Cost-Effectiveness Analysis and Disability
Forthcoming in Adam Cureton and David Wasserman (eds.), The Oxford Handbook of Philosophy and
Cost-effectiveness analysis (CEA) is an analytical tool in health economics. One of
the most important objections to it is that its use can lead to unjust discrimination against people with
disabilities. In this paper, I evaluate this objection. I argue that the standard examples of disability
discrimination are based on misunderstandings of CEA. However, I do point out that there is one case in
which the use of CEA may disadvantage people with disabilities. I go on to consider several proposals for
explaining the wrongness of discrimination, but I find that none of them accommodates this case.
Forthcoming in Hugh LaFollette (ed.), The International Encyclopedia of Ethics, 2nd edition.
It is often said that economics is the science of scarcity. But since a lot of
economics is just applied ethics, it is perhaps more apt to say the real science of scarcity is ethics. I
show this by considering a number of issues in ethics, from resource allocation to self-control, where
scarcity plays a major role.
Priority Setting and Age
In Eckhard Nagel and Michael Lauerer (eds.), Prioritization in Medicine: An International Dialogue. Springer,
The role of age in priority setting is one of the most controversial issues in health
policy. It has also been a contentious topic for many years in medical ethics and philosophy, and any
discussion of age as a criterion for setting priorities in health care is likely to stir up intense public
debate. In this paper, I provide an overview of the range of ideas that have been used to defend the
relevance of age.
Is Disability Mere Difference?
Journal of Medical Ethics 42 (2016), 46–49.
Some philosophers and disability advocates argue that disability is not bad for you.
Rather than treated as a harm, it should be considered and even celebrated as just another manifestation of
human diversity. Disability is mere difference. To most of us, these are extraordinary claims. Can they
Bioethics 29 (2015), 251–261.
In many societies, the aging of the population is becoming a major public policy
problem. On what is known as the fair innings view, it is not impermissible to give lower priority
to policies that primarily benefit the elderly. Philosophers have tried to justify this view on various
grounds. In this paper, I argue that all of these justifications have implausible implications. I end by
outlining a different kind of justification that avoids those implications and corresponds better to our
considered moral judgments.
QALYs, DALYs, and Their Critics
In John D. Arras, Elizabeth Fenton, and Rebecca Kukla (eds.), The Routledge Companion to Bioethics.
Routledge, 2015, 44–55.
This paper provides an introduction to evaluative measures of health,
including quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs).
It also discusses some of the ethical issues that arise for their application.
Empirical and Armchair Ethics
Utilitas 24 (2012), 467–482.
In a recent paper, Michael Otsuka and Alex Voorhoeve present a novel argument against
prioritarianism ["Why It Matters that Some are Worse Off than Others: An Argument against the Priority
View," Philosophy and Public Affairs 37 (2009), 171–199]. The argument takes its starting point
from empirical surveys on people's preferences in health care resource allocation problems. In this
article, I first question whether the empirical findings support their argument, and then I make some
general points about the use of "empirical ethics" in ethical theory.
Enhancement and Equality
Ethical Perspectives 19 (2012), 11–32.
Opponents of genetic enhancement technologies often argue that the pursuit of these
technologies will lead to self-defeating collective outcomes, massive social inequalities, or other forms of
collective harm. They assume that these harms will outweigh individual benefits. Defenders of genetic
enhancement technologies counter that individual benefits will outweigh collective harms and there will be
no conflict between individual and collective interests. The present contribution tries to advance the
debate by providing a more detailed discussion of the conditions under which individual and collective
interests may conflict. It presents a simple model that clarifies the conditions in which the use of genetic
enhancement technologies may lead to self-defeating collective outcomes and social inequalities. It argues
that given current inequalities, these conditions might indeed obtain as new genetic knowledge leads to a
transition in population health. If they do, then genetic enhancement will steepen the social gradient in
health. Thus, regulating access to enhancement technologies should be a matter of social justice.
Can the Maximin Principle Serve as a Basis for Climate Change
The Monist 94 (2011), 329–348.
The precautionary approach has been widely considered reasonable for many issues in
environmental policy, including climate change. It has also been recognized, however, that standard
formulations of the precautionary principle suffer from many difficulties. An influential strategy to avoid
these difficulties is to formulate a narrow version of the principle on the basis of the maximin rule. Rawls
proposed that following the maximin rule can be rational under certain conditions. Defenders of this
strategy argue that these conditions are approximated when it comes to issues like climate change. In the
first part of this paper, I argue that the Rawlsian conditions do not establish the unique rationality of
the maximin rule, hence the precautionary principle cannot be defended on its basis. When the Rawlsian
conditions are approximated, other principles can also lead to reasonable choices. In particular, a
prioritarian principle can capture the precautionary approach and serve a useful role in climate change
policy. I develop this proposal in the second part.
Impartiality and Disability Discrimination
Kennedy Institute of Ethics Journal 21 (2011), 1–23.
