Sufficientarians face a problem of arbitrariness: why place a sufficiency threshold at any particular point? One response is to seek universal goods to justify a threshold. However, this faces difficulties (despite sincere efforts) by either being too low, or failing to accommodate individuals with significant cognitive disabilities. Some sufficientarians have appealed to individuals’ subjective evaluations of their lives. I build on this idea, considering another individualized threshold: ‘tolerability’. I respond to some traditional challenges to individualistic approaches to justice: ‘expensive’ tastes, and adaptive preferences. Finally, I end by offering some suggestions about how this relates to policymaking.
A new paradox for well-being subjectivism
Davies B
August 2023
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Journal article
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Analysis
Subjectivists think that our well-being is grounded in our subjective attitudes. Many such views are vulnerable to variations on the ‘paradox of desire’, where theories cannot make determinate judgements about the well-being of agents who take a positive valuing attitude towards their life going badly. However, this paradox does not affect all subjectivist theories; theories grounded on agents’ prudential values can avoid it. This paper suggests a new paradox for subjectivist theories which has a wider scope, and includes such prudential judgement theories. I outline the new paradox and show how two plausible idealisztions (coherence and consideration) will not help. Subjectivists about well-being must either add an additional idealization that can solve the paradox of judgement or explain why such paradoxes do not constitute serious objections to a theory of well-being.
Feeding infants: choice-specific considerations, parental obligation, and pragmatic satisficing
Moriarty C, Davies B
June 2023
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Journal article
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Ethical Theory and Moral Practice
Health institutions recommend that young infants be exclusively breastfed on demand, and it is widely held that parents who can breastfeed have an obligation to do so. This has been challenged in recent philosophical work, especially by Fiona Woollard. Woollard’s work critically engages with two distinct views of parental obligation that might ground such an obligation—based on maximal benefit and avoidance of significant harm—to reject an obligation to breastfeed. While agreeing with Woollard’s substantive conclusion, this paper (drawing on philosophical discussion of the ‘right to rear’) argues that there are several more moderate views of parental obligation which might also be thought to ground parental obligation. We first show that an obligation to breastfeed might result not from a general obligation to maximally benefit one’s child, but from what we call ‘choice-specific’ obligations to maximise benefit within particular activities. We then develop this idea through two views of parental obligation—the Dual Interest view, and the Best Custodian view—to ground an obligation to exclusively breastfeed on demand, before showing how both these more moderate views fail. Finally, we argue that not only is there no general obligation to breastfeed children, but that it is often morally right not to do so. Since much advice from health institutions on this issue implies that exclusive breastfeeding on demand is the best option for all families, our argument drives the feeding debate forward by showing that this advice often misrepresents parents’ moral obligations in potentially harmful ways.
Medical need and health need
Davies B
May 2023
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Journal article
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Clinical Ethics
I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I also argue against an overly strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort.
Rationing, responsibility, and vaccination during COVID-19: a conceptual map
Park J, Davies B
April 2023
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Journal article
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American Journal of Bioethics
<p>Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive resource allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics.</p>
Healthcare priorities: the "young" and the "old"
Davies B
November 2022
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Journal article
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Cambridge Quarterly of Healthcare Ethics
Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off.
Affirmative action in healthcare resource allocation: vaccines, ventilators and race
Zohny H, Davies B, Wilkinson D
August 2022
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Journal article
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Bioethics
This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and ventilators because these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections.
The prospects for ‘Prospect Utilitarianism’
Davies B
July 2022
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Journal article
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Utilitas
Hun Chung argues for a theory of distributive justice—‘prospect utilitarianism’—that overcomes two central problems purportedly faced by sufficientarianism: giving implausible answers in ‘lifeboat cases’, where we can save the lives of some but not all of a group, and failing to respect the axiom of continuity. Chung’s claims that prospect utilitarianism overcomes these problems, and receives empirical support from work in economics on prospect theory. This paper responds to Chung’s criticisms of sufficientarianism, showing that they are misplaced. It then shows that prospect utilitarianism faces independent problems, since it too requires a threshold, which Chung bases on the idea of ‘adequate functioning’. The paper shows that there are problems with this as a threshold, and that it is not empirically supported by prospect theory.
