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 healthyears 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: Health Your Wellbeing My Wellbeing 1 10 1 2 20 2 3 25 2.5 • 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 Incr Weight Total Priority-Weighted HY 0 to 1 1 1 1 to 2 .9 1.9 2 to 3 .8 2.7 • 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.