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.

Experimental results on the Ellsberg paradox typically reveal behavior that is commonly interpreted as ambiguity aversion. The experiments reported in the current paper find the objective probabilities for drawing a red ball that make subjects indifferent between various risky and uncertain Ellsberg bets. They allow us to examine the predictive power of alternative principles of choice under uncertainty, including the objective maximin and Hurwicz criteria, the sure-thing principle, and the principle of insufficient reason. Contrary to our expectations, the principle of insufficient reason performed substantially better than rival theories in our experiment, with ambiguity aversion appearing only as a secondary phenomenon.

La cobertura universal de salud está en el centro de la acción actual para fortalecer los sistemas de salud y mejorar el nivel y la distribución de la salud y los servicios de salud. Este documento es el informe fi nal del Grupo Consultivo de la OMS sobre la Equidad y Cobertura Universal de Salud. Aquí se abordan los temas clave de la justicia (fairness) y la equidad que surgen en el camino hacia la cobertura universal de salud. Por lo tanto, el informe es pertinente para cada agente que infl uye en ese camino y en particular para los gobiernos, ya que se encargan de supervisar y guiar el progreso hacia la cobertura universal de salud.

I argue that Scanlon's Value of Choice View does not offer a plausible account of substantive responsibility. I offer a new account, which I call the Potential Value of Opportunities View. On this view, when a person is in a position to freely and capably make an informed choice, we assess her situation not by the outcome she achieves but by the potential value of her opportunities. This value depends on the value of the various things that she can achieve through her choices, as well as on how disposed she is to choose her better options and avoid her worse options. This view explains the priority we give to preventing harm that a person cannot avoid by choosing appropriately over harm that a person can so avoid by the fact that the second person has a valuable opportunity that the first does not have. It explains the importance of protecting people against choosing badly by the value of being placed in circumstances in which one is disposed to choose well, and the disvalue of being exposed to the danger of coming to harm by choosing badly.

Stuart Rachels and Larry Temkin have offered a purported counter-example to the acyclicity of the relationship 'all things considered better than'. This example invokes our intuitive preferences over pairs of alternatives involving a single person's painful experiences of varying intensity and duration. These preferences, Rachels and Temkin claim, are confidently held, entirely reasonable, and cyclical. They conclude that we should drop acyclicity as a requirement of rationality. I argue that, together with the findings of recent research on the way people evaluate episodes of pain, the use of a heuristic known as similarity-based decision-making explains why our intuitive preferences may violate acyclicity in this example. I argue that this explanation should lead us to regard these preferences with suspicion, because it indicates that they may be the result of one or more biases. I conclude that Rachels' and Temkin's example does not provide sufficient grounds for rejecting acyclicity

All conceptions of equal opportunity draw on some distinction between morally justified and unjustified inequalities. We discuss how this distinction varies across a range of philosophical positions. We find that these positions often advance equality of opportunity in tandem with distributive principles based on merit, desert, consequentialist criteria or individuals' responsibility for outcomes. The result of this amalgam of principles is a festering controversy that unnecessarily diminishes the widespread acceptability of opportunity concerns. We therefore propose to restore the conceptual separation of opportunity principles concerning unjustified inequalities from distributive principles concerning justifiable inequalities. On this view, equal opportunity implies that that morally irrelevant factors should engender no differences in individuals' attainment, while remaining silent on inequalities due to morally relevant factors. We examine this idea by introducing the principle of ‘opportunity dominance' and explore in a simple application to what extent this principle may help us arbitrate between opposing distributive principles. We also compare this principle to the selection rules developed by John Roemer and Dirk Van de Gaer.

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.