Preferences as fairness judgments: a critical review of normative frameworks of preference elicitation and development of an alternative based on constitutional economics.

Preference elicitation is widely used within health economic evaluations to inform coverage decisions. However, coverage decisions involve questions of social justice and it is unclear what role empirical evidence about preferences can play here. This study reviews the prevalent normative frameworks for using population-based preference elicitation and the criticisms they face, and proposes an alternative based on constitutional economics. The frameworks reviewed include a supposedly value-neutral framework of preferences as predictors of choice, preference utilitarian frameworks that aim to maximize preference satisfaction, and substantive consequentialist frameworks that aim to maximize happiness, health, or capabilities. The proposed alternative implements the idea that indices of social value are tools for conflict resolution, rather than tools for maximization. Preference elicitation is used for validating values generated by multi-criteria decision analysis results within representative processes of stakeholder deliberation.

Animal Welfare Science: Why and for Whom?

There are, in the literature, distinct ways to approach animal welfare. The objective of this work was to study the value attributed to farm animals in the scientific papers published in animal welfare and animal production journals at three different points in time, separated by a decade each. The first ten papers mentioning "animal welfare" or "animal well-being" in their objectives or hypotheses from each journal and each focus year were selected. The 180 papers were blindly scored by five assessors between 1 and 10, according to the degree of intrinsic value attributed to animals. The overall mean score and standard deviation were 5.60 ± 2.49, with 6.46 ± 2.29 and 4.74 ± 2.40 for AW and AP journals, respectively, and 5.37 ± 2.44, 5.68 ± 2.52 and 5.75 ± 2.41 for the focus years of 2000, 2010 and 2020, respectively. There was an interaction between focus year and publication area: papers from AW journals scored better over time, in contrast with papers from AP journals, for which scores remained similar over decades. The inter-assessor agreement is moderate, which may reflect the subject complexity, as the language used in the papers studied was ambiguous in relation to why and for whom it is performed. The low overall mean score evidenced that the animal welfare scientific publications are, on average, not prioritizing the interests of the animals. Thus, our results evidenced the presence of animal welfarism in animal welfare science, a problem that seems not to be intrinsic to animal welfare science itself, but rather to the way research is frequently conceived, conducted, interpreted, summarized and applied. Therefore, it seems urgent to further study the motivation for animal welfare research. The statement of the main justification for animal welfare papers, with an explicit declaration of the motivational priorities that constitute each scientific animal welfare study, may be an interesting recommendation for the improvement of animal welfare science.

A world of difference: The fundamental opposition between transhumanist "welfarism" and disability advocacy.

From the standpoint of disability advocacy, further exploration of the concept of well-being stands to be availing. The notion that "welfarism" about disability, which Julian Savulescu and Guy Kahane debuted, qualifies as helpful is encouraged by their claim that welfarism shares important commitments with that advocacy. As becomes clear when they apply their welfarist frame to procreative decisions, endorsing welfarism would, in fact, sharply undermine it. Savulescu and Kahane's Principle of Procreative Beneficence-which reflects transhumanism, or advocacy of radical bioenhancement-morally requires parents to choose the child who will, in all probability, have "the best life." Assuming the emergence of potent biotechnologies, procreative decision-making would be highly standardized, for prospective parents would be morally obliged to maximize select capacities, including intelligence, self-control, and hedonic set-point, in their children. Welfarism, applied to reproduction, is staunchly objectivist about what course is incumbent on decision-makers, giving no credence to first-personal values, aspirations, and experiences. Though this dismissal of individual perspectives applies to everyone, its implications for disability advocacy are especially severe. With that advocacy in view, greater attention to "well-being" should, therefore, be severed from the welfarism of Savulescu and Kahane.

Algorithms and heuristics of health technology assessments: A retrospective analysis of factors associated with HTA outcomes for new drugs across seven OECD countries.