Doctors as appointed fiduciaries: a supplemental model for medical decision-making
Davies B, Parker J
January 2022
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Journal article
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Cambridge Quarterly of Healthcare Ethics
How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an “appointed fiduciary” model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals.
Institutional responsibility is prior to personal responsibility in a pandemic
Davies B, Savulescu J
January 2022
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Journal article
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Journal of Value Inquiry
Responsibility and the recursion problem
Davies B
November 2021
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Journal article
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Ratio
A considerable literature has emerged around the idea of using ‘personal
responsibility’ as an allocation criterion in healthcare distribution, where a person’s
being suitably responsible for their health needs may justify additional conditions
on receiving healthcare, and perhaps even limiting access entirely, sometimes
known as ‘responsibilisation’. This discussion focuses most prominently, but not
exclusively, on ‘luck egalitarianism’, the view that deviations from equality are
justified only by suitably free choices. A superficially separate issue in distributive
justice concerns the two–way relationship between health and other social goods:
deficits in health typically undermine one’s abilities to secure advantage in other
areas, which in turn often have further negative effects on health. This paper
outlines the degree to which this latter relationship between health and other social
goods exacerbates an existing problem for proponents of responsibilisation (the
‘harshness objection’) in ways that standard responses to this objection cannot
address. Placing significant conditions on healthcare access because of a person’s
prior responsibility risks trapping them in, or worsening, negative cycles where
poor health and associated lack of opportunity reinforce one another, making
further poor yet ultimately responsible choices more likely. It ends by considering
three possible solutions to this problem.
‘Personal Health Surveillance’: the use of mHealth in healthcare responsibilisation
Davies B
May 2021
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Journal article
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Public Health Ethics
There is an ongoing increase in the use of mobile health (mHealth) technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses ‘medical monitoring’, and the second ‘personal health surveillance’. After outlining two problems which the use of mHealth might seem to enable us to overcome—fairness of burdens and reliance on self-reporting—I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim.
Grow the pie, or the resource shuffle? Commentary on Munthe, Fumagalli and Malmqvist
Davies B
December 2020
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Journal article
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Journal of Medical Ethics
The right not to know: Some steps towards a compromise
Davies B, Savulescu J
October 2020
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Journal article
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Ethical Theory and Moral Practice
There is an ongoing debate in medicine about whether patients have a ‘right not to know’ pertinent medical information, such as diagnoses of life-altering diseases. While this debate has employed various ethical concepts, probably the most widely-used, by both defenders and detractors of the right, is autonomy. Whereas defenders of the right not to know typically employ a ‘liberty’ conception of autonomy, according to which to be autonomous involves doing what one wants to do, opponents of the right not to know often employ a ‘duty’ understanding, viewing autonomy as involving an obligation to be self-governing. The central contribution of this paper is in showing that neither view of autonomy can reasonably be said to support the extreme stances on the right not to know that they are sometimes taken to. That is, neither can a liberty view properly defend a right not to know without limits, nor can a duty view form the basis of an absolute rejection of the right not to know. While there is still theoretical distance between these two approaches, we conclude that the views are considerably closer on this issue than they first appear, opening the way for a possible compromise.
autonomy, Mill, right not to know, Kant
From sufficient health to sufficient responsibility
Davies B, Savulescu J
July 2020
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Journal article
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Journal of Bioethical Inquiry
The idea of using responsibility in the allocation of healthcare resources has been criticized for, among other things, too readily abandoning people who are responsible for being very badly off. One response to this problem is that while responsibility can play a role in resource allocation, it cannot do so if it will leave those who are responsible below a “sufficiency” threshold. This paper considers first whether a view can be both distinctively sufficientarian and allow responsibility to play a role even for those who will be left with very poor health. It then draws several further distinctions that may affect the application of responsibility at this level. We conclude that a more plausible version of the sufficientarian view is to allow a role for responsibility where failure to do so will leave someone else who is not responsible below the sufficiency threshold. However, we suggest that individuals must exhibit “sufficient responsibility” in order for this to apply, involving both a sufficient level of control and an avoidable failure to respond adequately to reasons for action.
