Why it matters that some are worse off than others: An argument against the priority view

Philosophy and Public Affairs

Volumn 37, Issue 2, 2009, Pages 171-199

  Otsuka, Michael ^a   Voorhoeve, Alex ^b  

^a UNIVERSITY COLLEGE LONDON   (United Kingdom)

^b HARVARD UNIVERSITY   (United States)

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EID: 65549146749     PISSN: 00483915     EISSN: 10884963     Source Type: Journal    
DOI: 10.1111/j.1088-4963.2009.01154.x     Document Type: Article

References (45)

1. Unless we indicate otherwise, it should be assumed that the health states we refer to in this article will last from early adulthood until the end of the lives of individuals with equally long life spans, that people are equally well off in all respects other than those to which their differences in mobility give rise, that everyone who is in the same health state is at the same (interpersonally comparable) level of utility, and that it is through no choice or fault of any individual that she suffers from or is vulnerable to any impairment.
2. See Erik Nord, "The Trade-Off between Severity of Illness and Treatment Effect in Cost-Value Analysis of Health Care," Health Policy (1993): 227-38, and "The Person Trade-Off Approach to Valuing Health Care Programs," Medical Decision-Making (1995): 201-208. In these articles, Nord defined the slight impairment as "not being able to walk more than 1 km." In later work, he adjusted this to 2 km based on a fuller assessment of preference data. See Erik Nord, Jose-Louis Pinto Prades, Jeff Richardson, Paul Menzel, and Peter Ubel, "Incorporating Societal Concerns for Fairness in Numerical Valuations of Health Programmes," Health Economics (1999): 25-39, Table 1. See also the appendix to this article.
3. We shall assume throughout this article that the preferences we are considering satisfy the von Neumann-Morgenstern axioms. Given this assumption, the measurement procedure we describe is consistent with the procedure known in health economics as the standard gamble. (See Paul Dolan, "Output Measures and Valuation in Health," in Economic Evaluation in Health Care, ed. Michael Drummond and Alistair McGuire [Oxford: Oxford University Press, 2001], pp. 46-67.) In order to render such a preference based measure of utility plausible, we will need to restrict these preferences to something along the lines of the "self-interested preferences that the individual would have after ideal deliberation while thinking clearly with full pertinent information regarding those preferences." The quoted words are from Richard Arneson, "Primary Goods Reconsidered," Noûs (1990): 429-54, at p. 448. There he is supposing that "one identifies individual welfareö with the satisfaction of the specified preferences (ibid., emphasis added). By contrast, we are not spelling out a proposal regarding what utility is in the main text above. Rather, we are presenting an account of how to measure the magnitude of one's expected utility. One might believe that two options have the same expected utility for a person when she is indifferent between these options without also believing that utility is identical with, or even that it consists of, preference satisfaction. One might maintain that utility is, or consists of, something other than preference satisfaction, while also maintaining that the specified idealized preferences unerringly track the magnitude of this other thing.
4. We shall assume throughout this article that the morally motivated stranger is a private individual rather than a state official. We shall also assume throughout that the cost of providing assistance to another is never so great that such assistance would qualify as overly demanding
5. Throughout this article, we shall understand 'utility' to refer to this. Note that you might believe that this person's preferences provide an accurate measure of her utility without also believing that utility is, or consists of, preference satisfaction. (See n. 3 above.)
6. Nord et al., "Incorporating Societal Concerns for Fairness," Table 1. See also the appendix to this article.
