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 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. -/- .

Philippe van Parijs (2003) has argued that an egalitarian ethos cannot be part of a post- Political Liberalism Rawlsian view of justice, because the demands of political justice are confined to principles for institutions of the basic structure alone. This paper argues, by contrast, that certain principles for individual conduct—including a principle requiring relatively advantaged individuals to sometimes make their economic choices with the aim of maximising the prospects of the least advantaged—are an integral part of a Rawlsian political conception of justice. It concludes that incentive payments will have a clearly limited role in a Rawlsian theory of justice.

I review Shlomi Segall's book 'Why Inequality Matters'. I argue that it conclusively establishes that alongside egalitarians, prioritarians and sufficientarians must sometimes regard a prospect as better (in at least one respect) when it is not better (in terms of well-being) for anyone. Sufficientarians and prioritarians must therefore relinquish a treasured anti-egalitarian argument. It also makes a powerful case that among these three views, egalitarians are in the best position to explain such departures from what is in each person’s prudential interest. For egalitarians can point to the natural idea that it is unfair when, due to pure chance, some fare much better than others. By contrast, it remains unclear what value, if any, sufficientarians or prioritarians can appeal to in order to justify their departures from what best promotes people’s well-being.

When one faces competing claims of varying strength on public resources for health, which claims count? This paper proposes the following answer. One should count, or aggregate, a person’s claim just in case one could sympathize with her desire to prioritize her own claim over the strongest competing claim. It argues that this principle yields appealing case judgments and has a plausible grounding in both sympathetic identification with each person, taken separately, and respect for the person for whom most is at stake. It also defends this principle against several heretofore unanswered objections.

The Complaint Model is an interpretation of Scanlon’s contractualism which holds that (1) an individual can reasonably reject a distribution of well-being when her complaint against that distribution is larger than any other person’s complaint against any other distribution. The Complaint Model further holds that (2) the size of an individual’s complaint against a distribution is a function of (2a) her absolute level of well-being under that distribution, with the size of her complaint increasing as her absolute level of well-being decreases, and (2b) the size of her loss in well-being under that distribution relative to the level of well-being she could have enjoyed under the distribution most favourable to her, with the size of her complaint increasing as her loss increases. In this paper, I argue that the Complaint Model should be rejected, because the way in which it takes individuals’ losses into account leads to strongly counterintuitive results. In particular, I show that the Complaint Model may sacrifice the well-being associated with the least-well-off, secondleast-well-off, etc. positions for the sake of minimizing the largest complaint. I also argue that revisions to element (1) to allow for the aggregation of complaints must either leave the Complaint Model vulnerable to this objection or lead it to collapse into prioritarianism. The failure of the Complaint Model may lead us to search for an alternative way of taking losses into account. I conclude by arguing that the attractiveness of the Anonymous Pareto principle poses a challenge to any such alternative.

Suppose that you must make choices that may influence the well-being and the identities of the people who will exist, though not the number of people who will exist. How ought you to choose? This paper answers this question. It argues that the currency of distributive ethics in such cases is a combination of an individual’s final well-being and her expected well-being conditional on her existence. It also argues that this currency should be distributed in an egalitarian, rather than a prioritarian, manner.

In On Liberty, Mill famously propounded a view of the good life as the autonomous life. On this view, it is crucial that people develop and exercise, to a high degree, their ability to reason independently about what to believe and what to aim at in life. It is also important that they be able to freely hold and express their beliefs and effectively act on their aims. As Mill put it: The mental and the moral, like the muscular, powers are improved only by being used. ... He who lets the world ... choose his plan of life for him has no need of any other faculty than the ape-like one of imitation. He who chooses his plan of life for himself ... must use observation to see, reasoning and judgment to foresee, activity to gather materials for decision, discrimination to decide, and when he has decided, firmness and self-control to hold his deliberate decision. And these qualities he requires and exercises exactly in proportion as the part of his conduct which he determines according to his own judgment and feelings.... It is possible that he may be guided in some good path ... without any of these things. But what will be his comparative worth as a human being? (p. 56). Two of Mill’s arguments for familiar liberal rights—which include children’s right to a decent education, freedom of conscience, freedom of expression, and freedom of association— appeal to this ideal of autonomy. First, these rights are generally crucial for establishing the conditions under which people can freely make up their own minds about what to believe and how to live, and to act accordingly. Second, a society that respected these rights would, Mill thought, be more likely to have a vibrant public culture, in which divergent opinions and lifestyles lead to a ‘generally high scale of mental activity’, which together ‘raise even persons of the most ordinary intellect to something of the dignity of thinking beings’ (p. 33).

