Should priority in the allocation of organs be given to those who have previously donated or declared their willingness to do so? This article examines the Israeli priority rule in light of two prominent critiques of priority rules, pertaining to failure to reciprocate and unfairness. The scope and content of these critiques are interpreted from the perspective of equality of opportunity. Because the Israeli priority rule may be reasonably criticized for unfairness and failing to reward (...) certain behaviors, the article develops an adjusted priority rule, which removes and adjust the elements in the Israeli priority rule deemed problematic. However, such a priority rule is complex to the extent that it may fail to increase donation rates and furthermore introduce new concerns of fairness, as the better off may be better able to navigate the complex adjusted priority rule. (shrink)

In recent years there has been a good deal of discussion of equality’s place in the best account of distribution or distributive justice. One central question has been whether egalitarianism should give way to a principle requiring us to give priority to the worse off. In this article, I shall begin by arguing that the grounding of equality is indeed insecure and that the priority principle appears to have certain advantages over egalitarianism. But I shall then (...) claim that the priority principle itself is ungrounded and that the priority principle should itself give way to a sufficiency principle based — indirectly, via the notion of an impartial spectator — on compassion for those who are badly off. (shrink)

Derek Parfit has argued that (Teleological) Egalitarianism is objectionable by breaking a person-affecting claim to the effect that an outcome cannot be better in any respect - such as that of equality - if it is better for nobody. So, he presents the Priorty View, i.e., the policy of giving priority to benefiting the worse-off, which avoids this objection. But it is here argued, first, that there is another person-affecting claim that this view violates. Secondly, Egalitarianism can be (...) construed as person-affecting in a weaker sense. Thirdly, it is possible to construct a Relational version of the Priority View which incorporates the Egalitarian value of just equality in this sense. Two reasons are given for why this Relational View and Egalitarianism are superior to the Parfitian Absolute Priority View. However, no attempt is made to abjudicate between the first two views, the main point being that they both accept the value of just equality in the same sense. (shrink)

One of the central debates within contemporary Anglo-American political philosophy concerns how to formulate an egalitarian theory of distributive justice which gives coherent expression to egalitarian convictions and withstands the most powerful anti-egalitarian objections. This book brings together many of the key contributions to that debate by some of the world’s leading political philosophers: Richard Arneson, G.A. Cohen, Ronald Dworkin, Thomas Nagel, Derek Parfit, John Rawls, T.M. Scanlon, and Larry Temkin.

This paper aims to illuminate some issues in the equality, priority, or what debate. I characterize egalitarianism and prioritarianism, respond to the view that we should care about sufficiency or compassion rather than equality or priority, discuss the levelling down objection, and illustrate the significance of the distinction between prioritarianism and egalitarianism, establishing that the former is no substitute for the latter. In addition, I respond to Bertil Tungodden's views regarding the Slogan, the levelling down objection, (...) the Pareto Principle, leximin, the principle of personal good, strict moderate egalitarianism, the Hammond Equity Condition, the intersection approach, and non-aggregative reasoning. (shrink)

John Rawls’s thesis that a certain package of basic liberties should be given lexical priority is of great interest for legal and political philosophy, but it has received relatively little defense from Rawls or his supporters. In this paper, I examine three arguments for the thesis: the first is based on the two ‘moral powers’; the second, on the social bases of self-respect; and the third, on a Kantian notion of autonomy. I argue none of these accounts successfully establishes (...) 1) the distinct claim of lexical priority, 2) for the complete package of basic liberties, on the basis of reasons that are appropriately public. In turn, I propose an alternative argument, in support of those two claims, based on the social or ‘relational’ conception of equality. (shrink)

Suppose that you must make choices that may influence the well-being and the identities of the people who will exist, though not the number of people who will exist. How ought you to choose? This paper answers this question. It argues that the currency of distributive ethics in such cases is a combination of an individual’s final well-being and her expected well-being conditional on her existence. It also argues that this currency should be distributed in an egalitarian, rather than a (...) prioritarian, manner. (shrink)

:Both egalitarianism and prioritarianism give value to equality. Prioritarianism has an additively separable value function whereas egalitarianism does not. I show that in some cases prioritarianism and egalitarianism necessarily have different implications: I describe two alternatives G and H such that egalitarianism necessarily implies G is better than H whereas prioritarianism necessarily implies G and H are equally good. I also raise a doubt about the intelligibility of prioritarianism.

