Though the revised edition of A Theory of Justice, published in 1999, is the definitive statement of Rawls's view, so much of the extensive literature on Rawls's theory refers to the first edition. This reissue makes the first edition once again available for scholars and serious students of Rawls's work.

Suppose that you must make choices that may influence the well-being and the identities of the people who will exist, though not the number of people who will exist. How ought you to choose? This paper answers this question. It argues that the currency of distributive ethics in such cases is a combination of an individual’s final well-being and her expected well-being conditional on her existence. It also argues that this currency should be distributed in an egalitarian, rather than a (...) prioritarian, manner. (shrink)

The available resources for global health assistance are far outstripped by need. In the face of such scarcity, many people endorse a principle according to which highest priority should be given to the worst off. However, in order for this prioritarian principle to be useful for allocation decisions, policy-makers need to know what it means to be badly off. In this article, we outline a conception of disadvantage suitable for identifying the worst off for the purpose of making health resource (...) allocation decisions. According to our total advantage view: the worst off are those who have the greatest total lifetime disadvantage; advantage foregone due to premature death should be treated in the same way as other ways of being disadvantaged at a time; how badly off someone is depends on the actual outcomes that will befall her without intervention, not her prospects at a time; and all significant forms of disadvantage count for determining who is worst off, not just disadvantage relating to health. We conclude by noting two important implications of the total advantage view: first, that those who die young are among the globally worst off, and second, that the epidemiological shift in the global burden of disease from communicable to non-communicable diseases should not lead to a corresponding shift in global health spending priorities. (shrink)

Disability rights activists often claim that disability is not—by itself—something that makes disabled people worse off. A popular objection to such a view of disability is this: were it correct, it would make it permissible to cause disability and impermissible to cause nondisability. The aim of this article is to show that these twin objections don’t succeed.

In this article, I first compare positions I have taken in the past and those taken by Peter Singer on how the allocation of life-saving resources should be affected by the aggregation of expected quality of life, quantity of life, and need, both within the life of a person and across persons . I then reexamine the specific issue of whether and why differences in expected years of life and quality of life that a scarce resource can provide a disabled (...) and a nondisabled person should affect our allocation decisions. I attend to how the use of the veil of ignorance bears on this issue and also how the conclusions I reach differ in certain ways from my past positions. (shrink)

This study uses techniques from economics to illuminate fundamental questions in ethics, particularly in the foundations of utilitarianism. Topics considered include the nature of teleological ethics, the foundations of decision theory, the value of equality and the moral significance of a person's continuing identity through time.

Many believe that we ought to save a large number from being permanently bedridden rather than save one from death. Many also believe that we ought to save one from death rather than a multitude from a very minor harm, no matter how large this multitude. I argue that a principle I call “Aggregate Relevant Claims” satisfactorily explains these judgments. I offer a rationale for this principle and defend it against objections.

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

abstract In this paper I develop a characterization of disability according to which disability is in no way a sub-optimal feature. I argue, however, that this conception of disability is compatible with the idea that having a disability is, at least in a restricted sense, a harm. I then go on to argue that construing disability in this way avoids many of the common objections levelled at accounts which claim that disability is not a negative feature.

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)

University of Alberta Forthcoming in Utilias Consider Lives for Headaches: there is some number of headaches such that the relief of those headaches is sufficient to outweigh the good life of an innocent person. Lives for Headaches is unintuitive, but difficult to deny. The argument leading to Lives for Headaches is valid, and appears to be constructed out of firmly entrenched premises. In this paper, I advocate one way to reject Lives for Headaches; I defend a form of lexical superiority (...) between values. Based on an inquiry into the notion of human well-being, I argue that no amount of headaches is sufficient to outweigh the disvalue of the loss of a good life. Though this view has been thought subject to devastating objections, these objections are not dispositive against the form of value superiority I advance here. (shrink)

In "Futurc Generations: Further Problems,"‘ and Part Four of Reasons and Persons} Derek Pariit raises many perplexing questions. Although some think his ingenious arguments little more than delightful puzzles, I believe they challenge some of our deepest beliefs. In this article, I examine some of Pariit’s arguments, focusing mainly on "The Mere Addition Paradox." If my analysis is correct, Parfit’s arguments have extremely interesting and important implications that not even Pariit rcalized. In Part I, I present ParHt’s argument for the (...) Merc Addition Paradox, and show that given Pa.rHt’s assumptions, a radical conclusion seems t0 follow; the notion of "bctter th2m"—indced, even the notion of "aH things.. (shrink)

