Proxy Preferences and the Values of Children's Health States.

To assign values to the health states of children, some health economists have suggested relying on the 'proxy' preferences among the health states of children expressed by a random sample of the adult population. These preferences have been elicited in several ways, with respondents sometimes asked to express their (adult) preferences among the health states of children, and sometimes asked to imagine themselves as children and to express what they think their preferences would be. This essay discusses three grounds for eliciting the preferences of a random sample of adults that have been suggested as ways to assign values to the health states in the EQ-5D-Y, and criticizes the first two: (1) the evidential ground: the preferences of the population sample are good evidence of how good or bad the health states of children are; (2) the 'taxpayer' ground: the adult population has the authority to assign values to health states, therefore their preferences are determinative; and (3) the pragmatic grounds: surveying is straightforward and shifts the responsibility from health economists to the population. I argue that instead of surveying a random sample of the population, health economists should rely on deliberative groups that include older children, experts on children's health and development, as well as members of the population at large. These groups should engage with the reasons that lie behind preferences among health states.

Problems with NICE's severity weights.

This essay examines the implications, plausibility, and justification of the severity weighting that NICE (The National Institute for Health and Care Excellence) has endorsed for technology assessments in the U.K. It argues that the assignment by NICE of additional weights to health conditions which involve a large absolute or proportional shortfall of future expected QALYs (Quality-Adjusted Life Years) as compared to those who do not have these health conditions is not well supported and has troubling implications. The literature concerned with attitudes toward prioritizing severity has found a variety of notions of severity, and it is questionable to what extent those studies bear on whether to assign greater weights to health states involving large absolute or proportional shortfalls. In addition, the severity weighting is not well supported by either egalitarian or prioritarian political philosophy, because it is concerned only with the future and focuses only on health rather than well-being in general.

Eliciting preferences and respecting values: Why ask?

This essay explores the pitfalls and ambiguities in relying on preference elicitation to value health states, and it distinguishes preference elicitation, as a fallible method of measuring well-being, from public consultation, as an element of public deliberation. After distinguishing preference elicitation as a method of ascertaining opinions from preference elicitation as a method of measuring well-being, it points out that preferences depend on beliefs and the considerations speaking in favor of deferring to people's values do not carry over to deferring to their beliefs. Instead of valuing health states by their bearing on well-being, as measured by preferences, this essay argues for valuing health states by their bearing on activity limitations and suffering, as determined by public deliberation.

Is there a human right to essential health care?

In Global Health Impact, Nicole Hassoun joins the ranks of those defending a right to health. Unlike the World Health Organization, which views this right expansively, Hassoun would limit the right to the health needed to enjoy a minimally good life. This essay argues that this right is difficult to specify and insufficient to support the policies Hassoun defends. The essay sketches an alternative view of the obligations of institutions to address health problems that derives from imperfect individual duties to aid those who are doing badly or who are at risk of harm.

Challenge Trials: What Are the Ethical Problems?

If, as is alleged, challenge trials of vaccines against COVID-19 are likely to save thousands of lives and vastly diminish the economic and social harms of the pandemic while subjecting volunteers to risks that are comparable to kidney donation, then it would seem that the only sensible objection to such trials would be to deny that they have low risks or can be expected to have immense benefits. This essay searches for a philosophical rationale for rejecting challenge trials while supposing that they have huge benefits and relatively low risks. Although it finds some force in objections to challenge trials grounded in the obligations of researchers to limit the harms imposed on some individuals for the benefit of others, it argues that there is no compelling objection to challenge trials of vaccines for COVID-19-if they have the benefits and risks that have been claimed.

The Paradoxes of Respectful Guidance: A Comment on Kenneth V. Iserson, "Do you Believe in Magic? Shove, Don't Nudge: Advising Patients at the Bedside".

This commentary argues that the problems identified in Kenneth V. Iserson's Essay, "Do you Believe in Magic? Shove, Don't Nudge: Advising Patients at the Bedside," are perennial difficulties to which there is no single simple solution. In particular, recent work in psychology offers little help to caregivers, who are in the difficult position of guiding the decisions of their patients while respecting them and ultimately deferring to their wishes.

What Is Cancer?

This essay focuses on themes in Explaining Cancer: Finding Order in Disorder (2018) by Anya Plutynski, a monograph that has important things to say about both the peculiarities of cancers and our theories about them. Cancer's agents of destruction are human cells that have been recruited and to some extent transformed into pathological organisms or the building blocks of tumors. Cancers both undermine and exploit mechanisms of multicellular organization, and understanding them gives rise to difficult philosophical problems. In addition to sketching Plutynski's discussion of these problems, this essay defends Christopher Boorse's account of disease from Plutynski's criticisms, and it expresses some qualms about her treatment of scientific explanation.

Health and functional efficiency.