We discuss two leading theories of distributive justice: egalitarianism and prioritarianism. We argue that while each has particular merits and shortcomings, egalitarian views more fully satisfy a key requirement of distributive justice: respect for both the unity of the individual and the separateness of persons.

:This paper questions the distinction between egalitarianism and prioritarianism, arguing that it is important to separate the reasons for particular social preferences from the contents of these preferences, that it is possible to like equality and separability simultaneously, and that some egalitarians and prioritarians may therefore share the same social preferences. The case of risky prospects, for which Broome has proposed an interesting example meant to show that egalitarians and prioritarians cannot share the same preferences, is scrutinized. The levelling (...) down objection is also examined. (shrink)

Moral egalitarianism will depend on one of two basic ideas. The first is the idea of equality itself. We might believe that it is a good thing if different people have equal shares of resources, or if their lives score equally well in terms of whatever makes lives valuable, at least if there is no reason based on some other moral value for one person to do better than the other. Equality is a relationship between the lives of (...) different people. This version of egalitarianism claims that the existence of the relationship makes an outcome better. It attributes value to relations between lives rather than to the content of lives. (shrink)

How should we choose between uncertain prospects in which different possible people might exist at different levels of wellbeing? Alex Voorhoeve and Marc Fleurbaey offer an egalitarian answer to this question. I give some reasons to reject their answer and then sketch an alternative, which I call person-affecting prioritarianism.

The lifetime equality view has recently been met with the objection that it does not rule out simultaneous inequality: two persons may lead equally good lives on the whole and yet there may at any time be great differences in their level of well-being. And simultaneous inequality, it is held, ought to be a concern of egalitarians. The paper discusses this and related objections to the lifetime equality view. It is argued that rather than leading to a revision (...) of the lifetime equality view, these objections, if taken seriously, should make us account for our egalitarian concerns in terms of the priority view rather than the equality view. The priority view claims that there is a greater moral value to benefiting the worse off. Several versions of the priority view are also distinguished. (shrink)

Egalitarian theories of justice hold that equality should be promoted. Typically, perfect equality will not be achievable, and it will be necessary to determine which of various unequal distributions is the most equal. All plausible conceptions of equality hold that, where perfect equality does not obtain, (1) any benefit (no matter how small) to a worst-off person that leaves him/her still a worst-off person has priority (with respect to equality promotion) over any benefit (no (...) matter how large) to a best-off person, and (2) any benefit to a worse-off person (even if not a worst-off person) has priority over a benefit of the same size to a better off person (even if not a best-off person). Beyond that there is much disagreement. (shrink)

People condemn inequalities for many reasons. For example, many who have no concern with distribution per se criticize inequalities in health care, because these inequalities lessen the benefits provided by the resources that are devoted to health care. Others who place no intrinsic value on distribution believe that a just society must show a special concern for those who are worst off. Some people, on the other hand, do place an intrinsic value on equality of distribution, regardless of its (...) contribution to other goals. Derek Parfit and Larry Temkin call these people "egalitarians." I shall always employ quotation marks when referring to "egalitarians" in this special sense, because, as I shall argue, this terminology is misleading. One of its unhappy implications is that almost all egalitarians are not "egalitarians.". (shrink)

