commentators have warned against the emerging body of legislation for different reasons. This paper demonstrates that, when confronted with the argument that genetic information should be available to insurers for health insurance underwriting purposes, one should avoid appeals to rights of genetic privacy and genetic ignorance. The principle of equality of opportunity may nevertheless warrant restrictions. A choice-based account of this principle implies that it is (...) unfair to hold people responsible for the consequences of the genetic lottery, since we have no choice in selecting our genotype or the expression of it. However appealing, this view does not take us all the way to an adequate justification of inaccessibility of genetic information. A contractarian account, suggesting that health is a condition of opportunity and that healthcare is an essential good, seems more promising. I conclude that if or when predictive medical tests (such as genetic tests) are developed with significant actuarial value, individuals have less reason to accept as fair institutions that limit access to healthcare on the grounds of risk status. Given the assumption that a division of risk pools in accordance with a rough estimate of people's level of (genetic) risk will occur, fairness and justice favour universal health insurance based on solidarity. (shrink)

This paper is a contribution to a symposium on Michael Otsuka’s book, How to Pool Risk Across Generations. Following Otsuka, one may distinguish three distinct systems of cooperation within a standard pension arrangement: the retirement system, the longevity risk pool and the investment risk pool. It is important to observe, however, that only the retirement system constitutes a genuine system of intergenerational cooperation, the other two are essentially intragenerational, in that they pool risks among members of a cohort. Otsuka is (...) faulted for being occasionally less than clear on these distinctions. (shrink)

The Oregon Health Plan gained national attention by changing the focus of health care from who is covered to what is covered. This change was facilitated by insurance reforms in the areas of small market, employer mandates, high risk pooling and Medicaid. Most controversial of the reforms is the use by the legislature of a prioritized list of health services to determine benefit levels for the insurance programs. Significant debate has occured over whether the use of such a list is (...) rationing or reasoning. The Oregon Health Plan represents a thoughtful and deliberate blending of fact with public value for the purpose of responsible health policy. It is that unique blending of public values developed through community participation with fact that focused the attention of the world on Oregon. Keywords: community participation, employer mandates, health care reform, prioritization, rationing, small market insurance reform CiteULike Connotea Del.icio.us What's this? (shrink)

A risk management approach to farm policy, emblematic of ongoing neoliberalization of domestic agricultural policy, favors the private sector and large-scale producers at the expense of small and mid-sized producers, taxpayers, and rural communities. During 2014, direct payments paid to agricultural producers were finally eliminated in favor of commodity programs that mimic crop insurance. At the same time, poverty rates across rural America remain higher than national averages and, in some places, continue to increase. Previous approaches to explaining rural poverty (...) highlight the social, economic, and political processes that contribute to poverty in rural communities, yet the political economy of agriculture has rarely been considered a determinant of rural poverty. This paper expands earlier work on agricultural policy and rural poverty by investigating the relationship between farm policy and rural poverty across rural counties in the American Midwest since 1995. By employing a pooled-time series approach and utilizing poverty, unemployment, commodity payment, crop insurance payment, and agricultural data, the findings demonstrate that the elimination of direct payments has further reduced potential of farm programs to ameliorate poverty in rural communities and in some places, is related to an increase in poverty. Overall, the end of direct payments had standardized poverty rates in these counties at rates higher than national averages suggesting that the deepening of risk management approaches to farm policy has serious implications for both producers and rural communities. (shrink)

The documented efficacy and long-term benefit of antidepressants in patients with recurrent forms of severe anxiety or depressive disorders support their use in those individuals with these disorders, who experience suicidal thoughts or behavior. In general, it is assumed that antidepressants are beneficial for all symptoms of depression, including suicidality. However, some evidence suggests that Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas in vulnerable patients. Systematic reviews and pooled analysis of experimental, observational, and epidemiological studies have (...) investigated the use of SSRIs and their association with suicidality. Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise. (shrink)