The standard argument for the claim that rational preferences are transitive is the pragmatic money-pump argument. However, a money-pump only exploits agents with cyclic strict preferences. In order to pump agents who violate transitivity but without a cycle of strict preferences, one needs to somehow induce such a cycle. Methods for inducing cycles of strict preferences from non-cyclic violations of transitivity have been proposed in the literature, based either on offering the agent small monetary transaction premiums or on multi-dimensional preferences. (...) This paper argues that previous proposals have been flawed and presents a new approach based on the dominance principle. (shrink)

In slogan form, the thesis of this dissertation is that shaping the far future is overwhelmingly important. More precisely, I argue that: Main Thesis: From a global perspective, what matters most is that we do what is best for the general trajectory along which our descendants develop over the coming millions, billions, and trillions of years. The first chapter introduces some key concepts, clarifies the main thesis, and outlines what follows in later chapters. Some of the key concepts include: existential (...) risk, the world's development trajectory, proximate benefits and ripple effects, speeding up development, trajectory changes, and the distinction between broad and targeted attempts to shape the far future. The second chapter is a defense of some methodological assumptions for developing normative theories which makes my thesis more plausible. In the third chapter, I introduce and begin to defend some key empirical and normative assumptions which, if true, strongly support my main thesis. In the fourth and fifth chapters, I argue against two of the strongest objections to my arguments. These objections come from population ethics, and are based on Person-Affecting Views and views according to which additional lives have diminishing marginal value. I argue that these views face extreme difficulties and cannot plausibly be used to rebut my arguments. In the sixth and seventh chapters, I discuss a decision-theoretic paradox which is relevant to my arguments. The simplest plausible theoretical assumptions which support my main thesis imply a view I call fanaticism, according to which any non-zero probability of an infinitely good outcome, no matter how small, is better than any probability of a finitely good outcome. I argue that denying fanaticism is inconsistent with other normative principles that seem very obvious, so that we are faced with a paradox. I have no solution to the paradox; I instead argue that we should continue to use our inconsistent principles, but we should use them tastefully. We should do this because, currently, we know of no consistent set of principles which does better. (shrink)

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I also discuss (...) some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title. (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)

Suppose that a very large number of people, say one billion, will suffer a moderately severe headache for the next twenty-four hours. For these billion people, the next twenty-four hours will be fairly unpleasant, though by no means unbearable. However, there will be no side-effects from these headaches; no drop in productivity in the work-place, no lapses in concentration leading to accidents, no unkind words spoken to loved ones that will later fester. Nonetheless, it is clearly desirable that these billion (...) people avoid the headaches. Even though the headaches are moderate, they are impervious to pain-killing drugs, acupuncture, transcendental meditation, and just about any other remedy. In fact, there is only one way in which the headaches can be avoided. In a remote South American village, a young woman, Agnes, is suffering from a fever. A simple dose of antibiotics will save her life, otherwise she will die. If, and only if, she dies, the billion headaches will be prevented. You just happen to be passing through the village, in full knowledge of the circumstances. Although not a doctor (and therefore not bound by codes of professional ethics, Hippocratic oaths, etc.), you possess the requisite dose of antibiotics, for which you have no other use, and which will become useless, if not used in the next two hours. (shrink)

This paper discusses the attempt in this issue of the journal by Peter Singer, John McKie, Helga Kuhse and Jeff Richardson, to defend QALYs against the argument from double jeopardy which I first outlined in 1987. In showing how the QALY and other similar measures which combine life expectancy and quality of life and use these to justify particular allocations of health care resource, remain vulnerable to the charge of double jeopardy I am able to clarify some of the central (...) issues concerning the value of life. In particular, the idea that the value of a life varies with its life expectancy and with its quality, understood in terms of its richness, variety, success etc, is subjected to special examination. It is shown how defenders of QALYs are committed to the view that so far from all lives being of equal value, all lives are necessarily of subtly different value. The paper then analyses the use to which the notorious 'veil of ignorance' has been put both by Singer et al and by others and shows how this device of John Rawls's cannot do the work so often assigned to it. The paper then considers the issue of hypothetical consent and the role that it can play in justifying disposing of the lives of people who have not in fact consented to their lives being disposed of in particular ways. Finally, the paper makes some points about the comprehensive nature of the data collection and storage which would be required by QALY advocates and points out the independent problems attaching to licensing such comprehensive collection and use of personal data. (shrink)

This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.