We use probability-matching variations on Ellsberg’s single-urn experiment to assess three questions: (1) How sensitive are ambiguity attitudes to changes from a gain to a loss frame? (2) How sensitive are ambiguity attitudes to making ambiguity easier to recognize? (3) What is the relation between subjects’ consistency of choice and the ambiguity attitudes their choices display? Contrary to most other studies, we find that a switch from a gain to a loss frame does not lead to a switch from ambiguity aversion to ambiguity neutrality and/or ambiguity seeking. We also find that making ambiguity easier to recognize has little effect. Finally, we find that while ambiguity aversion does not depend on consistency, other attitudes do: consistent choosers are much more likely to be ambiguity neutral, while ambiguity seeking is much more frequent among highly inconsistent choosers.

This thesis argues that a particular version of equal opportunity for welfare is the best way of meeting the joint demands of three liberal egalitarian ideals: distributional equality, responsibility, and respect for individuals’ differing reasonable judgements of their own good. It also examines which social choice rules best represent these demands. Finally, it defends the view that achieving equal opportunity for welfare should not only be a goal of formal public institutions, but that just citizens should also sometimes be guided by it in their everyday life. The version of equal opportunity for welfare it defends differs from some well-known contemporary versions in the following ways. First, it rejects a definition of welfare as the degree of satisfaction of a person’s preferences, because, it argues, this conception of welfare cannot adequately deal with preference change. Instead, it suggests that we should adopt a conception of welfare based on a list of goods and conditions that are recognised as valuable from the perspective of a variety of different conceptions of the good. Second, it argues that individuals’ prima facie claim to an equally valuable share of the world’s resources—a claim which is based on their equal moral worth—is limited to situations in which giving one person a more valuable share means that someone else ends up with a less valuable share. It also argues that in situations where we can improve at least one person’s situation without worsening anyone else’s, we generally do not fail to respect each person’s equal moral worth by doing so, even if this leads to inequalities. Third, it defends a distinct view of responsibility, which justifies social arrangements that give people certain options with reference to the value that individuals can achieve (but don’t necessarily achieve) through their choices from these options.

The difference between the unity of the individual and the separateness of persons requires that there be a shift in the moral weight that we accord to changes in utility when we move from making intrapersonal tradeoffs to making interpersonal tradeoffs. We examine which forms of egalitarianism can, and which cannot, account for this shift. We argue that a form of egalitarianism which is concerned only with the extent of outcome inequality cannot account for this shift. We also argue that a view which is concerned with both outcome inequality and with the unfairness of inequality in individuals‘ expected utilities can account for this shift. Finally, we limn an alternative view, on..

This chapter analyses the behavioural economist Matthew Rabin's work on biases in decision-making. Rabin argues that these biases cause self-harm and that we should tax individuals to ensure that they do not give in to these biases. The chapter's core question is whether there is a soft-paternalistic justification for these taxes. The answer is nuanced. It argues that Rabin’s description of these biases as “irrational” is not always appropriate—sometimes, for example, they are merely a form of preference change. When they are due to the latter, the behaviour is fully voluntary, and there exists no soft-paternalistic justification for coercive intervention. It also argues that even when these biases do lead to substantially non-voluntary choices, we should prefer policies that improve self-knowledge and self-control to taxes. However, the paper notes that Rabin’s analysis reveals circumstances under which these autonomy-enhancing strategies will not be effective. In such cases, and only in such cases, Rabin’s taxes have a soft paternalistic justification.

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.