To better understand risk management and mutual aid among American ranchers, we interviewed and mailed a survey to ranchers in Hidalgo County, New Mexico, and Cochise County, Arizona, focusing on two questions: When do ranchers expect repayment for the help they provide others? What determines ranchers’ degrees of involvement in networks of mutual aid, which they refer to as “neighboring”? When needs arise due to unpredictable events, such as injuries, most ranchers reported not expecting to be paid back for the (...) help they provide. When help is provided for something that follows a known schedule or that can be scheduled, such as branding, most ranchers did expect something in return for the help they provide. This pattern makes sense in light of computational modeling that shows that transfers to those in need without expectations of repayment pool risk more effectively than transfers that create debt. Ranchers reported helping other ranchers more often when they belonged to more religious and civic organizations, when they owned larger ranches, when they relied less on ranch vs. other income, and when they had more relatives in the area. Operators of midsize ranches reported helping other ranchers more frequently than did those on smaller and larger ranches. None of our independent variables predicted how many times ranchers reported receiving help from other ranchers. Although ranch culture in the American West is often characterized by an ethic of individualism and independence, our study suggests that this ethic stands alongside an ethic of mutual aid during times of need. (shrink)

Anna J Dare,1 Anthony RJ Phillips,1–3 Michael Chu,1 Anthony JR Hickey,2 Adam SJR Bartlett1–31Department of Surgery, 2Maurice Wilkins Centre for Biodiscovery, University of Auckland, Auckland, New Zealand; 3New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New ZealandBackground: Hepatic steatosis is increasingly encountered among organ donors. Currently, there is no consensus guideline as to the type or degree of donor steatosis considered acceptable for liver transplantation, and little is known about local practices in this area. The aim of this survey (...) was to evaluate current clinical practices amongst liver transplant surgeons in Australia and New Zealand in the evaluation and use of steatotic donor livers in LT.Methods: An anonymous online twelve-question survey was emailed to all practicing LT surgeons in ANZ in January 2010.Results: The response rate was 83%. Estimated prevalence of steatosis in donor livers was between 40% and 60%. In determining suitability for LT, 90% of respondents reported rejecting organs with "severe" steatosis based on visual and palpation grounds alone. A total of 68% sought further histological assessment if the donor liver looked bad and there were risk factors for steatosis. The majority of respondents performed only one biopsy of the liver, using hematoxylin and eosin staining for fat assessment. There was wide variation in the upper limit of steatosis considered to be acceptable for LT. A total of 21% of respondents still considered microvesicular steatosis a risk factor for primary graft nonfunction.Conclusion: This survey highlights the significant variation in the appraisal and use of steatotic grafts by LT surgeons in ANZ. Accurate evaluation and judicious use of mild and moderately steatotic grafts is required if we are to utilize the available donor pool best.Keywords: liver transplantation, steatosis, fatty liver, organ donors. (shrink)

IntroductionInternet addiction is characterized by excessive and uncontrolled use of the internet affecting everyday life. Adolescents are the primary risk group for internet addiction. Data on internet addiction is lacking in Africa. Thus, this review aimed to determine the pooled prevalence of internet addiction and its associated factors among high school and university students in Africa.MethodsA comprehensive literature search was conducted using electronic databases to locate potential studies. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test (...) statistics and small-study effects were checked using Egger's statistical test at a 5% significance level. A sensitivity analysis was performed. A random-effects model was employed to estimate the pooled prevalence and associated factors of internet addiction among students. The primary outcome of measure of this review was the prevalence of internet addiction and the secondary outcome of measures are the factors associated with internet addiction.ResultsA total of 5,562 studies were identified among the five databases. Of these, 28 studies from 10 countries with 14,946 high school and university students were included in this review. The overall pooled prevalence of internet addiction among the students was 34.53% [95% Confidence Interval : 26.83, 42.23, I2 = 99.20%]. Male sex [Pooled Odds Ratio = 1.92, 95% CI:1.43, 2.57 I2 = 0.00], urban residence, and duration of daily internet use for more than 4 h (POR = 2.25, 95% CI:1.20, 4.21, I2 = 0.00%, were significantly associated with internet addiction among adolescents.ConclusionAlmost one-third of university and high school students in Africa are addicted to the internet. Male students, those from urban areas, and those who use the internet for more than 4 h per day have higher odds of internet addiction. Thus, we recommend that health planners and policymakers pay attention to the use of the internet and internet addiction in Africa. (shrink)

