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Health Care Analysis
Published in: Health Care Analysis 2/2019

Open Access 01-06-2019 | Original Article

Principles of Need and the Aggregation Thesis

Authors: Erik Gustavsson, Niklas Juth

Published in: Health Care Analysis | Issue 2/2019

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Abstract

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications.
Footnotes
1
Hence, when we refer to cost-effectiveness in this paper we do not refer to cost-effective analysis, which is an analytic tool for providing so-called cost-effectiveness ratios, rather than a principle for resource allocation.
 
2
For a discussion about the conceptual structure of needs see e.g. [12, 13, 27, 41, 44, 45].
 
3
In contrast to intrapersonal aggregation, which is concerned with how different parts of an individual’s life are combined. Moreover, we are interested in same number cases in this text. The issue of possible people may raise very different puzzles.
 
4
To combine a principle of need with a conception of health that entails an optimal level implies that if there are improvements that can be made for people above the optimal level, these people cannot have need-based claims to such improvements. This may, for example, rule out entitlements to some forms of enhancements. For the idea of optimal health in the holistic theory see further Nordenfelt [30, esp. pp. 97–98].
 
5
To have 0 represent death may be controversial. We make this assumption for simplicity reasons. It seems that there may be states that are worse than death. For a discussion on so-called negative QALYs see e.g. [36].
 
6
This kind of example may also be used in order to bring out the intuition (which we shall not discuss here) that small benefits to a large number of people should not outweigh large benefits to a few. Such an implication may be referred to as “welfare diffusion” [cf. 33].
 
7
Assume also that these patients are alike in all other relevant respects.
 
8
However, not necessarily all sorts of aggregation. For instance, one may accept principles that allow for interpersonal comparison but not continuity that would bar utilitarian principles but allow solutions to the different-number cases in favour of saving the many over the few; that would mean allowing aggregation but not unrestricted aggregation [see 19, esp. 19–41; 147–154]. We do not deny this; in fact our own solution favours aggregation but bars unrestricted aggregation. Moreover, writers like Kamm and Scanlon have claimed that they can provide an approach that justifies saving the many over the few without appealing to aggregation. This is often referred to as the Kamm–Scanlon argument. Space permits us from fully discuss this view here. It is contested, however, whether they in fact are appealing to aggregation [cf. 17].
 
9
For a recent discussion on the priority view see the special issue in Utilitas, 24, 3 (2012). To understand the priority view in this way is to exclude Absolute Priority discussed and rejected by [5, 8].
 
10
This point is also made by Crisp [8, p. 754].
 
11
For discussions about the arbitrariness of positioning the threshold see [1, 3, 4, 20, esp. pp. 127–134].
 
12
The focus on treatments also allow us to exclude research and development of new treatments from the following discussion.
 
13
Employment of multi-level versions of sufficiency principles has been done by others [see e.g. 3, 4, 23]. The thresholds in DTP are, however, specifically employed in order to handle questions about aggregation.
 
14
This will be assumed from now on.
 
15
Following Crisp here, we assume that these benefits are non-trivial.
 
16
In Official Norwegian Reports [31] it is also differentiated between three groups of severity. The purpose of these groups is different however. While we provide a deontic constrain of how tradeoffs are allowed between groups the Norwegian report suggests that we should allow for different cost per QALY (quality adjusted life years) within each group.
 
17
Thanks to an anonymous reviewer for pressing us to discuss this kind of case.
 
18
Consider also Crisp’s theory outlined above. Crisp uses mild hay fever as an example of a condition above the threshold and severe schizophrenia as an example of a condition below it.
 
19
Obviously, there is much more to be said about the issue of transitivity but a full discussion of this notion is far beyond the scope of this paper [see e.g. 39, see also 42].
 
20
Voorhoeve [43] also discusses this series of choices. However, our aim here is not to discuss Voorhoeve’s answer to this objection but to show that DTP can handle these kinds of worries.
 
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Metadata
Title
Principles of Need and the Aggregation Thesis
Authors
Erik Gustavsson
Niklas Juth
Publication date
01-06-2019
Publisher
Springer US
Published in
Health Care Analysis / Issue 2/2019
Print ISSN: 1065-3058
Electronic ISSN: 1573-3394
DOI
https://doi.org/10.1007/s10728-017-0346-6

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