In the effort to address the persistent organ shortage it is sometimes suggested that we should incentivize people to sign up as organ donors. One way of doing so is to give priority in the allocation of organs to those who are themselves registered as donors. Israel introduced such a scheme recently and the preliminary reports indicate increased donation rates. How should we evaluate such initiatives from an ethical perspective? Luck egalitarianism, a responsibility-sensitive approach to distributive justice, provides one (...) possible justification: Those who decide against being organ donors limit the health care resources available to others. As such, a priority rule can be justified by a luck egalitarian approach to distributive justice. Furthermore, a priority rule inspired by luck egalitarianism is well equipped to avoid prominent criticisms of such a procurement system. Luck egalitarianism provides us with reaons to exempt people who are not responsible for their inability to donate from receiving lower priority, provide sufficient information about donation, and mitigate social and natural circumstances affecting people’s choice to donate. (shrink)

-/- I start from three premises, roughly as follows: (1) that if possible world x is better than world y for every individual who exists in either world, then x is better than y; (2) that if x has a higher average utility, a higher total utility, and no more inequality than y, then x is better than y; (3) that better than is transitive. From these premises, it follows that benefits given to the worse off contribute no more to (...) the world’s value than equal-sized benefits given to the better off. (shrink)

This article argues that, contrary to the received view, prioritarianism and egalitarianism are not jointly incompatible theories in normative ethics. By introducing a distinction between weighing and aggregating, the authors show that the seemingly conflicting intuitions underlying prioritarianism and egalitarianism are consistent. The upshot is a combined position, equality-prioritarianism, which takes both prioritarian and egalitarian considerations into account in a technically precise manner. On this view, the moral value of a distribution of well-being is a product of two factors: (...) the sum of all individuals' priority-adjusted well-being, and a measure of the equality of the distribution in question. Some implications of equality-prioritarianism are considered. (shrink)

The moral principle of giving greater priority to benefiting people, the less well off they are, has been thought by some to share the plausibility of egalitarianism whilst avoiding the less plausible implications of the latter. This paper argues that the 'priority' principle does have an authentic place in our moral thinking, and that it is distinct from the idea of ‘equality’, but that the latter also has an indispensible role to play. The idea of ‘priority’has (...) its place as the expression of the moral standpoint of benevolent and sympathetic concern. ‘Equality’, in contrast, functions as a conception of social justice, from which it cannot be displaced by the idea of ‘priority’. (shrink)

The moral principle of giving greater priority to benefiting people, the less well off they are, has been thought by some to share the plausibility of egalitarianism whilst avoiding the less plausible implications of the latter. This paper argues that the 'priority' principle does have an authentic place in our moral thinking, and that it is distinct from the idea of ‘equality’, but that the latter also has an indispensible role to play. The idea of ‘priority’has (...) its place as the expression of the moral standpoint of benevolent and sympathetic concern. ‘Equality’, in contrast, functions as a conception of social justice, from which it cannot be displaced by the idea of ‘priority’. (shrink)

The lexical priority of fair equality of opportunity in John Rawls’s justice as fairness, which has been sharply criticized by Larry Alexander and Richard Arneson among others, is left almost entirely undefended in Rawls’s works. I argue here that this priority rule can be successfully defended against its critics despite Rawls’s own doubts about it. Using the few textual clues he provides, I speculatively reconstruct his defense of this rule, showing that it can be grounded on our (...) interest in self-realization through work. This reconstructed defense makes liberal use of concepts already present in A Theory of Justice , including the Aristotelian Principle (which motivates the achievement of increasing virtuosity) and the Humboldtian concept of social union (which provides the context for the development of such virtuosity). I also show that this commitment to self-realization, far from violating the priority of right in Rawls’s theory, stems directly from his underlying commitment to autonomy, which is the very foundation of the moral law in his doctrine of right. The reconstituted defense of this priority rule not only strengthens the case for justice as fairness but also has important and controversial implications for public policy. (shrink)