7. See Jose-Luis Pinto Prades, "Is the Person Trade-Off a Valid Method for Allocating Health Care Resources?" Health Economics (1997): 71-81; Jose-Luis Pinto Prades and Angel Lopez-Nicolk, "More Evidence of the Plateau Effect: A Social Perspective," Medical Decision-Making (1998): 287-94; Peter Ubel, George Loewenstein, Dennis Scanlon, and Mark Kamlet, "Value Measurement in Cost-Utility Analysis: Explaining the Discrepancy between Rating Scale and Person Trade-off Elicitations," Health Policy (1998): 33-44; and Ubel et al., "Individual Utilities Are Inconsistent with Rationing Choices: A Partial Explanation of Why Oregon's Cost-Effectiveness List Failed," Medical Decision-Making (1996): 108-16. However, Paul Dolan and Colin Green, "Using the Person Trade-Off Approach to Examine Differences between Individual and Social Values," Health Economics (1998): 307-12, does not find this priority.
8. Although we have drawn a contrast between a case involving a group and a case involving a single person, we could instead have drawn a contrast between two cases, each of which involves the same group of people. One of the two cases would simply be the case involving the group that was just presented in the main text above. The contrasting group involving case would differ from this one in just the following respects. The particular fate of the group's members is no longer known in advance. Rather, what is known is that either all will develop the slight impairment or all will develop the very severe impairment and there is an equal probability of either outcome. Every member of this group must receive the same treatment before it is known how things will turn out. The morally motivated stranger's two options are therefore to provide everyone with the treatment that will be effective if and only if each develops the slight impairment, or to provide everyone with the treatment that will be effective if and only if each develops the very severe impairment. This case is identical to our one-person case, save for the fact that this one person and her fate have been replicated many times over to create a group of people. Just as it is reasonable to provide the individual in our one-person case with the treatment that maximizes her expected utility, it is reasonable to provide each member of this group with the treatment that maximizes her expected utility. More generally, whatever claims we make in this article about what one ought to do in cases involving single persons apply, mutatis mutandis, to groups of identically fated people created by such replication.
9. "Equality or Priority?" The Lindley Lecture (Lawrence: University of Kansas, 1991), reprinted in The Ideal of Equality, ed. Matthew Clayton and Andrew Williams (Basingstoke: Palgrave, 2002), pp. 81-125, at p. 104. (All subsequent page referenceswill be to the reprinted version.) Henceforth, all references to "Prioritarianism" and "the Priority View" are to the "pure" version of this view that Parfit presents and considers in this lecture (ibid., p. 103). Although he describes its many merits, Parfit does not in fact endorse this (or any other) version of the Priority View in this lecture.
10. Ibid., p. 101. Parfit writes that this viewmight apply either to "(1) those who are worse off in their lives as a whole" or to "(2) those who are worse off at a time." He also notes that "(1) and (2) frequently diverge." It is a matter of controversy whether priority should be given to the former or the latter when the two diverge. Parfit sidesteps this controversy by assuming throughout his examples that "there is no difference between those who would be worse off at the time, and those who would be worse off in their lives as a whole." (See ibid., Sec. VIII.) We have followed Parfit in making this assumption. (See n. 1 above.) We have done so both to set this particular controversy to one side in order to place a spotlight on a different problem that the Priority View faces and to restrict ourselves to examples in which the requirements of this view are unambiguous.
11. "Equality or Priority?" p. 105.
12. Ibid., p. 104.
13. For further discussion of this point, see Wlodek Rabinowicz, "Prioritarianism and Uncertainty," in Exploring Practical Philosophy: From Action to Values, ed. Dan Egonsson, Jonas Josefsson, Björn Petersson, and Toni Rønnow-Rasmussen (Burlington, Vt.: Ashgate, 2001), pp. 139-66; and Rabinowicz, "Prioritarianism for Prospects," Utilitas (2002): 2-21. See also David McCarthy, "Utilitarianism and Prioritarianism II," Economics and Philosophy (2008): 1-33.
14. "Equality or Priority?" p. 103. Although our focus in this article is on the Priority View, we note here that not only that view but also various other influential noncomparative, anti-egalitarian views, such as those of Joseph Raz and Harry Frankfurt, are unsound if the shift is justified. See Joseph Raz, The Morality of Freedom (Oxford: Oxford University Press, 1986), chap. 9; and Harry Frankfurt, "Equality as a Moral Ideal," Ethics (1987): 21-42.
