This paper compares and contrasts three different substantive principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing principle. In conclusion, (...) it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions. (shrink)

We present the Welleye – a novel and conceptually clear framework that shows how attention links the objective circumstances of people’s lives and selves to how they spend their time and feel day to day. While existing wellbeing frameworks in policy contain many of the factors included in the Welleye, they all lack attention as the “lens” that determines the impact of these factors on how people feel. Policymakers and organizations can use the Welleye to better understand how people are (...) faring and design and evaluate interventions aimed at making people better off. (shrink)

Scarce healthcare resources can be allocated in many ways. The National Institute for Health and Clinical Excellence in the UK focuses on the size of the benefit relative to costs, yet we know that there is support among clinicians and the general public for reducing inequalities in health. This paper shows how the UK general public trade-off these sometimes competing objectives, and the data we gather allow us to show the weight given to different population groups, for example, 1 extra (...) year of life in full health to someone who would otherwise die at the age of 60 years is worth more than twice as much as an additional year of life to someone who would otherwise die at the age of 70 years. Such data can help inform the rationing decisions faced by all healthcare systems around the world. (shrink)

A large literature documents the correlates and causes of subjective well-being, or happiness. But few studies have investigated whether people choose happiness. Is happiness all that people want from life, or are they willing to sacrifice it for other attributes, such as income and health? Tackling this question has largely been the preserve of philosophers. In this article, we find out just how much happiness matters to ordinary citizens. Our sample consists of nearly 13,000 members of the UK and US (...) general populations. We ask them to choose between, and make judgments over, lives that are high in different types of happiness and low in income, physical health, family, career success, or education. We find that people by and large choose the life that is highest in happiness but health is by far the most important other concern, with considerable numbers of people choosing to be healthy rather than happy. We discuss some possible reasons for this preference. (shrink)

It is widely accepted that one of the main objectives of government expenditure on health care is to generate health. Since health is a function of both length of life and quality of life, the quality-adjusted life-year (QALY) has been developed in an attempt to combine the value of these attributes into a single index number. The QALY approach - and particularly the decision rule that healthcare resources should be allocated so as to maximise the number of QALYs generated - (...) has often been equated with the utilitarian philosophy of maximising `the greatest happiness of the greatest number'. This paper considers the extent to which the measurement and aggregation of QALYs really is utilitarian by developing a new taxonomy in order to classify utilitarianism and the different aspects of the QALY approach. It is shown that the measurement of QALYs is consistent with a number of different moral positions and that QALYs do not have to be aggregated according to the maximisation rule. Therefore it is inappropriate to necessarily equate QALYs with utilitarianism. It is shown that much turns on what in principle the QALY represents and how in practice it can be operationalised. The paper highlights the category confusion that is often present here and suggests possible avenues for future theoretical and empirical research. (shrink)

Behavioural spillovers refer to the influence that a given intervention targeting behaviour 1 exerts on a subsequent, non-targeted, behaviour 2, which may or may not be in the same domain (health, finance etc.) as one another. So, a nudge to exercise more, for example, could lead people to eat more or less, or possibly even to give more or less to charity depending on the nature of the spillover. But what if spillovers also operate backwards; that is, if the expectation (...) of behaviour 1 influences behaviour 0 that precedes it? For example, a person may form an intention to exercise prompted by a policy intervention but overeat at present as a result. We define such a possibility as a "spillunder". In the proposed article, we critically review the few papers that we have identified through a narrative literature review which have demonstrated spillunder effects to date, and we propose a conceptual framework. Based on evidence about the human mind and behaviour from psychology and economics, we argue that spillunder effects may be more common than the limited empirical findings suggest. We propose six representative mechanisms through which the prospect of behaviour 1 may impact behaviour 0: executive functions, moral licensing and moral cleansing, emotion regulation, energization, construal level, and savouring and dread. We further discuss the policy and practical implications of spillunder effects and examine methodological issues that need to be considered when empirically testing these effects. As with our earlier paper on spillovers, we aim to motivate other behavioural scientists to research behavioural spillunders more systematically and extensively, and to prompt decision makers to consider these effects when designing behavioural interventions. (shrink)