In this dissertation, I discuss two distributive principles in moral philosophy: Derek Parfit's Prioritarianism and Egalitarianism. I attempt to defend a version of Egalitarianism, which I call Weighted Egalitarianism. Although Parfit claims that Egalitarianism is subject to what he calls the Levelling Down Objection, I show that my proposed Weighted Egalitarianism is not subject to the Objection, and that it gives priority to the worse off people. The real difference between the two principles lies in how the weight of (...) each person's well-being is determined. Prioritarianism assumes that there is a moral scale of the goodness of well-being, independently of distributions of people's well-being. I raise two objections to this claim: firstly, it is hard to believe that the choice of the level of well-being affects our distributive judgement; secondly, it is hard to believe that there is such a moral scale independently of distributions of people's well-being. On the other hand, Weighted Egalitarianism claims that the weight is given by the rank order position of the person in the ranking by well-being level. This means that, in Weighted Egalitarianism, the goodness of a distribution is an increasing, linear function of people's well-being. Weighted Egalitarianism is not affected by the choice of the level of people's well-being. Nor does it require require the moral scale of the goodness of well-being independently of distributions of people's well-being. Leximin, which might be a version of Prioritarianism, avoids my objections. But it is hard to support Leximin, because it rules out the trade off between the better off and the worse off. I conclude that Weighted Egalitarianism is more acceptable than Prioritarianism. (shrink)

According to the Competing Claims View we decide between alternatives by looking at the competing claims held by affected individuals. The strength of these claims is a function of two features: how much they stand to benefit by each alternative, and how badly off they would be in its absence. The view can be, and is, endorsed by both egalitarians and prioritarians. For the former the second condition will concern looking at how badly off the person is relative to others, (...) whereas for the latter it will be how badly off she is in absolute terms. In this paper I want to argue that neither should be endorsed. The egalitarian version of CCV breaks down when attempting to assess the competing claims of possible persons who may never exist. Also, the view, on at least one plausible interpretation, leads to intransitive judgements. The prioritarian version of CCV, in turn, is vulnerable to its own unique objection, namely delivering an anti-prioritarian and rather implausible verdict in certain Single Person Cases. (shrink)

Derek Parfit has argued that prioritarianism “naturally” has global scope, i.e. naturally applies to everyone, irrespective of his or her particular national, state or other communal affiliation. In that respect, it differs from e.g. egalitarianism. In this article, I critically assess Parfit's argument. In particular, I argue that it is difficult to draw conclusions about the scope of prioritarianism simply from an inspection of its structure. I also make some suggestions as to what it would take to argue that prioritarianism (...) has either global or merely domestic scope. (shrink)

This paper introduces a symposium on Equality versus Priority. It explains how cases involving risk are key to distinguishing these views and discusses a 'social egalitarian' critique of both 'telic egalitarians' and 'telic prioritarians'.

When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children disagree (...) about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach. (shrink)

This article provides a systematic analysis of the proposal to use Covid‐19 vaccination status as a criterion for admission of patients with Covid‐19 to intensive care units (ICUs) under conditions of resource scarcity. The general consensus is that it is inappropriate to use vaccination status as a criterion because doing so would be unjust; many health systems, including the UK National Health Service, are based on the principle of equality of access to care. However, the analysis reveals that there (...) are several unique features of Covid vaccination status in the context of a pandemic that make this issue disanalogous to cases (such as lung cancer caused by smoking) discussed previously. First, there is equality in access to care at the point of vaccination; the unvaccinated refuse the offer of preventive care when they decline vaccination, weakening their claim to ongoing care if they become ill (this is qualitatively different from ‘poor lifestyle choices’ such as smoking). Second, the decision of one person to refuse vaccination substantially increases the risk that they will become seriously ill and need ICU care; the person who chooses not to get vaccinated thus potentially increases the pressure on intensive care bed provision, as well as increasing the risk that he or she will infect others who in turn might end up needing ICU care. Third, justice cuts both ways, and giving unvaccinated patients equal priority may itself be unjust when other patients have reduced their risk of ending up on the ICU by getting vaccinated. (shrink)

