Paul Anand

The book offers a novel account of human happiness suitable for the general or popular science reader. Drawing on evidence from psychology and economics, as well as recent thinking in ethics, Happiness Explained addresses two of the most important questions to humankind, namely, what is happiness and how can we take account of this in our everyday lives? The book starts by setting out what is wrong with focussing exclusively on gross national income as a measure of wellbeing and introduces a novel approach developed by Nobel prize-winner Amartya Sen. It then considers evidence relating to different aspects of wellbeing from a wide range of economics and psychological studies. It also examines issues of fairness and wellbeing, the emergence of policies and practice around the world that seek to account for human wellbeing explicitly, and the principles that underpin wellbeing over the life course.

The paper compares use of willingness to pay values with multi-attribute utility as ways of modelling social choice problems in the environment. A number of reasons for moving away from willingness to pay are reviewed. The view proposed is that social choice is about the integration of competing claim types (utilities, rights, social contracts and beliefs about due process). However, willingness to pay is only indirectly related to the first of these and assumes an Arrovian approach, namely one in which social choice is regarded as the aggregation of people's preferences.

This study used fMRI to investigate the neural substrates of moral cognition in health resource allocation decision problems. In particular, it investigated the cognitive and emotional processes that underpin utilitarian approaches to health care rationing such as Quality Adjusted Life Years. Participants viewed hypothetical medical and nonmedical resource allocation scenarios which described equal or unequal allocation of resources to different groups. In addition, participants were assigned to 1 of 2 treatments in which they either did or did not receive advanced instructions about the principles of utilitarianism. In all cases, participants were asked to judged the proposed allocations as “fair” or “unfair.” More brain activity was observed within the superior parietal lobe, angular gyrus, middle temporal gyrus, and bilateral caudate nucleus when participants viewed scenarios depicting equal divisions of resources. Conversely, unequal resource divisions were associated with more activity in the inferior frontal gyrus and insula cortex. Furthermore, instructions about the principles of utilitarianism led to significant activation differences within the inferior frontal gyrus and the middle frontal gyrus. Significant differences in activity were also found within the inferior frontal cortex and anterior insula between medical and nonmedical scenarios. The implications for cognitive control mechanisms and the cognitive and neural bases of utilitarian ethical judgment are discussed.

Sen’s capabilities approach offers a radical generalisation of the conventional approach to welfare economics. It has been highly influential in development and many researchers are now beginning to explore its implications for health care. This paper contributes to the emerging debate by discussing two examples of such applications: first, at the individual decision making level, namely the right to die, and second, at the social choice level. For the first application, which draws on Nussbaum’s list of capabilities, it is argued that many capabilities are ambiguously or indirectly related to the right to die, but the ability to form a concept of the good life and plan one’s own life provides a direct justification for such a right. In the second application, the focus is specifically on healthcare rationing and it is argued that, although not committed to age based rationing, the capabilities approach provides a more natural justification of age related access to health care than the fair innings argument, which is often used to justify the alleged ageism inherent in quality adjusted life years maximisation

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. We identify the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming.

In the context of multidimensional measures of well-being, a key question for policy is whether particular groups have differing priorities and are therefore likely to react differently to given economic or social shocks. We explore this issue by presenting the results of two related analyses that suggest positive answers on both counts. First, we apply reference class weights to unique data on adult capabilities in the UK and show that relative weights vary across some groupings. Furthermore, in some cases, deprivation rankings of groups vary depending on which weights are used. Second, we explore possible behavioural consequences of different weights by examining the extent to which groups respond differently to three economic and social shocks (unemployment, widowhood and ill health). In this case, we find that weights and responses vary noticeably with age and region and sometimes with gender. We conclude that whilst equal weighting may be practically unavoidable when constructing indices of welfare in the absence of information on weights, their estimation from survey or experimental data is likely to be justified and may change views about policy needs or efficacy.