This paper is a critique of Norman Daniels' and James Sabin's ‘Accountability for Reasonableness’ framework for making priority-setting decisions in health care in the face of widespread disagreement about values. Accountability for Reasonableness has been rapidly gaining worldwide acceptance, arguably to the point of becoming the dominant paradigm in the field of health policy. The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even (...) those who would be adversely affected will have reason to abide by them. I argue that the framework's four conditions are inadequate to this task. While we certainly require a fair and legitimate procedure for making priority setting decisions in health care despite a lack of consensus on relevant ethical and political issues, we must significantly revise the four conditions, and we cannot avoid facing our substantive disagreements head on if we hope to arrive at decisions that would (and should) be acceptable to everyone. I offer two suggestions. First, there is need for greater public involvement in all stages of deliberation. Second, we should give up on the idea that we can simplify the task of democratic deliberation by disallowing particular kinds or reasons and types of reasoning. Reasons of all kinds should be on the table, but then should be judged on their merits, such as consistency, plausibility and explanatory power, without any regard for their alleged sources of authority. (shrink)

It is widely held that individuals who are unable to provide informed consent should be enrolled in clinical research only when the risks are low, or the research offers them the prospect of direct benefit. There is now a rich literature on when the risks of clinical research are low enough to enroll individuals who cannot consent. Much less attention has focused on which benefits of research participation count as ‘direct’, and the few existing accounts disagree over how this crucial (...) concept should be defined. This disagreement raises concern over whether those who cannot consent, including children and adults with severe dementia, are being adequately protected. The present paper attempts to address this concern by considering first what additional protections are needed for these vulnerable individuals. This analysis suggests that the extant definitions of direct benefits either provide insufficient protection for research subjects or pose excessive obstacles to appropriate research. This analysis also points to a modified definition of direct benefits with the potential to avoid these two extremes, protecting individuals who cannot consent without blocking appropriate research. (shrink)

This article addresses the question of whether the relation of moral preference is transitive. I argue, following Larry Temkin and Stuart Rachels, that any ethical theory complex enough to be even minimally plausible allows us to generate intransitive sets of preferences. Even act utilitarianism cannot avoid this predicament unless we accept its least plausible version. We must reevaluate the assumption that an ethical theory must be transitive in order to be rational. This problem amounts to a foundational crisis in ethics. (...) However, it has not been taken seriously for two reasons—the belief that the problem has limited scope; and the claim that arguments against transitivity are 'merely' Sorites arguments. This article responds to both of these objections. I also point out some connections between intransitivity and the debate surrounding skepticism about the moral significance of numbers. (shrink)

Distance and morality. I argue that in "Faminine Ethics: the Problem of Distance in Morality and Singer's Ethical Theory" Frances Kamm fails to produce a pair of cases in which a moral difference is present that is not attributable to factors other than distance. I also point out that Kamm's attempts at explaining why distance could possibly matter in morality fall far short. I conclude that there is no reason for us to believe that distance matters in morality and offer (...) an explanation for why it might nevertheless appear to us that it does---there are numerous factors, normally correlated with distance, that are of great moral significance. In the process I offer a few methodological remarks. ;The problem of numbers. I argue that John Taurek's conclusion in "Should the Numbers Count?" remains a viable alternative to the standard view of the role of numbers in morality. I claim that Taurek brings up valid concerns regarding the standard view, and that the objections that have so far been raised against Taurek's position are by far insufficient to remove it from contention. I then point out and try to address several problems, including the problem of very large numbers, which should be a concern to anyone who is sympathetic to Taurek's views. I do not claim to have the answers, but I suggest a direction in which one may look for a solution. ;The return of the trolley. I examine several purported solutions to the Trolley Problem and find them all severely deficient. In light of the systematic failure of efforts to solve the Trolley Problem, I suggest that perhaps no solution has been found because there is no solution to find. I proceed to give a positive argument for the claim that diverting the trolley is not morally permissible and try to give an explanation of how the intuitions of the majority could have been so deeply mistaken. Since my proposed "solution" relies heavily on the making/allowing distinction, I conclude with a discussion of that distinction and a defense of its moral significance. (shrink)

It is a basic and intuitive assumption that the relation of moral preference must be transitive—if A is overall morally preferable to B; and B is overall morally preferably to C; then, if our views are coherent, it better be the case that A is overall morally preferable to C. However, recent work by Temkin and Rachels has undermined that assumption by showing that common-sense ethical distributive principles that we are unlikely to give up generate intransitive sets of moral preferences. (...) The consequences of this for resource allocation are profound—how can we come up with a just way of rationing limited resources if whatever course of action we adopt, there will be other alternatives that are morally preferable to it? However, regardless of the theoretical challenges, practical resource allocation decisions must be made every day! We explore an approach to dealing with some of the pragmatic aspects of the problem, even though the theoretical problem of intransitivity remains unsolved. We begin by considering whether the ways in which counterexamples to transitivity have (of necessity) been oversimplified actually contribute to the intractability of the problem by taking the possibilities of cost sharing, benefit splitting, and compensation (which are often available in real-life tradeoff situations) off the table. The proposal we end up suggesting does not rely on any assumptions or judgments about interpersonal aggregation, and so has a chance of allowing us to work around the most troubling kind of intransitivity. (shrink)

It is a basic and intuitive assumption that the relation of moral preference must be transitive—if A is overall morally preferable to B; and B is overall morally preferably to C; then, if our views are coherent, it better be the case that A is overall morally preferable to C. However, recent work by Temkin and Rachels has undermined that assumption by showing that common-sense ethical distributive principles that we are unlikely to give up generate intransitive sets of moral preferences. (...) The consequences of this for resource allocation are profound—how can we come up with a just way of rationing limited resources if whatever course of action we adopt, there will be other alternatives that are morally preferable to it? However, regardless of the theoretical challenges, practical resource allocation decisions must be made every day! We explore an approach to dealing with some of the pragmatic aspects of the problem, even though the theoretical problem of intransitivity remains unsolved. We begin by considering whether the ways in which counterexamples to transitivity have (of necessity) been oversimplified actually contribute to the intractability of the problem by taking the possibilities of cost sharing, benefit splitting, and compensation (which are often available in real-life tradeoff situations) off the table. The proposal we end up suggesting does not rely on any assumptions or judgments about interpersonal aggregation, and so has a chance of allowing us to work around the most troubling kind of intransitivity. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 28-29, July 2011.