This blog post was prompted by discussions with Frances Kamm, Jonathan Wolff, and others after a great presentation Jonathan gave on the Valuation of Life and Health in Government Policies.
To return to an issue I have discussed briefly in other work, the question is how we should count very small gains in health for large numbers of people, a sub-set of the aggregation problem. As I put the problem in a footnote in my Article Beyond Best Interests, 96 Minn. L. Rev. 1187 (2012):
Utilitarians typically aggregate small harms to many people and count the sum. See, e.g., John Rawls, A Theory of Justice 23-24 (1971) (discussing the societal balance of present and future gains against present and future losses). The deontologist Frances Kamm has instead suggested that not all harms and benefits are equal, under what she calls the “Principle of Irrelevant Utility”: Suppose two almost identical individuals A and B are mortally ill and we have only enough serum to save one, but because of tiny differences in how much serum they need if we save A there will be enough serum left over to also cure person C’s sore throat, but if we save B there will not be. Kamm argues that it would be unjust in this circumstance to allocate the serum to A rather than B on this basis as opposed to holding a straight lottery between the two. If the sore throat is not enough to justify giving A preference over B when everything is equal, says Kamm, it is an “irrelevant utility” such that even if we could save not only C’s sore throat but a million such sore throats, for example, it would not matter; the utility bonus is irrelevant and therefore even aggregated in large quantities cannot count. Quite different, she claims, would be a case where in fact the serum enables us to save C’s leg, which would be a relevant utility. See F.M. Kamm, Morality, Mortality: Death and Whom to Save from It 144-63 (1993); Frances M. Kamm, To Whom?, 24 Hasting Ctr. Rep. 29, 31-32 (1994).
On the other hand, this principle may have counter-intuitive implications. To use an example suggested by John Broome, the National Health Service (the U.K.’s universal health care system) gives out millions of analgesics for headaches; at some level, due to health care rationing and fixed budgets, that means that someone’s life will not be saved. John Broome, All Goods are Relevant, in WHO, Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications 727, 727-28 (Christopher J.L. Murray et al. eds., 2002).
What came up over dinner, and I thought was particularly interesting, was the following question:
If one agreed with Kamm regarding the applicability of the principle of irrelevant utilities to interpersonal distribution of goods (and to be fair I am not sure I do), is the same true for intrapersonal distribution? Could an individual justifiably choose a health insurance plan that covered analgesics for headaches throughout his or her life but not expensive transplant surgery that is life saving? If the answer is yes, and it does seem to me it should be, does the implausibility of the irrelevant utility principle for intrapersonal distribution have ramifications for the plausibility in the interpersonal distribution case? One could, of course, distinguish what we would choose for ourselves from what we owe each other, but it is not so clear to me why the relevance/irrelevance of utilities ought not to carry over both categories. Anyways, I would be curious if others have thoughts. Though quite theoretical sounding, in fact resolving this issue is very important in figuring out how to run a health care system.