Douglas MacKay

The value of health states is often understood to depend on their impact on the goodness of people's lives. As such, prominent health states metrics are grounded in particular conceptions of wellbeing – e.g. hedonism or preference satisfaction. In this paper, I consider how liberals committed to the public justification requirement – the requirement that public officials choose laws and policies that are justifiable to their citizens – should evaluate health states. Since the public justification requirement prohibits public officials from appealing to controversial conceptions of the good life, liberals committed to this principle face a significant puzzle.

In this article, I ask whether a principle analogous to the principle of clinical equipoise should govern the design and conduct of RCTs evaluating the effectiveness of policy interventions. I answer this question affirmatively, and introduce and defend the principle of policy equipoise. According to this principle, all arms of a policy RCT must be, at minimum, in a state of equipoise with the best proven policy that is also morally and practically attainable and sustainable. For all arms of a policy RCT, policy experts must either reasonably disagree about whether the trial arms are more effective than this policy, or know that they are.

Policy-makers must allocate scarce resources to support constituents’ health needs. This requires policy-makers to be able to evaluate health states and allocate resources according to some principle of allocation. The most prominent approach to evaluating health states is to appeal to the strength of people’s preferences to avoid occupying them, which we refer to as decision utility metrics. Another approach, experienced utility metrics, evaluates health states based on their hedonic quality. In this article, we argue that although decision utility metrics face a number of significant problems, the appropriate response to these problems is not to replace them with experienced utility metrics. Rather, decision utility metrics should be employed in conjunction with experienced utility metrics. Specifically, respondents to decision utility surveys should be provided with the results of experienced utility metrics in an effort to make their decisions better informed and more robust to the deficiencies of decision utility metrics. Ultimately, this approach would improve quality-adjusted life year calculations and enhance the decision-making of policy-makers in allocating resources to support constituents’ health needs.

Recent efforts by legislative officials and public health advocates to reform the US food stamp program, or Supplemental Nutrition Assistance Program, have focused on restricting the types of foods eligible for purchase with SNAP benefits, specifically sugar-sweetened beverages. We argue that it is, in principle, permissible for the US government to enact a SNAP-specific SSB ban prohibiting the purchase of SSBs with SNAP benefits. While the government has a duty to ensure that citizens meet their nutritional needs, since SSBs provide negligible nutrition, it has no obligation to subsidize them. Additionally, there is good reason to think that a SNAP-specific SSB ban would enable the government to better fulfill two other duties—improving citizens’ health and providing public services like Medicaid and Medicare in a more cost-effective manner. Still, because the costs and benefits of such a ban remain uncertain, we argue that the government should conduct well-designed pilot projects to help determine the effects of an SSB ban.

I. Glenn Cohen’s Patients with Passports: Medical Tourism, Law, and Ethics offers a thorough examination of the growing practice of medical tourism, the legal regulations governing it, and the many ethical issues it raises for policy-makers, health care providers, and prospective medical tourists. Demonstrating mastery of the relevant literatures in the social sciences, law, ethics, and political philosophy, Cohen provides a comprehensive overview of the current practice of medical tourism, and offers well-argued, sensible policy advice to guide its reform. Cohen’s book is a significant achievement of interdisciplinary scholarship and is essential reading for scholars and policy-makers. Medical...

In Rescuing Justice and Equality, G.A. Cohen argues that the incentive inequalities permitted by John Rawls's difference principle are unjust since people cannot justify them to their fellow citizens. I argue that citizens of a Rawlsian society can justify their acceptance of a wide range of incentive inequalities to their fellow citizens. They can do so because they possess the right to freedom of occupational choice, and are permitted – as a matter of justice – to exercise this right by making occupational decisions on the basis of a wide range of values and preferences

Many high-income countries have skill-selective immigration policies, favoring prospective immigrants who are highly skilled. I investigate whether it is permissible for high-income countries to adopt such policies. Adopting what Joseph Carens calls a " realistic approach " to the ethics of immigration, I argue first that it is in principle permissible for high-income countries to take skill as a consideration in favor of selecting one prospective immigrant rather than another. I argue second that high-income countries must ensure that their skill-selective immigration policies do not contribute to the non-fulfillment of their duty to aid residents of low-and middle-income countries.