In this article, we aim to map out the complexities which characterise debates about the ethics of vaccine distribution, particularly those surrounding the distribution of the COVID-19 vaccine. In doing so, we distinguish three general principles which might be used to distribute goods and two ambiguities in how one might wish to spell them out. We then argue that we can understand actual debates around the COVID-19 vaccine – including those over prioritising vaccinating the most vulnerable – as reflecting disagreements (...) over these principles. Finally, we shift our attention away from traditional discussions of distributive justice, highlighting the importance of concerns about risk imposition, special duties, and social roles in explaining debates over the COVID-19 vaccine. We conclude that the normative complexity this article highlights deepens the need for decision-making bodies to be sensitive to public input. (shrink)

Existing state surrogate decision-maker laws are fragmented and inconsistent and fail to ensure that all eligible decision makers of the same surrogate priority class are included in the healthcare decisions made for an incapacitated loved one. In this article, we explore three categories of harm that result from failing to include all surrogates of equal priority in a patient’s healthcare decision, namely harms to the patient, harms to the excluded surrogate, and harms to the family. Given these harms, (...) we argue that clinical ethicists have a moral obligation to take reasonable steps to include all surrogate decision makers of equal priority in the healthcare decision-making process for patients without a designated healthcare proxy. (shrink)

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be met in order (...) to ensure that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)

The coronavirus disease 2019 (COVID-19) pandemic has motivated medical ethicists and several task forces to revisit or issue new guidelines on allocating scarce medical resources. Such guidelines are relevant for the allocation of scarce therapeutics and vaccines and for allocation of ICU beds, ventilators, and other life-sustaining treatments or potentially scarce interventions. Principles underlying these guidelines, like saving the most lives, mitigating disparities, reciprocity to those who assume additional risk (eg, essential workers and clinical trial participants), and equal access may (...) compete with one another. We propose the use of a “categorized priority system” (also known as a “reserve system”) as an improvement over existing allocation methods, particularly because it may be able to achieve disparity mitigation better than other methods. (shrink)

Egalitarians think that equality in the distribution of goods somehow matters. But what exactly is egalitarianism? This article argues for a characterization based on novel principles essentially involving risk. The characterization is then used to resolve disputed questions about egalitarianism. These include: the way egalitarianism is concerned with patterns, in particular its relationship to strong separability; the relationship between egalitarianism and other distributive views, such as concerns with fairness and with giving priority to the worse off; and the (...) relationship between egalitarianism and evaluative measurement. But egalitarianism is subject to a particularly severe form of the levelling-down objection, and is claimed to be false. (shrink)

BackgroundThe idea that individuals are responsible for their health has been the focus of debate in the theoretical literature and in its concrete application to healthcare policy in many countries. Controversies persist regarding the form, substance and fairness of allocating health responsibility to the individual, particularly in universal, need-based healthcare systems.ObjectiveTo examine how personal health responsibility has been framed and rationalised in Norwegian key policy documents on priority setting.MethodsDocuments issued or published by the Ministry of Health and Care Services (...) between 1987 and 2018 were thematically analysed. We developed a predefined conceptual framework that guided the analysis. The framework included: the subject and object of responsibility, the level of conceptual abstraction, temporality, normative justificatory arguments and objections to the application of personal health responsibility.ResultsAs an additional criterion, personal health responsibility has been interpreted as relevant if: the patient’s harmful behaviour is repeated after receiving treatment, and if the success of the treatment is conditional on the patient’s behavioural change. When discussed as a retrospective criterion, considerations of reciprocal fairness have been dominant. When discussed as a prospective criterion, the expected benefit of treatment justified its relevance.ConclusionPersonal health responsibility appears to challenge core values of equality, inclusion and solidarity in the Norwegian context and has been repeatedly rejected as a necessary criterion for priority setting. However, the responsibility criterion seems to have some relevance in particular priority setting decisions. (shrink)

