Elsevier

Social Science & Medicine

Volume 60, Issue 2, January 2005, Pages 257-263
Social Science & Medicine

Concerns for the worse off: fair innings versus severity

https://doi.org/10.1016/j.socscimed.2004.05.003Get rights and content

Abstract

The original fair innings argument is about claims on length of life. Alan Williams has suggested that the argument also should apply to quality of life. His ‘generalised fair innings approach’ on the one hand, and the severity approach on the other, are two ways of incorporating concerns for fairness in economic evaluation of health care. They are based on different ethical arguments and therefore partly lead to different results. Both approaches incorporate concerns for current and future severity. There is strong support for this in formal theories of justice and government guidelines, and a number of public surveys even indicate the strength of these concerns. The generalised fair innings approach additionally incorporates concerns for past suffering. Intuitively, this is not unreasonable, but there is at this point little ethical theory or empirical evidence to suggest the strength of such concerns.

The fair innings argument can be decomposed in an ‘equal innings argument’ and a ‘sufficient innings argument’. When the fair innings argument is applied to quality of life, its sufficient innings component implies that young people should have priority over old people when it comes to functional improvements and symptom relief for non-fatal conditions. This runs counter to both moral intuitions and official goverment guidelines in Norway and Sweden.

Introduction

Distributive fairness is an important goal in health care, to be taken duly account of in the pursuit of allocative efficiency (Anand & Wailoo, 2000; Broome, 1988; Mooney & Olsen, 1991; Sen, 1992; Williams, 1988). Concerns for fairness are of various kinds. This paper addresses one of them. A common feature of different theories of fairness (Daniels, 1993; Rawls, 1971) and of the thinking of ordinary people about fairness (Nord, 1999) is a special concern for the worse off members of society. The concern implies that benefits are considered to have greater weight the worse off those who receive them are. Concerns for the worse off thus run counter to the utilitarian idea that resources should be allocated simply with a view to maximising overall health benefits. Parfit (1991) refers to concerns for the worse off as ‘The Priority View’. Brock (2001) offers a number of possible justifications for the view, including the argument that the worse off suffer undeserved relative deprivation, and/or that the worse off have more urgent needs.

If priority in health care is to be given to the worse off, there is first a question of whether one should be concerned about those worse off in health or those worse off overall, i.e. in their global life situation. While some would argue in favour of the latter, there is probably less agreement about this than about giving priority to those who are worse off in terms of health. I shall therefore restrict myself to discussing who is worse off in terms of health only. This is at any rate of interest in priority setting across groups who are equal on other aspects of life than health.

To decide who is worse of with respect to health is on the one hand a matter of determining the relative weights to be attached to different aspects of illness (pain, discomfort, bodily impairments, loss of capabilities, etc.) in judgements of the ‘badness’ of different conditions. This question has been widely addressed in the health-related quality of life literature and is not the theme of this paper. Instead I address a question that has to do with the time perspective of ‘worse-offness’: Is being worse off a matter of being in a bad state at a given point in time, or of having a bad prognosis, or of having had a poor history of health, or perhaps all of these, i.e. of having poor health as judged over a whole lifetime?

British economist Alan Williams has strongly advocated the latter view. He relates the notion of being worse off to the idea that resources should be allocated such as to ensure everybody a ‘fair innings’ of health over their life time (Williams, 1997). According to Williams, one is worse off the less quality adjusted life years one is expected to enjoy from birth till death.

Surprisingly few writers have discussed this proposition. One of the few is Amartya Sen (2001). He regards Williams’ approach as an interesting and potentially powerful one, particularly since it seems to deal with social class inequality in a fulsome way. But he also stresses its limitations for policy making. For example, Williams claims that men are not getting their fair innings, insofar as their health adjusted life expectancy is significantly lower than that of women. While acknowledging the latter fact, Sen suggests that giving preference to male patients ‘cannot but lack some quality that we would tend to associate with the process (my italicising) of health equity’ (p. 21). Sen thus warns against approaches that insist on taking a single-dimensional view of health equity, stating that ‘it is possible to accept the significance of a perspective, without taking that perspective to be ground enough for rejecting other ways of looking at health equity, which too can be important’.

This paper is written in a somewhat similar vein. It compares the fair innings approach to encapsulating concerns for the worse off with one that focuses on the severity of a patient's condition as an independent determinant of society's valuation (appreciation) of an intervention (Menzel, 1990; Nord, 1993; Pinto, 1997; Richardson, 1997; Ubel, 1998). Williams (2000), Williams (2001) has claimed that the former approach subsumes the latter and encapsulates distributive concerns in a more sensible way. In the following I examine this claim. I first explain the two approaches. I then point out their similarities and differences in terms of implications for social choice in a set of hypothetical health programs. Finally, I discuss briefly the extent to which the partly conflicting implications from each of the approaches are supported by moral argument, political documents and public opinion surveys.

Section snippets

Fair innings

The fair innings approach centres initially on the feeling that everyone is entitled to some ‘normal’ number of life years, say 70–75 years in Western Europe. The implication is that anyone failing to achieve this has in some sense been cheated, whilst anyone getting more than this is ‘living on borrowed time’ (Williams, 1997, p. 119). Williams proposes that gained life years in people facing less than a fair innings should be valued more highly (be assigned a larger weight) than life years

Severity

The basic hypothesis of the severity approach is that the societal value (appreciation) of a health improvement of a given size is greater the greater the severity of the patient's initial condition. For instance, if person A can be taken from 0.4 to 0.6 on a scale of individual utility with interval scale properties, and person B can be taken from 0.6 to 0.8 on the same scale, then society will value the former improvement more than the latter, due to a preference for giving priority to the

Comparing fair innings and severity

My focus in the following is on Williams’ expansion of the fair innings approach to include quality of life considerations, which is also what the severity approach purports to capture. I do not dispute the validity of the original fair innings approach, which is restricted to length of life considerations. The severity approach does not purport to encapsulate such considerations.

The fair innings approach and the severity approach both require procedures for weighting utility gains in terms of

Discussion

The hypothesis addressed in this paper is that the fair innings approach is a better way of encapsulating concerns for the worse off in economic evaluation in terms of QALYs than the severity approach. My response to this is that both approaches are technically feasible. But they are based on different ethical arguments and therefore lead to somewhat different results. The crucial question is which of these conflicting results is morally more defensible. To judge this, it is of interest to draw

Summary and conclusion

There is a need to incorporate concerns for fairness in economic evaluation of health care. Such concerns are of several kinds. One of them is the concern for the worse off. The severity approach and the generalised fair innings approach—which includes considerations of quality of life—are two ways of incorporating this particular moral concern. They are both technically feasible, but they are based on different ethical arguments and therefore partly lead to different results. The crucial

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