This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision makers distribute (...) scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

One of the central debates within contemporary Anglo-American political philosophy concerns how to formulate an egalitarian theory of distributive justice which gives coherent expression to egalitarian convictions and withstands the most powerful anti-egalitarian objections. This book brings together many of the key contributions to that debate by some of the world’s leading political philosophers: Richard Arneson, G.A. Cohen, Ronald Dworkin, Thomas Nagel, Derek Parfit, John Rawls, T.M. Scanlon, and Larry Temkin.

A comprehensive study of the ethics of killing in cases in which the metaphysical or moral status of the individual killed is uncertain or controversial. Among those beings whose status is questionable or marginal in this way are human embryos and fetuses, newborn infants, animals, anencephalic infants, human beings with severe congenital and cognitive impairments, and human beings who have become severely demented or irreversibly comatose. In an effort to understand the moral status of these beings, this book develops and (...) defends distinctive accounts of the nature of personal identity, the evaluation of death, and the wrongness of killing. The central metaphysical claim of the book is that we are neither nonmaterial souls nor human organisms but are instead embodied minds. In ethical theory, one of the central claims is that the morality of killing is not unitary; rather, the principles that determine the morality of killing in marginal cases are different from those that govern the killing of persons who are self‐conscious and rational. Another important theme is that killing in marginal cases should be evaluated in terms of the impact it would have on the victim at the time rather than on the value of the victim's life as a whole. What primarily matters is how killing would affect that which would be rational for the victim to care about at the time of death. By appealing to various foundational claims about identity, death, and the morality of killing, this book yields novel conclusions about such issues as abortion, prenatal injury, infanticide, the killing of animals, the significance of brain death, the termination of life support in cases of persistent vegetative state, the use of anencephalic infants as sources of organs for transplantation, euthanasia, assisted suicide, and advance directives in cases of dementia. In particular, the book defends the moral permissibility of abortion, infanticide, and euthanasia in certain cases and argues that brain death is not the appropriate criterion of death either for a person or a human organism. (shrink)

This paper presents a case for allocating health care resources so as to maximise Quality Adjusted Life Years (QALYs). Throughout parallels are drawn with the grounds for adopting utilitarianism. QALYs are desirable because they are essential for human flourishing and goal-attainment. In conditions of scarcity the principle of QALY maximisation may involve unequal treatment of different groups of people; and it is argued that this is not objectionable. Doctors in their dealings with patients should not be continually consulting the principle (...) (though it can sometimes be useful); instead by following existing ethical codes more QALYs will be produced overall. In the formulation of policy, however, the principle should be applied in a thoroughgoing way and, if it is, it will not have some of the counterintuitive consequences it may have in interpersonal situations. (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)

According to Epicurus (1966a,b), neither death, nor anything that occurs later, can harm those who die, because people who die are not made to suffer as a result of either. In response, many philosophers (e.g., Nagel 1970, Feinberg 1984, and Pitcher 1984) have argued that Epicurus is wrong on both counts. They have defended the mortem thesis: death may harm those who die. They have also defended the post-mortem thesis: posthumous events may harm people who die. Their arguments for this (...) joint view are by now quite familiar, and there is no need to rehearse them here (for a summary, see Luper 2002). Instead, our topic is a third position, which carves out intermediate ground between the other two. The intermediate view takes the mortem thesis for granted, like the critics of Epicurus, but rejects the post-mortem thesis, like Epicurus himself. For Epicurus’ project—the attainment of ataraxia, or equanimity—the intermediate view is almost useless (we are not tranquil if we regard death as a tragedy whose peculiarity is that it frees us from the possibility of any further misfortune); however, it is far more plausible than Epicurus’ own position since it avoids his absurd claim that death cannot harm us, while retaining his view that events occurring while we are dead and gone cannot harm us. According to the proponent of the intermediate view, when we understand the harm death inflicts, we must reject the idea that events following death can be bad for us. The damage death itself does is so severe that people are not subject to harm by any subsequent events. Thus the intermediate view rests on the mortem thesis together with the immunity thesis: death leaves its victims immune from posthumous harm. (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)

Bioethics' traditional focus on clinical relationships and exotic technologies has led the field away from population health, health disparities, and issues of justice. The result: a myopic view that misses the institutional context in which clinical relationships operate and can overlook factors that affect health more broadly than do exotic technologies. A broader bioethics agenda would take up unresolved questions about the distribution of health and the development of fair policies that affect health distribution.

One way of evaluating health is in terms of its impact on well-being. It has been shown, however, that evaluating health this way runs into difficulties, since health and other aspects of well-being are not separable. At the same time, the practical implications of the inseparability problem remain unclear. This paper assesses these implications by considering the relations between theories, components, and indicators of well-being.

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)

Regarding the sinking lifeboat scenario involving several human beings and a dog, nearly everyone agrees that it is right to sacrifice the dog. I suggest that the best explanation for this considered judgment, an explanation that appears to time-relative interests, contains a key insight about prudential value. This insight, I argue, also provides perhaps the most promising reply to the future-like-ours argument, which is widely regarded as the strongest moral argument against abortion. Providing a solution to a longstanding puzzle in (...) value theory across species while illuminating the morality of abortion, the time-relative interest account proves worthy of sustained theoretical attention. (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)