Cost-Effectiveness Analysis and Disability Discrimination
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 be defended?
This paper got
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.
Ben Davies has a nice
reply paper [paywalled]
to this. We're mostly in agreement, though.
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.
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
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.
I always wanted to write a paper with such a title, as an homage to John
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.
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.
Quality of Life: Subjective or Objective?
Ravaud, Isabelle Ville and Serge Poiraudeau (eds.), Handicap et Qualité de Vie. GMsanté, 2010, 17–24.
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 debate.
There is even
a French translation!
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 resource allocation.
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 applications.