Alex Voorhoeve

I outline and defend two egalitarian theories, which yield distinctive and, I argue, complementary answers to why health-related inequalities matter: a brute luck egalitarian view, according to which inequalities due to unchosen, differential luck are bad because unfair, and a social egalitarian view, according to which inequalities are bad when and because they undermine people’s status as equal citizens. These views identify different objects of egalitarian concern: the brute luck egalitarian view directs attention to health-related well-being, while social egalitarianism focuses on health-related capabilities that are central to a person’s status as a citizen. I argue that both views are correct and should jointly guide priority-setting in health.

Progress towards Universal Health Coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the WHO Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases and how should one adjudicate between them when their demands conflict? This paper by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three principal dimensions of progress towards UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to pre-payment with pooling of funds. Our cases are simplified to highlight common trade-offs. While we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for the worse off, and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

This article criticises one of Stuart Rachels' and Larry Temkin's arguments against the transitivity of 'better than'. This argument invokes our intuitions about our preferences of different bundles of pleasurable or painful experiences of varying intensity and duration, which, it is argued, will typically be intransitive. This article defends the transitivity of 'better than' by showing that Rachels and Temkin are mistaken to suppose that preferences satisfying their assumptions must be intransitive. It makes cler where the argument goes wrong by showing that it is a version of Zeno's paradox of Achilles and the Tortoise.

I critically examine a common liberal egalitarian view about the justification for, and proper content of, mandatory health insurance. This view holds that a mandate is justified because it is the best way to ensure that those in poor health gain health insurance on equitable terms. It also holds that a government should mandate what a representative prudent individual would purchase for themselves if they were placed in fair conditions of choice. I argue that this common justification for a mandate is incomplete. A further reason for mandated insurance is that it helps secure social egalitarian public goods that would be underprovided if insurance were optional. I also argue that rather than mandating what a representative individual would choose for themselves, we should design the mandatory package by appealing to a pluralistic egalitarian view, which cares about improving people’s well-being, reducing unfair inequality, and maintaining egalitarian social relations.

Common principles for resource allocation in health care can prioritize the alleviation of small health burdens over lifesaving treatment. I argue that there is some evidence that these principles are at odds with a sizable share of public opinion, which holds that saving a life should take priority over any number of cures for minor ailments. I propose two possible explanations for this opinion, one debunking and one vindicatory. I also outline how well-designed surveys and moral inquiry could help decide between them. Finally, I consider how priority-setting principles could be adjusted if the view that saving a life always trumps alleviating small burdens were vindicated.

When people must either save a greater number of people from a smaller harm or a smaller number from a greater harm, do their choices reflect a reasonable moral outlook? We pursue this question with the help of an experiment. In our experiment, two-fifths of subjects employ a similarity heuristic. When alternatives appear dissimilar in terms of the number saved but similar in terms of the magnitude of harm prevented, this heuristic mandates saving the greater number. In our experiment, this leads to choices that are inconsistent with all standard theories of justice. We argue that this demonstrates the untrustworthiness of distributive judgments in cases that elicit similarity-based choice.

In 'Rethinking the Good', Larry Temkin makes two core claims. First, the goodness of a distribution is sometimes ‘essentially comparative’ – it sometimes depends on which alternative distribution(s) it is compared to. Second, such cases threaten the transitivity of ‘all things considered better than’. I argue that the goodness of a distribution may indeed depend on what other distributions are feasible. But contrary to Temkin, I also argue that transitivity holds even when the goodness of a distribution depends on the feasible set of which it is a member.

The political and philosophical problems John Rawls set out to solve arise out of the identity and conflicts of interests between citizens. There is identity of interests because social cooperation makes possible for everyone a life that is much better than one outside of society. There is a conflict of interests because people all prefer a larger to a smaller share of the benefits of social cooperation, and people have ideological differences. The problem a theory of justice has to solve is how, in the face of these conflicts, effective social cooperation can come about on terms that are justifiable to all.

Can we trust our intuitive judgments of right and wrong? Are moral judgements objective? What reason do we have to do what is right and avoid doing what is wrong? In Conversations on Ethics, Alex Voorhoeve elicits answers to these questions from eleven outstanding philosophers and social scientists: -/- Ken Binmore; Philippa Foot; Harry Frankfurt; Allan Gibbard; Daniel Kahneman; Frances Kamm; Alasdair MacIntyre; T. M. Scanlon; Peter Singer; David Velleman; Bernard Williams. -/- The exchanges are direct, open, and sharp, and give a clear account of these thinkers' core ideas about ethics. They also provide unique insights into their intellectual development - how they became interested in ethics, and how they conceived the ideas for which they became famous. Conversations on Ethics will engage anyone interested in moral philosophy.

We analyse three moral dilemmas involving resource allocation in care for HIV-positive patients. Ole Norheim and Kjell Arne Johansson have argued that these cases reveal a tension between egalitarian concerns and concerns for better population health. We argue, by contrast, that these cases reveal a tension between, on the one hand, a concern for equal *chances*, and, on the other hand, both a concern for better health and an egalitarian concern for equal *outcomes*. We conclude that, in these cases, there is much less tension than Norheim and Johansson claim between egalitarian concerns and concerns for better population health.

Policy-makers must sometimes choose between an alternative which has somewhat lower expected value for each person, but which will substantially improve the outcomes of the worst off, or an alternative which has somewhat higher expected value for each person, but which will leave those who end up worst off substantially less well off. The popular ex ante Pareto principle requires the choice of the alternative with higher expected utility for each. We argue that ex ante Pareto ought to be rejected because it conflicts with the requirement that, when possible, one ought to decide as one would with full information. We apply our argument in an analysis of US policy on screening for breast cancer. -/- .