Nearly all psychological research on basic cognitive processes of category formation and reasoning uses sample populations associated with large research institutions in technologically-advanced societies. Lopsided attention to a select participant pool risks biasing interpretation, no matter how large the sample or how statistically reliable the results. The experiments in this article address this limitation. Earlier research with urban-USA children suggests that biological concepts are thoroughly enmeshed with their notions of naive psychology, and strikingly human-centered. Thus, if children are to develop (...) a causally appropriate model of biology, in which humans are seen as simply one animal among many, they must undergo fundamental conceptual change. Such change supposedly occurs between 7 and 10 years of age, when the human-centered view is discarded. The experiments reported here with Yukatek Maya speakers challenge the empirical generality and theoretical importance of these claims. Part 1 shows that young Maya children do not anthropocentrically interpret the biological world. The anthropocentric bias of American children appears to owe to a lack of cultural familiarity with non-human biological kinds, not to initial causal understanding of folkbiology as such. Part 2 shows that by age of 4-5 Yukatek Maya children employ a concept of innate species potential or underlying essence much as urban American children seem to, namely, as an inferential framework for understanding the affiliation of an organism to a biological species, and for projecting known and unknown biological properties to organisms in the face of uncertainty. Together, these experiments indicate that folkpsychology cannot be the initial source of folkbiology. They also underscore the possibility of a species-wide and domain-specific basis for acquiring knowledge about the living world that is constrained and modified but not caused or created by prior non-biological thinking and subsequent cultural experience. (shrink)

It is not uncommon for multiple clinical trials at the same institution to recruit concurrently from the same patient population. When the relevant pool of patients is limited, as it often is, trials essentially compete for participants. There is evidence that such a competition is a predictor of low study accrual, with increased competition tied to increased recruitment shortfalls. But there is no consensus on what steps, if any, institutions should take to approach this issue. In this article, we argue (...) that an institutional policy that prioritises some trials for recruitment ahead of others is ethically permissible and indeed prima facie preferable to alternative means of addressing recruitment competition. We motivate this view by appeal to the ethical importance of minimising the number of studies that begin but do not complete, thereby exposing their participants to unnecessary risks and burdens in the process. We then argue that a policy of prioritisation can be fair to relevant stakeholders, including participants, investigators and funders. Finally, by way of encouraging and helping to frame future debate, we propose some questions that would need to be addressed when identifying substantive ethical criteria for prioritising between studies. (shrink)

Over the years, companies have adopted hiring algorithms because they promise wider job candidate pools, lower recruitment costs and less human bias. Despite these promises, they also bring perils. Using them can inflict unintentional harms on individual human rights. These include the five human rights to work, equality and nondiscrimination, privacy, free expression and free association. Despite the human rights harms of hiring algorithms, the AI ethics literature has predominantly focused on abstract ethical principles. This is problematic for two reasons. (...) First, AI principles have been criticized for being vague and not actionable. Second, the use of vague ethical principles to discuss algorithmic risks does not provide any accountability. This lack of accountability creates an algorithmic accountability gap. Closing this gap is crucial because, without accountability, the use of hiring algorithms can lead to discrimination and unequal access to employment opportunities. This paper makes two contributions to the AI ethics literature. First, it frames the ethical risks of hiring algorithms using international human rights law as a universal standard for determining algorithmic accountability. Second, it evaluates four types of algorithmic impact assessments in terms of how effectively they address the five human rights of job applicants implicated in hiring algorithms. It determines which of the assessments can help companies audit their hiring algorithms and close the algorithmic accountability gap. (shrink)

This article explores the social benefits and moral arguments in favour of women and couples freezing eggs and embryos for social reasons. Social IVF promotes equal participation by women in employment; it offers women more time to choose a partner; it provides better opportunities for the child as it allows couples more time to become financially stable; it may reduce the risk of genetic and chromosomal abnormality; it allows women and couples to have another child if circumstances change; it offers (...) an option to women and children at risk of ovarian failure; it may increase the egg and embryo pool. There are strong arguments based on equal concern and respect for women which require that women have access to this new technology. Freezing eggs also avoids some of the moral objections associated with freezing embryos. (shrink)

