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.

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.

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. -/- .

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.

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 judgements in cases that elicit similarity-based choice.

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.

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.

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 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.

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.

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.