I’m Senior Lecturer in Practical Philosophy at Stockholm University and Senior Researcher at the Stockholm Centre for Healthcare Ethics (CHE). My research is in normative and applied ethics, especially bioethics and what is known as politics, philosophy, and economics (PPE). I’m particularly interested in priority setting in health care, demographic change and population aging, and moral relativism.
I talk about my work here and my academic background there.
Here you can look at my CV or contact me.
I’m currently working on an edited volume with Axel Gosseries on the ethics of age limits and age discrimination for Oxford University Press. No final decision on the title yet.
With Iwao Hirose, I’m also working on the second, expanded edition of The Ethics of Health Care Rationing (Routledge). The first edition was published in 2014, followed by a Japanese translation in 2017. You can wait for the second edition or buy the first one from Amazon or Book Depository.
The Value of Longevity. Politics, Philosophy & Economics 19 (2020), 229–247.
Longevity is valuable. Most of us would agree that it’s bad to die when you could go on living, and death’s badness has to do with the value your life would have if it continued. Most of us would also agree that it’s bad if life expectancy in a country is low, it’s bad if there is high infant mortality, and it’s bad if there is a wide mortality gap between different groups in a population. But how can we make such judgments more precise? How should we evaluate the harm of mortality in a population? Although philosophers have written a lot about the harm of death for individuals, very little work has been done on the harm of mortality for populations. In this paper, I take the first steps towards developing a theory of the harm of population mortality. Even these first steps, I argue, lead to surprising results.
Cost-Effectiveness Analysis and Disability Discrimination. In Adam Cureton and David Wasserman (eds.), The Oxford Handbook of Philosophy and Disability. Oxford University Press, 2020, 653–668. (Preprint)
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.
Catering for Responsibility: Brute Luck, Option Luck, and the Neutrality Objection to Luck Egalitarianism. Economics and Philosophy 35 (2019), 259–281.
The distinction between brute luck and option luck is fundamental for luck egalitarianism. Many luck egalitarians write as if it could be used to specify which outcomes people should be held responsible for. In this paper, I argue that the distinction can’t be used this way. In fact, luck egalitarians tend to rely instead on rough intuitive judgments about individual responsibility. This makes their view vulnerable to what’s known as the neutrality objection. I show that attempts to avoid this objection are unsuccessful. I conclude that until it provides a better account of attributing responsibility, luck egalitarianism remains incomplete.
Age, demography, and the global burden of disease
Age and Time in the Measurement of the Burden of Disease. In Nir Eyal, Samia A. Hurst, Christopher J. L. Murray, S. Andrew Schroeder, and Daniel Wikler (eds.), Measuring the Global Burden of Disease: Philosophical Dimensions. Oxford University Press, 2020, 257–270. (Preprint)
A basic principle of the Global Burden of Disease (GBD) studies is that all units of health loss have the same value. However, in earlier iterations of the GBD studies this principle had some qualifications. One was that the value of the same health loss may differ between individuals of different ages; that is, DALYs were age-weighted. Age-weighting has now been removed for ethical reasons. A year of healthy life has the same value regardless of the age of the person living it. Contrary to this claim, however, I argue that a form of implicit age-weighting is still implied by the GBD methodology. But I also argue that this kind of age-weighting can be defended on moral grounds.
Overpopulation and Procreative Liberty. Ethics Policy & Environment 22 (2019), 319–330.
The aim of this paper is to demonstrate that anti-natalist population policies need not involve the violation of procreative liberty and personal autonomy. To show this, I revive two radical proposals from the old debate on overpopulation. The first involves mandatory long-term contraception; the second involves the introduction of tradeable procreation entitlements. I show that contrary to what many people believe, these policies can be defended on the basis of broadly liberal principles. It turns out that they not only do not conflict with procreative liberty and personal autonomy, but they can actually increase liberty and promote autonomy.
Fair Innings. 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.
Age-Weighting. 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.
Equality, scarcity, and saving lives
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.
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 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.
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 rivals.
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.
Priority setting, disability, and the quality of life
Rethinking Patient Involvement in Healthcare Priority Setting. Co-written with Lars Sandman and Bjørn Hofmann. Bioethics 34 (2020), 403–411.
With healthcare systems under pressure from scarcity of resources and ever-increasing demand for services, difficult priority setting choices need to be made. At the same time, increased attention to patient involvement in a wide range of settings have given rise to the idea that those who are eventually affected by priority setting decisions should have a say in those decisions. In this paper, we investigate arguments for the inclusion of patient representatives in priority setting bodies at the policy level. We find that the standard justifications for patient representation, such as to achieve patient-relevant decisions, empowerment of patients, securing legitimacy of decisions, and the analogy to democracy, all fall short of supporting patient representation in this context. We conclude by briefly outlining an alternative proposal for patient participation that involves patient consultants.
The Mismarriage of Personal Responsibility and Health. Cambridge Quarterly of Healthcare Ethics 29 (2020), 196–204.
This paper begins with a simple illustration of the choice between individual and population strategies in population health policy. It describes the traditional approach on which the choice is to be made on the relative merits of the two strategies in each case. It continues by identifying two factors—our knowledge of the consequences of the epidemiological transition and the prevalence of responsibility-sensitive theories of distributive justice—that may distort our moral intuitions when we deliberate about the choice of appropriate risk-management strategies in population health. It argues that the confluence of these two factors may lead us to place too much emphasis on personal responsibility in health policy.
Fairness and the Puzzle of Disability. Theoria 84 (2018), 337–355.
Consider two cases. In Case 1, you must decide whether you save the life of a disabled person or you save the life of a person with no disability. In Case 2, you must decide whether you save the life of a disabled person who would remain disabled, or you save the life of another disabled person who, in contrast, would also be cured as a result of your intervention. It seems that most people agree that you should give equal chances in Case 1: saving the life of the person with no disability would be unfair discrimination against the person with disability. Yet, in Case 2, it appears that many people believe that you are at least permitted to save straightaway the person who would have no disability after your intervention. There would be no unfair discrimination against the other person. I argue that these judgments present a puzzle for theories of resource allocation in normative ethics. The puzzle is straightforward for consequentialists: the two cases have the same outcomes, but the judgments are different. But the puzzle also presents a problem for nonconsequentialist views. After introducing the cases, I show this by reviewing a number of proposals for solving the puzzle. I argue that none of these proposals are successful. I then make my own proposal and conclude by spelling out its implications.
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?
Priority Setting and Age. In Eckhard Nagel and Michael Lauerer (eds.), Prioritization in Medicine: An International Dialogue. Springer, 2016, 163–177.
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.
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.
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.
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.
Authentic Happiness. 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.
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.
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.