CONTEXT: Positive health technology assessment (HTA) outcomes can have important implications for equity, efficiency and timely patient access to novel therapies. Several outcomes and dimensions of benefit beyond utility feed into HTA processes. OBJECTIVE: We analyse a proprietary dataset of HTA outcomes in 7 countries, to (a) test whether HTA decision-making is grounded in welfarist or extra-welfarist approaches; and (b) empirically determine the factors associated with positive HTA outcomes, the time to achieve these and establish the magnitude of inter-country differences in assessment processes. METHODS: Data were extracted from publicly available HTA reports on drugs that received marketing authorisation between 2009 and 2018 (N = 1415). The outcomes of interest were the probability of positive HTA outcomes and the time-to-HTA outcome; these were examined with respect to clinical, regulatory, product- and disease-related, evidence uncertainty and contextual variables. Econometric models utilising survival analysis and multinomial logistic regression were specified. FINDINGS: Positive HTA outcomes accounted for 87.3% of the sample (n = 1235), of which 71% (n = 1004) were restricted. Drugs with positive HTA outcomes were subject to clinical restrictions (n = 652, 46%), financial risk-sharing (n = 439, 31%) or had been rejected at least once (n = 282, 20%). Significant predictors of positive HTA outcomes were orphan drugs with cancer indications, high quality of evidence linked to clinical and economic evidence uncertainties which had been overcome, and contextual considerations, particularly innovativeness and unmet need. Comparative analyses revealed systematic differences between countries in their propensity to accept the same drugs, particularly oncology and orphan drugs. CONCLUSIONS: Our results are contextual and reinforce arguments in favour of explicitly accounting for social value judgements, establishing separate assessment frameworks for highly uncertain products, adopting risk mitigation strategies for novel therapies with early phase evidence, and sharing of HTA practices across settings. Lastly, HTA agencies have adopted an extra-welfarist approach to value assessment and resource allocation.

Religious preferences in healthcare: A welfarist approach.

This paper offers a general approach to ethics before considering its implications for the question of how to respond to religious preferences in healthcare, especially those of patients and healthcare workers. The first section outlines the two main components of the approach: (1) demoralizing, that is, seeking to avoid moral terminology in the discussion of reasons for action; (2) welfarism, the view that our ultimate reasons are grounded solely in the well-being of individuals. Section 2 elucidates the notion of religious preferences and describes the history and importance of their protection by human rights legislation. The following section defends the 'Preference Principle', according to which there is a reason to satisfy any preference (in so far as that satisfaction advances well-being). Section 4 discusses the implications of this principle for religious preferences in healthcare, again seeking to bring out the special social and political importance of respect, and respect for such preferences in particular. The paper ends with a brief description of how to approach such problems from the perspective of a demoralized welfarism.

Doctor, please make me freer: Capabilities enhancement as a goal of medicine.

Biomedical innovations are making possible the enhancement of human capabilities. There are two philosophical stances on the role that medicine should play in this respect. On the one hand, naturalism rejects every medical intervention that goes beyond preventing and treating disease. On the other hand, welfarism advocates enhancements that foster subjective well-being. We will show that both positions have considerable shortcomings. Consequently, we will introduce a third characterization in which therapies and enhancements can be reconciled with the legitimate objectives of medicine inasmuch as they improve the capabilities that enable the freedom to pursue personal well-being.

Disability and multidimensional quality of life: A capability approach to health status assessment.

This paper offers an approach to assessing quality of life, based on Sen's (1985) theory, which it uses to understand loss in quality of life due to mobility impairment. Specifically, it provides a novel theoretical analysis that is able to account for the possibility that some functionings may increase when a person's capabilities decrease, if substitution effects are large enough. We then develop new data consistent with our theoretical framework that permits comparison of quality of life between those with a disability (mobility impairment) and those without. Empirical results show that mobility impairment has widespread rather than concentrated impacts on capabilities and is associated with high psychological costs. We also find evidence that a small number of functionings are higher for those with a disability, as our theory allows. The paper concludes by discussing possible implications for policy and health assessment methods.

Animal Morality: What It Means and Why It Matters.

