Jonathan Wolff

Metabolism of propionate in human subjects was studied using bolus administration of l- 13 C-propionate i.v. or orally. The study population consisted of five patients with propionic acidemia, eight with methylmalonic acidemia, one each with multiple carboxylase deficiency and transcobalamin-II deficiency, and five healthy volunteers. Concentrations of l- 13 C-propionate were measured in blood in three patients with PA, two with MMA, and two controls. Breath samples were obtained at intervals during 3 h after the dose, isotopic enrichment of 13 C0 2 was measured, and the cumulative percentage of recovery of 13 C was calculated from the individual’s predicted resting energy expenditure. Recovery of 13 C0 2 and half-time of l- 13 C-propionate in PA were significantly less than normal. The same parameters in MMA were below normal, but significantly greater than in PA. Recovery of 13 C0 2 was well correlated with clinical severity in PA, but did not correlate in MMA. Differences between MMA and PA may indicate different distribution of propionate pools, differences in inducibility of residual enzyme activities, or an alternate pathway for decarboxylation of propionate available in MMA but not PA. Only one patient with PA demonstrated increased 13 C0 2 production during biotin treatment. In a B 12 -responsive MMA patient, no differences were noted within 2 d of initiating treatment with B 12, but there was an increase in 13 C0 2 production after 4 mo. Recovery of 13 C0 2 was normal in the patient with transcobalamin-II deficiency before and after treatment with vitamin B 12. In the patient with multiple carboxylase deficiency, 13 C0 2 generation was nearly normal while he was receiving his maintenance dose of biotin, and was not significantly changed after 3 and 7 d without biotin treatment, despite a decrease of 30% in lymphocyte propionyl-CoA carboxylase activity. © 1991 International Pediatric Research Foundation, Inc.

The human right to health has been established in international law since 1976. However, philosophers have often regarded human rights doctrine as a marginal contribution to political philosophy, or have attempted to distinguish ‘human rights proper’ from ‘aspirations’, with the human right to health often considered as falling into the latter category. Here the human right to health is defended as an attractive approach to global health, and responses are offered to a series of criticisms concerning its demandingness.

Utilitarianism has a curious history. Its most celebrated founders—Jeremy Bentham and John Stuart Mill—were radical progressives, straddling the worlds of academic philosophy, political science, economic theory and practical affairs. They made innumerable recommendations for legal, social, political and economic reform, often (especially in Bentham’s case) described in fine detail. Some of these recommendations were followed, sooner or later, and many of their radical ideas have become close to articles of faith of western liberalism. Furthermore many of these recommendations were made expressly to improve the condition of the deprived, or of oppressed groups. Yet the moral theory which inspired this reforming zeal is, at least officially, utilitarianism, and when we teach this theory to our students we feel it our duty to point out the horrors that could be justified by any theory which assesses the moral quality of actions in terms of the maximization of good consequences over bad. No consequence is so bad that it cannot, in principle, be outweighed by a large aggregation of smaller goods. Hence there are circumstances in which utilitarianism can require slavery, the punishment of the innocent, and redistribution of resources from the poor to the rich, or from the disabled and the sick to the able bodied and healthy. Indeed, in the right circumstances, it can justify pretty much anything you can think of. For all their intelligence and imagination neither Bentham nor Mill seemed to recognise or discuss these catastrophic possibilities.

Innovation in basic science is often a cause for won­der and excitement. Those associated with a new development are quick to point out the anticipated benefits: a cure for cancer or dementia, an end to unsafe water or hunger. These advocates are slower to draw at­tention to the possible costs, which may become known only much later. It is always hard to have an accurate overview, as it is almost impossible to predict the total effects of the widespread adoption of any new technology and, especially, its longer‐term or cumulative effects, as as­bestos and CFCs demonstrate. For this reason, some policy‐makers or members of the public hope that we can apply “the precautionary principle” to innovation. Unfortunately, if one is looking for a principle that can guide action, then, strictly speaking, there is no pre­cautionary principle. One might better speak of a “pre­cautionary approach,” although even this needs to be unpacked.

What contribution can political philosophers make to policy questions, such as the best configuration of the welfare state? On one view, political philosophers set out abstract theories of justice that can guide policy makers in their attempt to transform existing institutions. Yet it rarely seems the case that such a model is used in practice, and it therefore becomes unclear how political philosophy can contribute to policy debates. Following a suggestion from Margaret MacDonald, I consider the view that political philosophers can contribute by drawing attention to relatively neglected values. I develop this view to add the possibility that political philosophers can try to correct a situation in which a particular value, though important, can come to be too highly emphasised. I illustrate the account by considering the rise of the value of ‘responsibility’ in the welfare state, and ultimately the damage that has been done to society to disadvantaged groups by the over-insistence on the importance of responsibility

A number of schemes have been attempted, both in public health and more generally within social programmes, to pay individuals to behave in ways that are presumed to be good for them or to have other beneficial effects. Such schemes are normally regarded as providing a financial incentive for individuals in order to outweigh contrary motivation. Such schemes have been attacked on the basis that they can ‘crowd out’ intrinsic motivation, as well as on the grounds that they are in some sense ‘corrupt’. In response, they have been defended on the grounds that they can ‘crowd in’ improved motivation. I will argue that these debates have tended to overlook the difficulties individuals can have when attempting to behave against peer group norms. In some cases, financial payments can allow individuals to defend their actions on the grounds that ‘I am only doing it for the money’ in circumstances when it would be difficult to defend their action on their real motivations. Examples of paying children to read books, and paying women to give up smoking in pregnancy, will be discussed

Train crashes cause, on average, a handful of deaths each year in the UK. Technologies exist that would save the lives of some of those who die. Yet these technical innovations would cost hundreds of millions of pounds. Should we spend the money? How can we decide how to trade off life against financial cost? Such dilemmas make public policy is a battlefield of values, yet all too often we let technical experts decide the issues for us. Can philosophy help us make better decisions? Ethics and Public Policy: A Philosophical Inquiry is the first book to subject important and controversial areas of public policy to philosophical scrutiny. Jonathan Wolff, a renowned philosopher and veteran of many public committees, such as the Gambling Review Body, introduces and assesses core problems and controversies in public policy from a philosophical standpoint. Each chapter is centred on an important area of public policy where there is considerable moral and political disagreement. Topics discussed include: Can we defend inflicting suffering on animals in scientific experiments for human benefit? What limits to gambling can be achieved through legislation? What assumptions underlie drug policy? Can we justify punishing those who engage in actions that harm only themselves? What is so bad about crime? What is the point of punishment? Other chapters discuss health care, disability, safety and the free market. Throughout the book, fundamental questions for both philosopher and policy maker recur: what are the best methods for connecting philosophy and public policy? Should thinking about public policy be guided by an ‘an ideal world’ or the world we live in now? If there are ‘knock down’ arguments in philosophy why are there none in public policy? Each chapter concludes with ‘Lessons for Philosophy’ making this book not only an ideal introduction for those coming to philosophy, ethics or public policy for the first time, but also a vital resource for anyone grappling with the moral complexity underlying policy debates

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style reasoning are commonly combined in an ethically acceptable fashion.