15. If the aforementioned estimates of the typical priority people give to the less well off are correct, a treatment for the very severe impairment that brought a person up to the condition of the severe impairment will have an expected moral value of 1,500 times the expected moral value of the treatment for the slight impairment.
16. The divergence between what the Priority View requires and what would maximize expected utility in one-person cases is noted by Rabinowicz, in "Prioritarianism and Uncertainty" and "Prioritarianism for Prospects," by Dennis McKerlie, in "Dimensions of Equality," Utilitas (2001): 263-88, and by McCarthy, in "Utilitarianism and Prioritarianism II." Our claims in this article differ from theirs in the following respects. First, neither Rabinowicz nor McKerlie argues that the Priority View should be rejected because of this divergence. Second, unlike Rabinowicz and McKerlie, and contrary to McCarthy, we argue in Sections III and IV that there should be a shift in the moral weight that we accord to improvements in a person's condition when we move from our one-person case with risk to our multi-person case with certainty, where this shift is justified by an appeal to essentially comparative considerations. By contrast, McCarthy argues that the Priority View should be rejected in favor of utilitarianism, according to which there should be no shift in the weight we give to improvements lower down the utility scale when we move from our one-person case with risk to our multi-person case with certainty.
17. As in our previous one-person case, here it should be assumed that you are considering the individual's fate in isolation from any consideration of how well off or badly off anybody else is.
18. See Michael Otsuka, "Equality, Ambition, and Insurance," Proceedings of the Aristotelian Society supplementary volume (2004): 151-66, at p. 151; and Larry Temkin, "Equality, Priority, and the Leveling Down Objection," in The Ideal of Equality, pp. 126-61, at pp. 129-30.
19. See "Equality or Priority?" pp. 98, 105, and Sec. XII. (Parfit notes that this objection to equality was suggested in earlier writings by Joseph Raz and Larry Temkin.)
20. Compare Thomas Nagel, "Equality," in Mortal Questions (Cambridge: Cambridge University Press, 1979), pp. 106-27, at p. 123. See also Nagel, Equality and Partiality (Oxford: Oxford University Press, 1991), chap. 7.
21. Compare Nagel, Equality and Partiality, pp. 68-69. It is noteworthy that Nagel's view is immune to a different objection that Parfit makes to comparative views that do not appeal to the intrinsic badness of inequality. Parfit suggests that such views will not be able to give us any reason to hope that a more egalitarian distribution will come about in a situation in which there are two possible distributions of which one is more egalitarian and more to the benefit of the worst off than the other, and the distribution of well-being that 184 Philosophy & Public Affairs will come about is entirely beyond anyone's control (see "Equality or Priority?" p. 116). On Nagel's view we have reason to hope that the more equal of these possible distributions will come about because we have reason to hope that the morally stronger claim will be satisfied.
22. We should add that, in order to account both for this shift in weighting when we move from the one-person to the multi-person case and for the fact that people are willing, in other cases, to cure a sufficiently large number of people with the slight impairment rather than partially alleviate the condition of one person with the very severe impairment, one would have to supplement these comparative views in order to capture this latter element. One might do so by adopting a pluralist account that gives some independent weight to aggregative considerations that are sensitive to the number of people cured and their gain in well-being. For such pluralist views, see Nagel, "Equality," p. 127; Parfit, "Equality or Priority?" p. 85; and Bertil Tungodden, "The Value of Equality," Economics and Philosophy (2003): 1-44.
23. Cf. Thomas Hurka, "Asymmetries in Value," Noûs (forthcoming), n. 4.
24. Note, moreover, that one could not object that the stranger would be acting paternalistically if he confers the dispreferred treatment that maximizes expected priority weighted utility. This would not be paternalistic, since the stranger would not be acting in what he takes to be that person's interest by giving her the treatment she disprefers. The stranger believes that the person is accurate in her assessment of her own interests and therefore recognizes that it is not in that person's interests, measured by her utility as determined by her preferences, to have expected priority-weighted utility maximized.
