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Health Prioritarianism. Peter Vallentyne University of Missouri. Background. Universal Coverage Question: What determines whether one form of universal coverage is morally better than another?

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health prioritarianism

Health Prioritarianism

Peter Vallentyne

University of Missouri

background
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
  • 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 prioritarianism1
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
  • 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 wellbeing1
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
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
  • 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
Additive Prioritarianism
  • Assume a set of finitelydecreasing 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-weightedhealth-years is better.
    • (2) For same total priority-weightedhealth-years, the policies are equally good.
  • This treats priority as more than a tie-breaker for the same total health-years.
additive prioritarianism1
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
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
  • 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 numberof people who are only slightly more healthy a massive increase in health.
conclusion
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.