Richard J. Arneson version 7/27/99 Is having a disability more like being a member of a racially stigmatized group or like lacking a talent? Both analogies might be apt. The Americans with Disabilities Act stresses the former analogy. The framing thought is that people with disabilities are objects of prejudice and prejudiced behaviors which wrongfully exclude them from participation in important social practices such as the labor market. Think for example of a blind person whose job applications are always automatically (...) rejected because she is blind and without any consideration of her aptitude for this or that specific job. Such a person suffers wrongful discrimination and is denied equality of opportunity. (shrink)

Some of us believe in giving priority to people who are badly off in designing social policies and in acting ourselves to help others. As Thomas Nagel puts it, the badly off should be first in the queue when benefits are distributed. This idea is one way of explaining moral views that are called ‘egalitarian.’ Egalitarian moral views can depend either on the idea of valuing equality itself or on the idea of giving priority to the interests (...) of the badly off. This paper is concerned with the second kind of egalitarianism.The purest form of the idea explains the priority in this way: a benefit for someone badly off can be more important morally, or can have more value, than a benefit of the same size for someone better off. This is to suppose that the priority in question cannot be explained by thinking in utilitarian terms and accepting the principle of diminishing marginal utility. (shrink)

Recognising and responding to injustices that benefit us is a pervasive problem of contemporary life, and arguably a mark of moral seriousness in anyone who presumes to take moral stands at all. In response, a number of authors have defended the view that such benefits normally bring with them prima facie obligations of compensation. This ‘wrongful-benefits’ approach has considerable intuitive plausibility, much of it founded in the financial metaphor that gives it an appearance of precision. Yet while the compensation scenario (...) works reasonably well in one-off cases such as receiving stolen property, it yields incoherent results when facing ongoing structural injustices. In such cases ‘innocence’ is ambiguous and our status as beneficiaries and victims is complex. In contrast, solidarity — understood as a principle of equity requiring that we side with the least well off — provides a better account of duties to respond to structural injustice. In solidarity the agent follows the lead of organised out-groups and defers to their judgment about collective actions to overcome injustice. Solidarity leads us to support the organised group that suffers from the greatest inequity. Solidarity does not use a financial metaphor and thus it neither requires full disgorgement, nor absolves us of further action when we reach the point of net-zero benefit. Rather, solidarity is a principal means for ordinary citizens to promote equity by affirming the equal status of the victims, and to atone for having benefited from injustice, whether they did so willingly or otherwise. (shrink)

Positional goods are goods whose relative amount determines their absolute value. Many goods appear to have positional aspects. For example, one’s relative standing in the distribution of education and wealth may determine one’s absolute condition with respect to goods like employment opportunities, self-respect, and social inclusion. Positional goods feature in recent arguments from T.M. Scanlon, Brian Barry, and Harry Brighouse and Adam Swift that assert that we should favor egalitarian distributions of positional goods even if we reject equality as (...) a fundamental principle of distributive justice. With respect to positional goods, worsening the better off is required to better the worse off. Thus, we have reason to “level down” goods such as education and wealth in order to benefit those worse off with respect to the value of those goods. I argue that the allegedly positional aspects of the goods in question are not actually positional. Moreover, leveling down these goods risks self-defeat: it may produce a net decrease in the value of the shares of individuals with less of such goods. If so, leveling down measures would fail on their own terms. (shrink)

In their paper ‘Why It Matters That Some Are Worse Off Than Others: An Argument against the Priority View’, Michael Otsuka and Alex Voorhoeve argue that prioritarianism is mistaken. I argue that their case against prioritarianism has much weaker foundations than it might at first seem. Their key argument is based on the claim that prioritarianism ignores the fact of the ‘separateness of persons’. However, prioritarianism, far from ignoring that fact, is a plausible response to it. It may be (...) that prioritarianism disregards the fact of the ‘unity of the individual’. But even if this is true, that doesn’t straightforwardly tell against prioritarianism as a view about distributive justice. In the end, Otsuka and Voorhoeve’s argument relies on a non-decisive intuition that they appeal to early in their paper. Their conclusion, as a result, is not compelling. (shrink)