Health Prioritarianism Peter Vallentyne University of Missouri

Background Universal Coverage Question: What determines whether one form of universal coverage is morally better than another? More General Question: What determines whether a health policy/system, for a given country at a given time, is morally better than another? General Assumption: If one system is Pareto superior to the other (i.e., gives some people more wellbeing, and none less), then it is morally better. Simplifying Assumptions: –A useful proxy for individual’s lifetime wellbeing is individual health-adjusted years of life (e.g., number of Dalys) –Fixed population (so that total = average; and to avoid non-identity problem) –Certainty in outcomes (to avoid the need to appeal to probabilities) Health-year = df one year of “perfect” health (e.g., one Daly)

Health Utilitarianism Health Utilitarianism (no priority to less healthy): –(1) Greater total health-years is better. –(2) For same total health-years, the policies are equally good. Problem (no sensitivity to equity): No sensitivity to how individual health-years are distributed among people. Equity (relevant distribution-sensitivity): –Might appeal to desert –Might appeal to equality –Might appeal to priority for worse off. I shall focus on priority for worse off. Arguably, the appeal to wellbeing, or health-years, should be to brute luck wellbeing or health-years (i.e., not attributable to her agency). For simplicity, I ignore this.

Health Prioritarianism Health Prioritarianism: It is morally more important to increase the health-years of a given person by n units than to increase the health- years of a person with more health-years by n units. Questions: –(1) Is Health Prioritarianism correct? –(2) What are some of the main forms that it can take? Two reasons to endorse Health Prioritarianism: –Decreasing Marginal Impact of Health on Wellbeing –Wellbeing Prioritarianism Let’s explore each.

Decreasing Marginal Impact of Health on Wellbeing Decreasing Marginal Impact of Health on Wellbeing: For a given individual, all else being equal, increasing a person’s health-years by a given number of units has a smaller impact on her wellbeing, the higher her level of health-years is. Example: Suppose that increasing someone’s health-years from 1 unit to 2 increases her wellbeing by 1 unit. –Then, all else being equal, increasing her health-years from 2 units to 3 increases her wellbeing by less than 1 unit. Health Prioritarianism does not follow from Decreasing Marginal Impact on Wellbeing (in conjunction with Wellbeing Utilitarianism). The former is an interpersonal condition, whereas the latter is purely intrapersonal.

Decreasing Marginal Impact of Health on Wellbeing Example: HealthYour WellbeingMy Wellbeing We each have decreasing marginal impact of health on wellbeing, but increasing your health from 2 to 3 (increase of 5 units of wellbeing) may be more morally more important than increasing my health from 1 to 2 (increase of 1 unit of wellbeing). Health Prioritarianism does follow, if we assume (1) Wellbeing utilitarianism (maximize total), and (2) everyone’s cardinal wellbeing is cardinally affected by health in the same way (all else being equal). (2) is false, but it may be a good working assumption for aggregate measures of wellbeing for large populations. Let’s assume so.

Wellbeing Prioritarianism A second reason to endorse Health Prioritarianism: Wellbeing Prioritarianism: It is morally more important to increase the wellbeing of a given person by a given number of units than to increase the wellbeing of a person with greater wellbeing by the same number of units. This does not entail Health Prioritarianism: A person with lower health can have higher wellbeing (since health is not the only factor for wellbeing). Still, for large populations, at the aggregate level, wellbeing and health will be closely correlated. So, if Wellbeing Prioritarianism is correct, then there is a second reason to endorse Health Prioritarianism in practice when dealing with aggregates for large populations. Let us now consider some forms that Health Prioritarianism can take.

Weakly Prioritarian Health Utilitarianism Weakly Prioritarian Health Utilitarianism: –(1) Greater total health-years is better. –(2) For same total health-years, the policy with the greater lowest individual number of health-years is better (and, for ties, compare the second lowest number of health-years, etc.). This invokes priority only as a tie-breaker. –This is arguably too little priority.

Additive Prioritarianism Assume a set of finitely decreasing priority-weights for health-year increments. For example: Health-year IncrWeight Total Priority-Weighted HY 0 to to to Additive Prioritarianism: –(1) Greater total priority-weighted health-years is better. –(2) For same total priority-weighted health-years, the policies are equally good. This treats priority as more than a tie-breaker for the same total health-years.

Additive Prioritarianism One problematic feature is that this entails that it can judge it better to give a trivial increase in health to sufficiently many very healthy people rather than to give a major increase in health to one very unhealthy person. The severity of this problem will depend on how quickly the priority weights decrease. –They might decrease so slowly that in practice they are equivalent to constant marginal weights (as with utilitarianism). –Or they might decrease so quickly that in practice they are equivalent to leximin (absolutely priority of the worse off; see below).

Threshold prioritarianism Set a threshold for adequate health-years. A person’s truncated health-years is the lesser of her actual level of health-years and the threshold. –For example, if the threshold is 10, and A has 8 health-years and B has 12, then their respective truncated health-years are 8 and 10. Threshold prioritarianism: –(1) Greater total truncated prioritarian-weighted health-years (which ignores health above the threshold) is better. –(2) For the same total truncated prioritarian-weighted health-years, greater total prioritarian-weighted health-years (with no truncation) is better. Below the threshold, this gives finite priority to those who are worse off, and likewise above the threshold. –Moreover, it gives absolute priority to the health of those below the threshold over those above the threshold. Thus, it avoids the above problem “numbers problem”. This involves, however, a questionable discontinuity at the threshold.

Leximin Leximin: –(1) Greater health-years for a person with the least health-years is better. –(2) If there is a tie, greater health-years for a person with the second least health-years is better. Etc. This gives absolute priority to a less healthy person. It faces the problem that it deems it better to give the least healthy person a trivial increase in health rather than to give a massive number of people who are only slightly more healthy a massive increase in health.

Conclusion If one adopts Health Prioritarianism, there is the question of how strong the priority should be for the less healthy. There is an on-going investigation of these issues by moral philosophers and normative economists.