Equity certainly matters—roughly, it’s better for two people to each have a piece of cake rather than for one person to have two and the other none. But translating into utility or QALYs already accounts for this; it’s generally easier to increase the utility/health of someone with less. The claim that equity in variables like utility or QALYs matters is much stronger and much more philosophically fraught. For example, I would rather a marginal dollar go to a typical Nigerian’s health than a typical Brit’s, but I’m indifferent about which should get a marginal QALY.
Separately, axiology is not a democracy, so surveys about people’s attitudes on equity in health feel like they’re answering the wrong question (psychological/sociological rather than moral). I’m not familiar with philosophical defenses of equity in variables like utility or QALYs for non-instrumental reasons, but if they exist I’d be curious how they make that argument.
“But translating into utility or QALYs already accounts for this; it’s generally easier to increase the utility/health of someone with less.”
I think there are certainly cases where this is true, and the premise of this argument is that there are cases where this might not be the case. If we take the burden of mental health or chronic illnesses, I think there are many possible and actual examples where it may be”easier” to increase the utility of those living in a HIC as opposed to a LMIC
I am also interested as to how you make the distinction between a marginal dollar and a marginal QALY if we recognise there is a significant gap in both income and health outcomes between say, Nigeria and the UK
For those who won’t read this dense 40-page essay, Parfit (among other worthwhile discussion) discusses Nagel’s prioritarian arguments:
By straightforward intuition: the needs of the worse-off are more urgent and thus higher-priority.
By straightforward intuition: equality is fundamentally valuable.
For instrumental (indirect) reasons: equality generally has good effects.
We can reject the first two points for various reasons (chief among them: accepting aggregative consequentialism, or rejecting theories that rely on persons as irreducible-locations-of-value). We should pay great heed to the third point, not ignoring indirect effects—but by the time it is specified that one action produces 9 QALYs and another 10, we have already taken indirect effects into account. (If the 9-QALY action has other positive indirect effects, we should have called it a 12-QALY action, or whatever the sum comes out to.)
Equity certainly matters—roughly, it’s better for two people to each have a piece of cake rather than for one person to have two and the other none. But translating into utility or QALYs already accounts for this; it’s generally easier to increase the utility/health of someone with less. The claim that equity in variables like utility or QALYs matters is much stronger and much more philosophically fraught. For example, I would rather a marginal dollar go to a typical Nigerian’s health than a typical Brit’s, but I’m indifferent about which should get a marginal QALY.
Separately, axiology is not a democracy, so surveys about people’s attitudes on equity in health feel like they’re answering the wrong question (psychological/sociological rather than moral). I’m not familiar with philosophical defenses of equity in variables like utility or QALYs for non-instrumental reasons, but if they exist I’d be curious how they make that argument.
“But translating into utility or QALYs already accounts for this; it’s generally easier to increase the utility/health of someone with less.”
I think there are certainly cases where this is true, and the premise of this argument is that there are cases where this might not be the case. If we take the burden of mental health or chronic illnesses, I think there are many possible and actual examples where it may be”easier” to increase the utility of those living in a HIC as opposed to a LMIC
I am also interested as to how you make the distinction between a marginal dollar and a marginal QALY if we recognise there is a significant gap in both income and health outcomes between say, Nigeria and the UK
Derek Parfit has a good discussion of “prioritarian” views that place greater weight on the welfare of the less well-off: https://www.philosophy.rutgers.edu/joomlatools-files/docman-files/3ParfitEqualityorPriority2000.pdf
Thanks!
For those who won’t read this dense 40-page essay, Parfit (among other worthwhile discussion) discusses Nagel’s prioritarian arguments:
By straightforward intuition: the needs of the worse-off are more urgent and thus higher-priority.
By straightforward intuition: equality is fundamentally valuable.
For instrumental (indirect) reasons: equality generally has good effects.
We can reject the first two points for various reasons (chief among them: accepting aggregative consequentialism, or rejecting theories that rely on persons as irreducible-locations-of-value). We should pay great heed to the third point, not ignoring indirect effects—but by the time it is specified that one action produces 9 QALYs and another 10, we have already taken indirect effects into account. (If the 9-QALY action has other positive indirect effects, we should have called it a 12-QALY action, or whatever the sum comes out to.)