Background Non-adherence to medication is associated with increased risk of relapse in patients with bipolar disorder. Objectives To validate patient-evaluated adherence to medication measured via smartphones against validated adherence questionnaire; and investigate characteristics for adherence to medication measured via smartphones. Methods Patients with BD evaluated adherence to medication daily for 6–9 months via smartphones. The Medication Adherence Rating Scale and the Rogers’ Empowerment questionnaires were filled out. The 17-item Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Functional (...) Assessment Short Test were clinically rated. Data were collected multiple times per patient. The present study represents exploratory pooled reanalyses of data collected as part of two randomised controlled trials. Findings During the study 90.50% of the days were evaluated as ‘medication taken’, 6.91% as ‘medication taken with changes’ and 2.59% as ‘medication not taken’. Adherence to medication measured via smartphones was valid compared with the MARS. Younger age and longer illness duration were significant predictors for non-adherence to medication. Decreased affective symptoms measured with smartphone-based patient-reported mood and clinical ratings as well as decreased empowerment were associated with non-adherence. Conclusions Smartphone-based monitoring of adherence to medication was valid compared with validated adherence questionnaire. Younger age and longer illness duration were predictors for non-adherence. Increased empowerment was associated with adherence. Clinical implications Using smartphones for empowerment of adherence using patient-reported measures may be helpful in everyday clinical settings. Trial registration number NCT01446406 and NCT02221336. (shrink)

Data platforms represent a new paradigm for carrying out health research. In the platform model, datasets are pooled for remote access and analysis, so novel insights for developing better stratified and/or personalised medicine approaches can be derived from their integration. If the integration of diverse datasets enables development of more accurate risk indicators, prognostic factors, or better treatments and interventions, this obviates the need for the sharing and reuse of data; and a platform-based approach is an appropriate model for facilitating (...) this. Platform-based approaches thus require new thinking about consent. Here we defend an approach to meeting this challenge within the data platform model, grounded in: the notion of ‘reasonable expectations’ for the reuse of data; Waldron’s account of ‘integrity’ as a heuristic for managing disagreement about the ethical permissibility of the approach; and the element of the social contract that emphasises the importance of public engagement in embedding new norms of research consistent with changing technological realities. While a social contract approach may sound appealing, however, it is incoherent in the context at hand. We defend a way forward guided by that part of the social contract which requires public approval for the proposal and argue that we have moral reasons to endorse a wider presumption of data reuse. However, we show that the relationship in question is not recognisably contractual and that the social contract approach is therefore misleading in this context. We conclude stating four requirements on which the legitimacy of our proposal rests. (shrink)

This article outlines and compares current and proposed global institutional mechanisms to increase equitable access to COVID-19 vaccines, focusing on their institutional and operational complementarities and overlaps. It specifically considers the World Health Organization's (WHO’s) COVAX (COVID-19 Vaccines Global Access) model as part of the Access to COVID-19 Tools Accelerator (ACT-A) initiative, the WHO’s COVID-19 Technology Access Pool (C-TAP) initiative, the proposed TRIPS (Trade-Related Aspects of Intellectual Property Agreement) intellectual property waiver and other proposed WHO and World Trade Organization technology (...) transfer proposals. We argue that while various individual mechanisms each have their specific individual merits—and in some cases weaknesses—overall, many of these current and proposed mechanisms could be highly complementary if used together to deliver equitable global access to vaccines. Nonetheless, we also argue that there are risks posed by the proliferation of proposals in this context, including the potential to disperse stakeholder attention or to delay decisive action. Therefore, we argue that there is now a clear need for concerted global multilateral action to recognise the complementarities of specific models and to provide a pathway for collaboration in attaining global equitable access to vaccines. The institutional infrastructure or proposals to achieve this amply exist at this point in time—but much greater cooperation from industry and clear, decisive and coordinated action from states and international organisations are urgently needed. (shrink)