The Ethics of Health Care Rationing, our book
with Iwao Hirose, was published by Routledge in 2014. It has been used
as a textbook at Harvard University, McGill University, UCL, LSE, La Trobe University, the University of Maryland,
Stockholm University, and the University of Aarhus. (If you have used it at other places, please let me know.)
From the publisher's website:
The rationing of health care is universal and inevitable, taking place in poor and affluent countries,
in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst
aging populations severely stretch the availability of resources.
The Ethics of Health Care Rationing is a clear and much-needed introduction to this
increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation,
scarcity and rationing of health care.
Buy this book at once from Routledge,
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 be
This paper got
Bioethics 29 (2015), 251–261.
In many societies, the aging of the population is becoming a major problem. It
raises difficult issues for ethics and public policy. 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 look at a consequentialist, a fairness-based, and a contractarian
justification. I argue that all of them have implausible implications and fail to correspond to our moral intuitions.
I end by outlining a different kind of consequentialist justification that avoids those implications and corresponds
better to our considered moral judgments.
Ben Davies has a nice
reply paper [paywalled]
to this. We're mostly in agreement, though.
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.
A colleague once told me this paper is widely considered to
have refuted the Otsuka-Voorhoeve argument. I wish she was right…
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.
The stuff about monarchs and oranges is still one of my favorite social
Can the Maximin Principle Serve
as a Basis for Climate Change Policy?
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 way. Thus, I conclude by outlining an alternative strategy for
answering the question.
This paper and the next got me a couple of paragraphs in the
Stanford Encyclopedia of Philosophy. However,
I don't think I actually defended the view that is attributed to me…
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
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 sciences.
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.
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 resource allocation.
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 applications.