Governments must determine the legal procedures by which their residents are registered, or can register, as organ donors. Provided that governments recognize that people have a right to determine what happens to their organs after they die, there are four feasible options to choose from: opt-in, opt-out, mandated active choice, and voluntary active choice. We investigate the ethics of these policies' use of nudges to affect organ donor registration rates. We argue that the use of nudges in this context is morally problematic. It is disrespectful of people's autonomy to take advantage of their cognitive biases since doing so involves bypassing, not engaging, their rational capacities. We conclude that while mandated active choice policies are not problem free—they are coercive, after all—voluntary active choice, opt-in, and opt-out policies are potentially less respectful of people's autonomy since their use of nudges could significantly affect people's decision making.

A chief objection to opt-out organ donor registration policies is that they do not secure people's actual consent to donation, and so fail to respect their autonomy rights to decide what happens to their organs after they die. However, scholars have recently offered two powerful responses to this objection. First, Michael B Gill argues that opt-out policies do not fail to respect people's autonomy simply because they do not secure people's actual consent to donation. Second, Ben Saunders argues that opt-out policies do secure people's actual—if not explicit—consent, provided that certain conditions are satisfied. I argue that Gill and Saunders’ arguments are not successful. My conclusion does not imply that jurisdictions should not implement opt-out policies—their failure to secure people's actual consent may be outweighed by other considerations. But, my conclusion does imply that Gill and Saunders are mistaken to claim that opt-out policies are respectful of people's autonomy.

In a recent article, Seana Valentine Shiffrin offers a distinctive egalitarian critique of the types of incentive inequalities that are permitted by John Rawls's difference principle. She argues that citizens of a well-ordered society, who publicly accept Rawls's two principles of justice and their justifications, may not demand incentives to employ their talents in productive ways since such demands are inconsistent with a major justification for the difference principle: the moral arbitrariness of talent. I argue that there is no such inconsistency. Citizens can publicly accept the claim that talent is morally arbitrary and accept incentives to employ their talents productively without inconsistency. In the standard case that Rawls envisions, citizens who do so take their preferences to be a reason for a higher salary, not their talents

Political philosophers often formulate the problem of distributive justice as the problem of how the government ought to distribute different types of goods—for example, income or health care—to its citizens. They therefore presuppose that the government is a unitary agent that governs its citizens directly. However, although a number of governments are unitary in this way, many are federations, exhibiting a division of sovereignty between two or more levels of government having independent grounds of authority. In contrast to unitary states, therefore, within a federation, two or more levels of government directly govern their citizens and are directly accountable to them. Because of the way in which different levels of government in a federation can separately affect the distribution of goods in society, federations face resource allocation problems that are far more complex than those of unitary states. In addition to determining what a just distribution of goods is, federations must also determine (1) whether distributive justice is a shared responsibility amongst different levels of government, and, if so, (2) how this shared responsibility should be allocated between them.

In this paper, I explore the ethics of subject selection in the context of biomedical research. I reject a key principle of what I shall refer to as the standard view. According to this principle, investigators should select participants so as to minimise aggregate risk to participants and maximise aggregate benefits to participants and society. On this view, investigators should exclude prospective participants who are more susceptible to risk than other prospective participants. I argue instead that investigators should select subjects in accordance with an alternative principle: formal equality of opportunity. According to this principle, investigators must treat all prospective participants the same unless differential treatment is warranted by the scientific goals of the study or the need to promote participants' medically related interests. All prospective participants (1) who meet the scientifically defined eligibility criteria and (2) for whom participation is consistent with their medically related interests should have an equal, formal opportunity to participate in the study. Prospective participants should not be excluded simply because they are more susceptible to risk than others.