Health systems that provide for universal patient access through a scheme of prepayments—whether through taxes, social insurance, or a combination of the two—need to make decisions on the scope of coverage that they secure. Such decisions are inherently controversial, implying, as they do, that some patients will receive less than comprehensive health care, or less than complete protection from the financial consequences of ill-heath, even when there is a clinically effective therapy to which they might have access.Controversial decisions of this (...) sort call for a public justification for covering or not covering a given treatment. Priority-setting agencies play a key role in providing such a justification. A recent... (shrink)

As health policy-makers around the world seek to make progress towards universal health coverage, they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate (...) interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play. (shrink)

There are two discourses that are used in connection with the provision of good healthcare: a rights discourse and a beneficial design discourse. Although the logical force of these two discourses overlaps, they have distinct and incompatible implications for practical reasoning about health policy. The language of rights can be interpreted as the ground of a well-designed healthcare system stressing the values of equality and inclusion, but it has less application when dealing with questions of cost-effectiveness. This difference reflects the (...) distinction between the deontological status of rights claims and a teleological approach presupposed in the language of beneficial design. However, the value of the separateness of persons contained in the discourse of rights can impose constraints on the adoption of a simple maximizing principle when thinking about the allocation of healthcare resources within a social contract for health. Throughout these issues are discussed by reference to the work of Peter Jones. (shrink)

The political theory of the property-owning democracy can be seen as a way of overcoming the ideological conflict between individualism and collectivism. Rawls offers the contemporary reference-point for this theory. Rawls contrasted the ideal-type of the property-owning democracy with the ideal-type of a capitalist welfare state. However, the terms of that contrast are not well drawn and raise a number of questions, in particular regarding Rawls’s a priori specification of the welfare state. An inductively derived specification of ideal-typical welfare states (...) suggests that horizontal redistribution, in line with the principle of social savings, is more important than vertical redistribution. Rawls’s preference for a social dividend or negative income tax scheme can be contrasted with the use of social insurance, but the latter has a claim to instantiate Rawlsian ideals better than a social dividend. There is a potential problem with the pre-emption of private savings in the welfare state, but this turns out not to be troublesome empirically or conceptually. The irony of the discussion is that those who have interpreted Rawlsian theory as justifying the welfare state have the better of the argument, despite Rawls’s own views. (shrink)

Populism sees representative government as intrinsically elitist, preferring to think about democracy in terms of the will of the people, expressed through devices such as referendums. However, this view is not one that can be made sense of and seeking to pursue the will of the people is dangerous to democracy. Citizen engagement is important in a representative democracy, but this is best conceived on a model of civil society organizations undertaking practical public deliberation. A philosophical model of deliberation leading (...) to choice is introduced, and the argument that such a theory is itself elitist is considered but found wanting. (shrink)

How much by way of economic reward is due to health care providers? Although this problem usually presents itself as a practical matter of policy, it has buried within it a number of philosophical issues, for it can be regarded as a question in the theory of economic justice. The formal principle of justice is that we should render persons what is due to them. But on what consideration in the case of health care providers can we make an assessment (...) of what is due? The answer we give to this question has significant implications for the ethical appraisal of the allocation of resources in the health care system. Some of the most difficult issues of ethical appraisal emerge when we consider the problems of allocating potentially life-saving resources between different groups of patients. Many of the most significant current issues in medical ethics—the role of QALYs, the meaning of equality and the economic evaluation of life—find their point of reference in the ‘tragic choices’ that are created when there are insufficient resources to meet apparently legitimate medical need. Yet, as Robert Evans has pointed out, it is a simple matter of accounting identity that health care expenditures must equal health providers' incomes. So, in asking how we limit or allocate costly health care resources, we are implicitly offering an answer to the question of how much we should pay providers. I hope by seeking an answer explicitly to that question to throw light on the problems that are raised when considering ethically the allocation of health care resources. (shrink)

One rationale policy-makers sometimes give for declining to fund a service or intervention is on the grounds that it would be ‘unaffordable’, which is to say, that the total cost of providing the service or intervention for all eligible recipients would exceed the budget limit. But does the mere fact that a service or intervention is unaffordable present a reason not to fund it? Thus far, the philosophical literature has remained largely silent on this issue. However, in this article, we (...) consider this kind of thinking in depth. Albeit with certain important caveats, we argue that the use of affordability criteria in matters of public financing commits what Parfit might have called a ‘mistake in moral mathematics’. First, it fails to abide by what we term a principle of ‘non-perfectionism’ in moral action: the mere fact that it is practically impossible for you to do all the good that you have reason to do does not present a reason not to do whatever good you can do. And second, when used as a means of arbitrating between which services to fund, affordability criteria can lead to a kind of ‘numerical discrimination’. Various attendant issues around fairness and lotteries are also discussed. (shrink)