This essay argues that what is central to Christopher Boorse's biostatistical theory of disease as statistically subnormal part function (BST) are comparisons of the "functional efficiency" of parts and processes and that statistical considerations serve only to pick out a healthy level of functional efficiency. On this interpretation, the distinction between health and pathology is less important than comparisons of functional efficiency, which are entirely independent of statistical considerations. The clarifications or revisions of the BST that this essay offers are friendly amendments that render moot some of the most prominent criticisms of Boorse's account.

Health, well-being, and measuring the burden of disease.

This essay asks whether the global burden of diseases, injuries, and risk factors (GBD) should be measured in terms of their consequences for health, as maintained by most of those who are attempting to measure the GBD, or in terms of their consequences for well-being, as argued by John Broome. It answers that the burden of disease should be understood in terms of the consequences of disease for health, and it defends the wider efforts to measure health by those who are in other ways skeptical of the project of measuring the GBD.

How can irregular causal generalizations guide practice?

In this essay, I shall be concerned with the sort of "irregular" causal generalizations that epidemiologists aim to discover. Examples include "Smoking causes lung cancer," "HIV viruses cause AIDs," or "Low dose aspirin prevents strokes." What do these claims mean and how should they guide action? I argue that philosophers have mistakenly believed that answering these questions calls for a theory of what it is for one event to be a probabilistic cause of another. But this theory fails to provide plausible truth conditions for irregular causal generalizations. Indeed, it implies that most of them are false. I sketch a more plausible view, but point out the risks one takes in relying on these generalizations to guide action.

Valuing health: a new proposal.

After criticizing existing systems of health measurement for their unargued commitment to evaluating health states in terms of preferences or well-being, this essay argues that public rather than private values of health states should help guide the allocation of health-related resources. Private evaluation of health states is relative to a prior individual choice of specific activities and goals, while public evaluation is relative to the whole range of important activities and goals. Public evaluation is concerned with securing a wide range of choices as well as with success given one's choice. A reasonable simplification from the public perspective is to focus on just two features of health states: the subjective feelings attached to health states and the limitations that health states imply on the range of important activities that individuals can pursue. Focusing on just these two dimensions permits the construction of a parsimonious classification of health states with regard to what matters most from the public perspective. This classification, which resembles those in the HALex and the Rosser and Kind Disability and Distress Index, might best be built on top of existing health-state classifications, by mapping the health states they define to activity-limitation/feeling pairs. To assign values to these pairs, I propose relying on deliberative groups to make comparisons among the pairs with respect to the relation 'is a more serious limitation on the range of objectives and good lives available to members of the population'. A ranking according to this property, is not a preference ranking, because it is not a ranking in terms of everything that matters to individuals. Working back from the weights attached to the activity-limitation/feeling pairs, one can impute weights for the health states in other classification systems that were mapped to those pairs. If those weights coincide roughly with current weights, then one legitimizes current weights and provides a vehicle for their public discussion and possible revision. If those weights do not coincide, then one has both an argument for revising current views of the cost effectiveness of treatments and policies and a method to carry out such a revision.

Valuing health properly.

This comment on Paul Dolan's essay, 'Developing methods that really do value the "Q" in the QALY,' seconds his critique of current preference-based methods of valuing health states but disputes both his assumption that health states should be appraised by their bearing on well-being and his conclusion that the bearing of health states on well-being should be measured in terms of subjective experience. This comment defends instead the view that health states should be valued in terms of the range of activities that they permit.

Group risks, risks to groups, and group engagement in genetics research.

This essay distinguishes between two kinds of group harms: harms to individuals in virtue of their membership in groups and harms to "structured" groups that have a continuing existence, an organization, and interests of their own. Genetic research creates risks of causing both kinds of group harms, and engagement with the groups at risk can help to mitigate those harms. The two kinds of group harms call for different kinds of group engagement.

Polling and public policy.

This commentary distinguishes five reasons why one might want to conduct a survey concerning people's beliefs about death and the permissibility of harvesting organs: (1) simply to learn what people know and want; (2) to determine if current law and practice conform to the wishes of the population; (3) to determine the level of popular support for or opposition to policy changes; (4) to ascertain the causes and effects of popular beliefs and attitudes; and (5) to provide guidance in determining which law and practices are ethical. The commentary expresses qualms about how well surveys in general can perform with respect to the fifth objective, and it provides specific reasons to doubt whether this survey is informative from the perspective of a moral philosopher concerned with the nature of death and the contours of a permissible system of organ procurement.

Health inequalities and why they matter.

Health inequalities are of concern both because studying them may help one learn how to improve health and because health inequalities may be unjust. This paper argues that attending to these reasons why health inequalities may be important undercuts the claims of researchers at the World Health Organization in favor of focusing on individual health variation rather than on social group health differences. Inequalities in individual health are of little interest unless one goes on to study how they are related to other factors.