Jonathan Cohen

Quality Adjusted Life Years (QALYs) have become a household word among health economists. Their use as a means of comparing the value of health programmes and medical interventions has stirred up controversy in the medical profession and the academic community. In this paper, I argue that QALY analysis does not adequately take into account the differentiated nature of the health state values it measures. Specifically, it does not distinguish between needs and preferences with respect to its valuation of health states. I defend the view that needs and preferences are clearly distinguishable, and that the concept of needs cannot be dispensed with, as many health economists suggest. It is argued that the scale along which health states are measured in QALY analysis is not a continuous interval scale, but one which concerns two distinctly different value dimensions. Measuring the values of health state intervals may reveal the weighting attached to the different value dimensions.

Full-length studies of individual books of Nietzsche have been lacking until now both because of the immaturity of the field and because Nietzsche's style itself seems to contraindicate them. Close reading, however, reveals a great deal of literary and philosophical unity. This holds good even of Human, All-Too-Human, Nietzsche's longest and most unwieldy work. The book represents Nietzsche's break with Schopenhauer and Wagner, as well as the birth of Nietzsche as we know him in the later works. The book's embrace of science as conducive to culture follows the early works' vilification of science as anathema to culture. This reassessment is possible because science is now seen as a method and a discipline rather than an insatiable drive for knowledge, and culture is now a broad set of symbols and activities rather than a narrowly focussed "unity of artistic style." Both changes were motivated by Nietzsche's rejection of Wagner. Part of the help science provides culture is its release from restrictive metaphysical beliefs. Nietzsche battles metaphysics, principally that of Schopenhauer, by means of scientific arguments meant both to provide alternative explanations of phenomena and to expose the origin of countervailing metaphysical beliefs. However, even when combined in a two-pronged attack, these arguments still fall short of their goal of refuting metaphysics. The scientific world-view may nonetheless aid the development of "free spirits," whose unalloyed devotion to knowledge makes them science's paragons. The free spirits are the prototypes for the later works' strong individuals, yet here they are viewed as crucial elements in the cultural development of general society. Nietzsche seeks both to create them and to encourage their devotion to the needs of culture. Part of his effort to do this is the deployment of a terse, elliptical style which will involve the reader more thoroughly than can be done by means of argument alone. Study of the book's structure reveals that its core, Parts 1, 5, and 9, outlines the relation between science, culture, and free spirits.

In the central section of the _Protagoras_, the discussion between Socrates and Protagoras has broken down in a seemingly irresolvable dispute about methodology - Protagoras wants to make long speeches, while Socrates wants to proceed by means of the short questions and answers characteristic of the elenchus. The onlookers offer solutions in an attempt to restart the discussion. This section appears to be a mere dramatic interlude, but I argue that in fact it constitutes a parable establishing links between philosophy, education, and politics in which authority and control are contrasted with genuine democratic discussion.