John Broome

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII).

Abstract:Standard lessons from economics tell us that an externality creates inefficiency, and that this inefficiency can be removed by internalizing the externality. This papers considers how successfully these lessons can be extended to intergenerational externalities such as emissions of greenhouse gas. For intergenerational externalities, the standard lessons involve comparisons between states whose populations of people differ, either in their identities or their numbers. Common notions of efficiency break down in these comparisons. This paper supplies a new notion of efficiency that allows the lessons to survive, but at the cost of reducing their practical significance.

This chapter considers whether the neutral level for extending life is a constant. It shows there are plausible grounds for thinking it may not be. However, it adopts the assumptions that it is constant as a default view. This leads to the standardized total principle for lives, which says that the value of a life is the total of temporal wellbeing contained in the life. This amounts to intrapersonal utilitarianism. The chapter considers the implication of this conclusion for the badness of death.

This chapter demonstrates how the assumptions made so far in the book imply that there is a single neutral level for existence. That is, there is a single level of wellbeing such that adding a person at that level is neither better nor worse than not adding her. It explains how this conclusion conflicts strongly with an intuition shared by many people: the ‘neutrality intuition’ that adding a person to the world’s population is generally ethically neutral. It uses examples such as the mere addition paradox. It outlines various ways in which the conflict with intuition might be circumvented.

This chapter starts to consider how wellbeing can be aggregated across a distribution. It describes two possible route to aggregation, called ‘the people route’ and the ‘snapshot route’. Each relies on a particular assumption of separability, which the chapter explains. The chapter examines the credibility of separability of times. It shows how separability of times conflicts with the value of longevity, and concludes that this principle cannot be relied on. It therefore rejects the snapshot route to aggregation.

This chapter distinguishes a notion of separability of lives from a stronger notion of separability of people, which takes into account the possibility of a person’s nonexistence. It defends separability of lives on the basis of the principle of personal good. It thereby opens up the people route to aggregation when the population of the world is constant. It assesses the principle of personal good, particularly considering its relation to the value of equality and its conflict with discounting for time.

This chapter opens the question of aggregating wellbeing across time to determine the value of a single person’s life. It explains the imperfect analogy between this sort of aggregation and aggregation across time to determine the overall value of a world. It assesses the principle of temporal good, the analogue of the principle of personal good. It shows there are plausible grounds for doubting the principle, which derive from various putative pattern goods. Nevertheless, this chapter eventually adopts the principle of temporal good as a default position. From this default position, it derives a same-lifetime addition theorem, which says that wellbeing is aggregated within a life additively.

This chapter considers how far what one ought to do when facing a decision of life and death is determined by the goodness of the distribution that will result. It defines, examines and assesses the principles of teleology and consequentialism in ethics. It compares normative theory with axiology. It considers how far a person’s lifetime wellbeing depends on all the wellbeing that comes to the person at times within her life, and how far the goodness of the world depends on the wellbeing of the people. It introduces the idea of pattern goods such as equality and longevity.

Practical reasoning is a process of reasoning that concludes in an intention. One example is reasoning from intending an end to intending what you believe is a necessary means: 'I will leave the next buoy to port; in order to do that I must tack; so I'll tack', where the first and third sentences express intentions and the second sentence a belief. This sort of practical reasoning is supported by a valid logical derivation, and therefore seems uncontrovertible. A more contentious example is normative practical reasoning of the form 'I ought to φ, so I'll φ', where 'I ought to φ' expresses a normative belief and 'I'll φ' an intention. This has at least some characteristics of reasoning, but there are also grounds for doubting that it is genuine reasoning. One objection is that it seems inappropriate to derive an intention to φ from a belief that you ought to φ, rather than a belief that you ought to intend to φ. Another is that you may not be able to go through this putative process of reasoning, and this inability might disqualify it from being reasoning. A third objection is that it violates the Humean doctrine that reason alone cannot motivate any action of the will. This paper investigates these objections

In 1955 John Harsanyi proved a remarkable theorem that connects general good with the personal good of individuals. This chapter interprets Harsanyi’s theorem. It explains the meaning of its conclusion, the way it links together intrapersonal and interpersonal aggregation, and in particular the link it makes between the value of avoiding risk and the value of avoiding inequality between people. It explains how the theorem connects prioritarianism with risk avoidance and utilitarianism with risk neutrality. It sets out the theorem’s premises and assesses the various objections that have been made to them. Finally, it considers how far Harsanyi’s theorem gives support to utilitarianism.