In order to create sustainable health systems, many countries are introducing ways to prioritize health services underpinned by a process of health technology assessment. While this approach requires technical judgments of clinical effectiveness and cost-effectiveness, these are embedded in a wider set of social (societal) value judgments, including fairness, responsiveness to need, non-discrimination and obligations of accountability and transparency. Implementing controversial decisions faces legal, political and public challenge. To help generate acceptance for the need for health prioritization and the resulting (...) decisions, the purpose of this paper is to develop a novel way of encouraging key stakeholders, especially patients and the public, to become involved in the prioritization process. (shrink)

Modern Social Contract Theory provides an exposition and evaluation of major work in social contract theory from 1950 to the present. It locates the central themes of that theory in the intellectual legacy of utilitarianism, particularly the problems of defining principles of justice and of showing the grounds of moral obligation. It demonstrates how theorists responded in a novel way to the dilemmas articulated in utilitarianism, developing in their different approaches a constructivist method in ethics, a method that aimed to (...) vindicate a liberal, democratic and just political order. A distinctive feature of the book is its comparative approach. By placing the works of Barry, Buchanan and Tullock, Harsanyi, Gauthier, Grice, Rawls, and Scanlon alongside one another, similarities and differences are brought out, most notably in the way in which principles are derived by each author from the contractual construction as well as the extent to which the obligation to adopt those principles can be rationally grounded. Each theory is placed in its particular intellectual context. Special attention is paid to the contrasting theories of rationality adopted by the different authors, whether that be utility theory or a deliberative conception of rationality, with the intention of assessing how far the principles advanced can be justified by reference to the hypothetical choices of rational contracting agents. The book concludes with a discussion of some principal objections to the enterprise of contract theory, and offers its own programme for the future of that theory taking the form of the empirical method. (shrink)

Is it possible to reconcile a classical liberal approach to economics with a concern for the environment? The contributors to Economics and the Environment: A Reconciliation contend that it is. But they fail to distinguish properly between classical liberalism and a widespread orthodoxy in environmental policy communities in Europe and North America to the effect that economic instruments for environmental policy need more serious attention than they have hitherto received. Once this orthodoxy is distinguished from classical liberalism, the latter is (...) seen to be implausible. In particular, the classical liberal approach fails to deal with the practical and administrative problems involved in enforcing private property rights solutions to problems of environmental protection, wrongly generalizes from the failures of U.S. environmental policy to the failure of public regulation as such, and fails to take into account the claim that nature should be accorded intrinsic value. (shrink)

John Horton has argued for an associative theory of political obligation in which such obligation is seen as a concomitant of membership of a particular polity, where a polity provides the generic goods of order and security. Accompanying these substantive claims is a methodological thesis about the centrality of the phenomenology of ordinary moral consciousness to our understanding of the problem of political obligation. The phenomenological strategy seems modest but in some way it is far-reaching promising to dissolve some long-standing (...) problems of political theory. However, it fails at just the point at which a theory of political obligation is needed, namely when individuals question the grounds of their political obligation. A principle of obligation is needed to provide individuals with a reason for compliance with authoritative social rules when the exercise of that obligation is irksome. It is at this point that we need to invoke the idea of society as an implicit social contract, in which obligations are seen as stemming from those terms that it would be in the interests of individuals to agree in a social contract. This is consistent with the method of reflective equilibrium. (shrink)

(2012). Introduction: The value and limits of rights: essays in honour of Peter Jones. Critical Review of International Social and Political Philosophy: Vol. 15, The Value and Limits of Rights: Essays in Honour of Peter Jones, pp. 387-394. doi: 10.1080/13698230.2012.699394.

The two books offer a contextual reinterpretation of Rawlsian and post-Rawlsian liberalism. Nelson’s main thesis is that debates in liberal political theory re-enact theological debates about theod...

Brian Barry was the leading European normative political theorist of his generation, his intellectual influence being felt in Europe, North America, Australasia, and indeed wherever normative political theory in the analytical mode is practised. As well as being a Fellow of the British Academy, he was a Fellow of the American Academy of Arts and Sciences and the only Briton to have received the prestigious Johann Skytte prize from the University of Uppsala for achievement in the study of political science. (...) During his life Barry published seven single-authored books and five co-edited volumes, as well as over seventy articles and a large number of reviews and review essays, some of the latter being full-length and original articles in their own right. He had a deep and abiding commitment to the professionalization of the study of politics and was an inspiration to many younger scholars. (shrink)