The right not to know and the obligation to know
Davies B
May 2020
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Journal article
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Journal of Medical Ethics
There is significant controversy over whether patients have a ‘right not to know’ information relevant to their health. Some arguments for limiting such a right appeal to potential burdens on others that a patient’s avoidable ignorance might generate. This paper develops this argument by extending it to cases where refusal of relevant information may generate greater demands on a publicly funded healthcare system. In such cases, patients may have an ‘obligation to know’. However, we cannot infer from the fact that a patient has an obligation to know that she does not also have a right not to know. The right not to know is held against medical professionals at a formal institutional level. We have reason to protect patients’ control over the information that they receive, even if in individual instances patients exercise this control in ways that violate obligations.
No blame no gain? From a No Blame Culture to a responsibility culture in medicine
Parker J, Davies B
May 2020
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Journal article
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Journal of Applied Philosophy
Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
The right not to know and the obligation to know: response to commentaries
Davies B
April 2020
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Journal article
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Journal of Medical Ethics
Thinking Through Utilitarianism: A Guide to Contemporary Arguments, by Andrew T. Forcehimes and Luke Semrau
Davies B
January 2020
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Journal article
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Teaching Philosophy
5003 Philosophy, 50 Philosophy and Religious Studies
Responsibility and the limits of patient choice
Davies B
November 2019
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Journal article
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Bioethics
Solidarity and responsibility in health care
Davies B, Savulescu J
July 2019
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Journal article
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Public Health Ethics
HEALTH(CARE) AND THE TEMPORAL SUBJECT
Davies B
June 2019
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Journal article
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Les ateliers de l'éthique
Bursting bubbles? QALYs and discrimination
Davies B
September 2018
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Journal article
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Utilitas
The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify.
Paternalism and Evaluative Shift
Davies B
November 2017
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Journal article
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Moral Philosophy and Politics
<jats:title>Abstract</jats:title><jats:p>Many people feel that respecting a person’s autonomy is not sufficiently important to obligate us to stay out of their affairs in all cases; but the ground for interference may often turn out to be a hunch that the agent cannot</jats:p>
Publish or Perish
Davies B, Felappi G
October 2017
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Journal article
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Metaphilosophy
Ageing and Terminal Illness: Problems for Rawlsian Justice
Davies B
February 2017
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Journal article
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Journal of Applied Philosophy
Utilitarianism and Animal Cruelty: Further Doubts
Davies B
February 2017
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Journal article
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De Ethica
<jats:p>
Utilitarianism has an apparent pedigree when it comes to animal welfare. It supports the view that animal welfare matters just as much as human welfare. And many utilitarians support and oppose various practices in line with more mainstream concern over animal welfare, such as that we should not kill animals for food or other uses, and that we ought not to torture animals for fun. This relationship has come under tension from many directions. The aim of this article is to add further considerations in support of that tension. I suggest three ways in which utilitarianism comes significantly apart from mainstream concerns with animal welfare. First, utilitarianism opposes animal cruelty only when it offers an inefficient ratio of pleasure to pain; while this may be true of eating animal products, it is not obviously true of other abuses. Second, utilitarianism faces a familiar problem of the inefficacy of individual decisions; I consider a common response to this worry, and offer further concerns. Finally, the common utilitarian argument against animal cruelty ignores various pleasures that humans may get from the superior status that a structure supporting exploitation confers.
</jats:p>
Enhancement and the Conservative Bias
Davies B
December 2016
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Journal article
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Philosophy & Technology
Fair innings and time-relative claims
Davies B
December 2015
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Journal article
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Bioethics
Greg Bognar has recently offered a prioritarian justification for 'fair innings' distributive principles that would ration access to healthcare on the basis of patients' age. In this article, I agree that Bognar's principle is among the strongest arguments for age-based rationing. However, I argue that this position is incomplete because of the possibility of 'time-relative' egalitarian principles that could complement the kind of lifetime egalitarianism that Bognar adopts. After outlining Bognar's position, and explaining the attraction of time-relative egalitarianism, I suggest various ways in which these two kinds of principle could interact. Since various options have very different implications for age-based rationing, proponents of such a rationing scheme must take a position on time-relative egalitarianism to complement a lifetime prioritarian view like Bognar's.