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Ethics
A note on Brock: prioritarianism, egalitarianism and the distribution of life years
  1. O F Norheim
  1. Correspondence to Ole Frithjof Norheim, Division for Medical Ethics, Department of Public Health and Centre for International Health, University of Bergen, Kalfarveien 18, 5018 Bergen, Norway; ole.norheim{at}isf.uib.no

Abstract

The moral philosopher Dan Brock has argued that equality of health outcomes “even if achievable” is problematic as a goal in its own right—because it is open to the levelling down objection. The levelling down objection to egalitarianism has received surprisingly little attention in the bioethics literature on distribution of health and healthcare and deserves more attention. This paper discusses and accepts an example given by Brock showing that prioritarianism and egalitarianism may judge distributions of health outcomes differently. We should accept that levelling down is never a good thing, all things considered, but that equality often is. By discussing variants of Brock’s example, it is demonstrated that if equality, prioritarianism and aggregation are combined, as in a population-wide summary measure of health, such as the health achievement index, this combined set of principles is not open to levelling down. The paper suggests—although a more thorough investigation of the properties of the achievement index is needed—that this measure (a) is always sensitive to inequality in health, (b) is always sensitive to average health, (c) can assign priority to those with lowest health outcomes and (d) is not sensitive to levelling down. Levelling down is not an embarrassment for egalitarians if they adopt a pluralist theory that integrates fairness with goodness. Equality is not the only value egalitarians promote. But equality is so important that we should not reject it.

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Footnotes

  • Competing interests None declared.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

  • i Parfit distinguishes between telic egalitarian principles and deontic egalitarian principles (where the former has intrinsic value and the latter instrumental value). Egalitarianism in the definition discussed above implies that inequality is bad in itself. If we aim for equality, “we shall thereby make the outcome better”, as Parfit says.

  • ii Norheim OF. Gini impact analysis: measuring pure health inequity before and after interventions. Unpublished manuscript, University of Bergen 2008:25 pages.

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