25. "Equality," p. 124. More precisely, Nagel notes that this greater urgency provides a pro tanto and in many cases decisive reason to benefit him
26. See "Equality or Priority?" p. 108.
27. Ibid., p. 105.
28. Ibid., p. 108.
29. It is, in fact, only if the Priority View applies to such choices that Parfit could have argued on behalf of its superiority to egalitarian approaches in handling leveling down cases.
30. See Thomas Nagel, The View from Nowhere (New York: Oxford University Press, 1986), pp. 166-71. See also T. M. Scanlon, "Preference and Urgency," Journal of Philosophy (1975): 655-69, at pp. 659-60.
31. The View from Nowhere, p. 168.
32. Our imagined critic maintains that people's judgments when they imagine themselves in a position of a third party thinking about the appropriate treatment for a single person considered in isolation will differ from their judgments when considering treatments for themselves. Contrary to this claim, Ubel et al., "Value Measurement in Cost-Utility Analysis," reports no significant difference between the treatments people would prefer from these two perspectives.
33. See n. 36 below for evidence of the existence of a further shift of this kind.
34. See Nord, "The Trade-Off between Severity of Illness and Treatment Effect" and "The Person Trade-Off Approach." See also the Appendix to this article.
35. Nord et al., "Incorporating Societal Concerns for Fairness," Table 1.
36. Not only do Nord et al. report that people are indifferent between treating one person with the very severe impairment and treating fifteen people with the moderate impairment. Recall that they also report that people are indifferent between treating one person with the very severe impairment and treating 1,500 people with the slight impairment. (Other studies cited in n. 7 above also report a phenomenon of this kind.) When one could instead treat someone else who is afflicted with the very severe impairment, why is treating people afflicted with the slight impairment regarded as so much less important than treating people afflicted with the moderate impairment? Our conjecture is as follows. Not only do the comparative considerations that we described in Section IV tell more strongly in favor of treating someone with the very severe impairment when the alternative is treating others with the slight as opposed to the moderate impairment. But also the case for treating others with the slight as opposed to the moderate impairment is weakened further, in the judgment of many, on account of the fact that it is far less apparent that treatment of the slight impairment meets people's needs than it is that treatment of the moderate impairment meets people's needs.
37. Parfit writes that "on the Priority View, we should give priority, not to meeting special needs, but to benefiting those people who are worse off" ("Equality or Priority?" p. 103).
38. Parfit constructs one such case in ibid., pp. 102-3.
39. See ibid., p. 106.
40. On What Matters (manuscript dated September 24, 2008), Section 21.
41. See Larry G. Epstein and Uzi Segal, "Quadratic Social Welfare Functions," Journal of Political Economy 100 (1992): 691-712. We are grateful to Marc Fleurbaey for drawing our attention to this view. For an innovative argument against ex ante views in social choice, see Fleurbaey, "Assessing Risky Social Situations" (unpublished manuscript, 2007).
42. Indeed, given a von Neumann-Morgenstern measure of utility, it is easy to see that ex ante Prioritarianism will always follow each person's judgments of her own good in one-person cases.
43. In this judgment, the two comparative views we have surveyed agree, though for different reasons. If we believe in the intrinsic badness of inequality, those with the very severe impairment have a stronger claim because by aiding them we diminish intrinsically bad ex post inequality. From the alternative perspective that appeals to the comparative strength of different people's claims, those who will develop the very severe impairment have a stronger claim on the treatment for that impairment because they will be worse off than those who will develop the slight impairment.
44. See for remarks by Derek Parfit in reply to this article, plus the authors' response.
45. See Nord et al., "Incorporating Societal Concerns for Fairness."