Cost-effectiveness analysis is the standard analytical tool for evaluating the
aggregate health benefits of treatments and health programs. According to a common objection, however, its
use may lead to unfair discrimination against people with disabilities. Since the disability discrimination
objection is seldom articulated in a precise way, I first provide a formulation that avoids some implausible
implications. Then I turn to the standard defense of cost-effectiveness analysis and argue that it does not
succeed. But this does not settle the question of whether the use of cost-effectiveness analysis leads to
unfair discrimination. Rather, it shows that the controversy should be approached in a different
Does Cost Effectiveness Analysis Unfairly
Discriminate Against People with Disabilities?
Journal of Applied Philosophy 27 (2010), 394–408.
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.
Saving Lives and Respecting Persons
Co-written with Samuel J. Kerstein.
Journal of Ethics & Social Philosophy 5 (2010), 1–20.
In the distribution of resources, persons must be respected, or so many philosophers
contend. Unfortunately, they often leave it unclear why a certain allocation would respect persons, while
another would not. In this paper, we explore what it means to respect persons in the distribution of
scarce, life-saving resources. We begin by presenting two kinds of cases. In different age cases, we have
a drug that we must use either to save a young person who would live for many more years or an old person
who would only live for a few. In different numbers cases, we must save either one person or many persons
from certain death. We argue that two familiar accounts of respect for persons—an equal worth account,
suggested by Jeff McMahan, and a Kantian account, inspired by the Formula of Humanity—have implausible
implications in such cases. We develop a new, "three-tiered" account: one that, we claim, generates results
in such cases that accord better with many people's considered judgments than those produced by its
Utilitas 22 (2010), 272–284.
This article discusses L. W. Sumner's theory of well-being as authentic happiness. I
distinguish between extreme and moderate versions of subjectivism and argue that Sumner's characterization
of the conditions of authenticity leads him to an extreme subjective theory. More generally, I also
criticize Sumner's argument for the subjectivity of welfare. I conclude by addressing some of the
implications of my arguments for theories of well-being in philosophy and welfare measurement in the social
Complete Lives in the Balance
Co-written with Samuel J. Kerstein.
The American Journal of Bioethics 10 (2010), 37–45.
The allocation of scarce health care resources such as flu treatment or organs for
transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently
proposed a novel system for such allocation. Their "complete lives system" incorporates several principles,
including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to
persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations.
Persad and colleagues' defense of giving priority to those between 15 and 40 leaves them open to the charge
that they discriminate unfairly against children. Second, the paper contends that the complete lives system
fails to provide meaningful practical guidance in central cases, since it contains no method for balancing
its principles when they conflict. Finally, the paper proposes a new method for balancing principles of
saving the most lives and maximizing life-years.
Quality of Life: Subjective or Objective?
In Jean-François Ravaud, Isabelle Ville and Serge Poiraudeau (eds.), Handicap et Qualité de Vie.
GMsanté, 2010, 17–24. [French translation]
In the last several decades, quality of life research has become an extensive and
diverse field. Governments, public policy institutes and other organizations have developed various indexes
to measure the quality of life. But there remain unsettled issues and deep disagreements between
researchers. Perhaps the most important debate concerns the use of objective and subjective indicators of
quality of life. This paper attempts to sort out the various ambiguities and misunderstandings in the
Welfare Judgments and Risk
In Lotte Asveld and Sabine Roeser (eds.), The Ethics of Technological Risk. Earthscan, 2009, 144–160.
This paper begins by distinguishing between theories of welfare and models of welfare
judgments. Then it introduces the ideal advisor model of welfare judgments: on this model, welfare judgments
are made by appealing to what a person, were she fully informed and ideally rational, would prefer. I argue
that this model is often implicit in discussions of well-being and our ordinary practice of making welfare
judgments. I go on to develop an argument against the model, showing that it needs to be amended, at least
for a certain class of welfare judgments. The amendment takes the form of a substantive account of
reasonable and unreasonable risks.
Economics and Philosophy 24 (2008), 167–189.
Some empirical findings seem to show that people value health benefits differently
depending on the age of the beneficiary. Health economists and philosophers have offered justifications for
these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent
examples of both sorts of justification: the defence of age-weighting in the WHO’s global burden of disease
studies and the fair innings argument. I argue that neither sort of justification has been worked out in
satisfactory form: age should not be taken into account in the framework of the burden of disease measure,
and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator
of some other factor. I conclude by describing the role of age in theories of justice of healthcare
Well-Being and Health
Health Care Analysis 16 (2008), 97–113.
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 Concept of Quality of Life
Social Theory & Practice 31 (2005), 561–580.
Quality of life research aims to develop and apply indices for the measurement of
human welfare. It is an increasingly important field within the social sciences and its results are an
important resource for policy making and evaluation. This paper explores the conceptual background of
quality of life research. It focuses on its single most important issue: the controversy between the use of
"objective social indicators" and the use of people's "subjective evaluations" as proxies for welfare. Most
quality of life researchers today argue that people's own evaluations have an indispensable role in quality
of life measurement. I argue that their position must be defended on philosophical grounds, because their
use of evaluations commits them to some particular theories of welfare. I explore the connections between
theories of welfare in philosophy and the use of evaluations in quality of life research. I conclude that
even though evaluations may have a role in particular applications, they are unlikely to have a role in all