It has been argued that some animals are moral subjects, that is, beings who are capable of behaving on the basis of moral motivations (Rowlands 2011, 2012, 2017). In this paper, we do not challenge this claim. Instead, we presuppose its plausibility in order to explore what ethical consequences follow from it. Using the capabilities approach (Nussbaum 2004, 2007), we argue that beings who are moral subjects are entitled to enjoy positive opportunities for the flourishing of their moral capabilities, and that the thwarting of these capabilities entails a harm that cannot be fully explained in terms of hedonistic welfare. We explore the implications of this idea for the assessment of current practices involving animals.

Can a Welfarist Approach be Used to Justify a Moral Duty to Cognitively Enhance Children?

The desire to self-improve is probably as old as humanity: most of us want to be smarter, more athletic, more beautiful, or more talented. However, in the light of an ever increasing array of possibilities to enhance our capacities, clarity about the purpose and goal of such efforts becomes crucial. This is especially true when decisions are made for children, who are exposed to their parents' plans and desires for them under a notion of increasing wellbeing. In recent years, cognitive enhancement has become a popular candidate for the promotion of wellbeing; welfarists even impose a moral duty on parents to cognitively enhance their children for the sake of their wellbeing. In this article, I aim to show that welfarists are mistaken in inferring such a moral obligation from the potential benefit of cognitive enhancement. In support of this, I offer three arguments: (a) the vagueness of wellbeing as a theoretical concept means it becomes impossible to apply in practice; (b) the link between cognition and wellbeing is far from unequivocal; and (c) quantification issues with regard to cognition make a duty impossible to discharge. In conclusion, I reject the welfarist approach as a justification for a parental moral obligation to cognitively enhance children.

A Framework for Including Family Health Spillovers in Economic Evaluation.

Health care interventions may affect the health of patients' family networks. It has been suggested that these "health spillovers" should be included in economic evaluation, but there is not a systematic method for doing this. In this article, we develop a framework for including health spillovers in economic evaluation. We focus on extra-welfarist economic evaluations where the objective is to maximize health benefits from a health care budget (the "health care perspective"). Our framework involves adapting the conventional cost-effectiveness decision rule to include 2 multiplier effects to internalize the spillover effects. These multiplier effects express the ratio of total health effects (for patients and their family networks) to patient health effects. One multiplier effect is specified for health benefit generated from providing a new intervention, one for health benefit displaced by funding this intervention. We show that using multiplier effects to internalize health spillovers could change the optimal funding decisions and generate additional health benefits to society.

Pedaços do Tempo: legado de Paulo Freire no Serviço Social / Pieces of Time: the legacy of Social Work Paulo Freire

O ensaio traz um estudo exploratório de cunho bibliográfico acerca das contribuições de Paulo Freire no Serviço Social abrangendo o período de 1950 a 1979. Apresenta ainda a análise das obras Pedagogia do Oprimido, Educação e Mudança em relação à perspectiva ontológica e as críticas ao assistencialismo no processo de reconceituação latino-americana.

The test brings an exploratory study of literature concerning nature of the contributions of Paulo Freire Social Work covering the period 1950-1979. It also presents the analysis of works Oppressed Pedagogy and Education and Change in relation to the ontological perspective and criticism of welfarism in the process of reconceptualization of Latin American.

A política de emprego no Brasil: o caminho da flexinsegurança / Employment policy in Brazil: the pathy of flexinsecurity

Este artigo discute a política de emprego implementada no Brasil nos últimos vinte anos como resposta ao aumento do desemprego provocado pela crise estrutural e pela reestruturação produtiva, fruto do atual estágio de acumulação capitalista. No entanto, tais políticas têm apenas reforçado a precarização das condições de vida e de trabalho da classe trabalhadora ao flexibilizar direitos e contratos trabalhistas e criar programas de geração de renda que primam pelo assistencialismo ao promover renda aos comprovadamente pobres, distanciando‑se da perspectiva de (re) inserção no mercado de trabalho.

This article discusses the employment policy implemented in Brazil in the last 20 years as a response to rising unemployment caused by structural crisis and the restructuring of production, due to the current stage of capitalist accumulation. However, such policies have only reinforced the precarious conditions of life and work of the working class rights and flexible labor contracts and create income‑generating programs that strive to promote the welfarism income to the poor proved to distancing themselves from the perspective of (re) integration into the labor market.