:: Article

What’s Fair About Disability, Rationing Health Care, Ageing and Overpopulation?

Interview by Richard Marshall.

Policies have winners and losers; some people usually have to suffer a loss or forgo a gain, but hopefully there are always others who receive a greater benefit. It is the task of ethics to help us make these trade offs in ways that are acceptable to all, or at least are based on good reasons. If there was no scarcity, ethics would be largely unnecessary.

I don’t think that equality in itself is valuable. We should care about inequalities, but we shouldn’t try to deal with them by making people more equal; rather, we should help those who are worse off. In philosophical terms, that makes me a prioritarian rather than an egalitarian. A prioritarian holds that a unit of benefit has more value when it goes to a worse off person, and the worse off the person is, the greater its value; but she does not think it’s worth pursuing equality for its own sake.

Many philosophers tend to think of the demands of justice between us and future generations in terms of equality. Perhaps this is because they are attracted to the idea of equality when it comes to the distribution of benefits in the present, so they extend it to the future. But I think equality is even less attractive when it comes to our relations to generations that will come much later in time. I don’t think that future generations should be just as well off as we are; I think they should be better off than we are, and we should make it possible for them to be so. In other words, I think progress is important.

Greg Bognar is a Senior Lecturer in Practical Philosophy at Stockholm University and a Senior Researcher at the Stockholm Centre for Healthcare Ethics (CHE). His research is in normative and applied ethics, especially bioethics and what is known as politics, philosophy, and economics (PPE). In his writings, he often end up defending prioritarianism. Currently, he is interested in the ethical challenges raised by ageing, overpopulation, and demographic transitions. He also has an interest in moral relativism. For ethical reasons, he’s not on Facebook, Twitter, or other social media. Here he discusses the ethical position of treating disability as difference and why he rejects the position, the ethics of rationing in health care, equality, using empirical data to inform philosophical positions in ethics, climate change and the challenge of overpopulation.

3:AM: What made you become a philosopher, and why practical philosophy?

Greg Bognar: I became a philosopher mostly by accident. I grew up in Hungary in the late1980s and early 1990s. This was the time the Berlin Wall came down. Like so many other young people, I was interested in politics; I wanted to understand the changes happening around me. I thought of becoming a journalist, but there were no university programs in journalism or politics. So I chose to study philosophy as the next best thing. I wanted to learn about political theory and social ethics.

What I hadn’t realized was that philosophy programs at universities were changing too. Before communism collapsed, philosophy had been mainly just Marxism-Leninism. As the country was transitioning to democracy, philosophy programs were trying to adopt Western-style curricula. I was lucky because everything was in flux and that enabled me to focus on what I was interested in the most: political philosophy and ethics. I could largely avoid things I had little interest in, like Marxism or phenomenology. There was a small group of enthusiastic professors who kept up with current debates in philosophy in the West, and I could complete my undergraduate studies, for the most part, by taking their courses. Soon, I was hooked.

For my graduate studies, I went to the Central European University (CEU). Things were unusual there too: since the university was less than ten years old, there wasn’t yet a Philosophy Department. Philosophy back then was part of the Political Science program. But that suited me perfectly, as I could also take courses in economics, politics, and other subjects I was interested in. So, officially, my degree isn’t even in Philosophy but in Political Science… After I finished, I spent a couple of years as a post-doc at the (now sadly defunct) Program in Ethics & Health at Harvard. By that time, my main interests were more in ethics and public policy than in politics itself, and I ended up working in bioethics and at the intersection of politics, philosophy, and economics. It was a long and winding road!

3:AM: You’ve looked at the idea that disability is merely difference rather than something that is bad for you. Can you first sketch what the reasons are for arguing that disability is mere difference?

GB: Philosophy of disability is a young field, and the debates still revolve around some of the fundamental questions. I came to it through my work on human well-being and the value of health, where it is uncontroversial to hold that
it’s generally a good thing to prevent disability and to cure it if possible.This is because disability is a harm. However, many philosophers of disability claim that this belief expresses “ableist” prejudice. They claim that the disadvantages of people with disabilities are caused by the social environment, rather than their condition; remove these social factors, and disability is no harm at all. It’s more like other human differences, like race or sex. Remove the disadvantages caused by racial or gender-based prejudice, and one’s skin color or gender is no longer an obstacle to flourishing. On the mere difference view, disability is just like this.

I do agree that many of the disadvantages of people with disabilities are socially imposed, and I also do agree that all of the disadvantages due to one’s race or gender are socially imposed. A decent society will work towards eliminating these disadvantages. But I disagree that disability is just like race or sex. Even in a perfectly just and inclusive society, with no prejudice and discrimination, disability would remain an obstacle to human flourishing.

3:AM: So you don’t think the position that disability is mere difference can be defended?

GB: No, I don’t. But it’s important to be clear about what I mean when I say that disability is not just a form of human difference. I certainly don’t mean that if you are disabled, your life is necessarily bad. No philosopher who is
skeptical of the mere difference view — and I’m certainly not the only one — thinks that. People with disabilities can of course live perfectly happy, satisfying lives. Rather, the claim has an important “other things being equal” clause. Imagine two ways your life could go: in both of these lives, you would have the same interests, you would like to enjoy the same activities, you would want to take advantage of the same opportunities. The only difference is that in one of these lives you have a disability. Other things being equal, it would be worse for you to have the life with disability than the life without. For one thing, it would be more difficult to succeed in your life.

I don’t think this should be a controversial or particularly implausible thing to say. Most people will experience some form of disability in their lives. Many of them, even if they remain happy and satisfied, will consider that a bad thing.

3:AM: Many of these issues are about rationing — health care in particular. Can you sketch for us what you see as the main philosophical challenges that rationing raises?

GB: In the book I co-wrote with Iwao Hirose, The Ethics of Health Care Rationing, we provide an introduction for general readers to this area. We explain that since resource scarcity is inevitable, rationing — or priority setting, to use a less loaded word — is ubiquitous. It happens in rich and poor societies and in publicly funded and privately financed health care systems alike. So it’s important to make priority setting decisions on ethically acceptable grounds. We explain how different health states can be evaluated, how to make trade-offs between maximizing health benefits and fairness, whether small benefits to a large number of people can outweigh large benefits to the few. We explore the moral role that considerations of personal responsibility, disability, or age can play in setting health care priorities.

3:AM: Speaking of age, what is the “fair innings” view concerning the treatment of the elderly?

GB: It’s rather a family of views, all based on the idea that when resources are scarce, you have to set priorities; and when it comes to medical resources, sometimes you can’t meet the health needs of everyone. In those cases, it’s not unfair to give priority to the needs of younger people. So, for instance, if you are over 70, you are not eligible for expensive, life-prolonging medical treatment as long as the resources can be used to prolong the lives of people who are below 70. You should still receive palliative care, but you’ve already had your “fair innings”, and it’s more important to enable others to get to where you already are.

3:AM: It seems pretty awful as a view.

GB: Yeah, but that’s because you’re forgetting about scarcity. If there was no resource scarcity, no one would advocate such views — there would be no need to. But there’s always scarcity. Policies have winners and losers; some people
usually have to suffer a loss or forgo a gain, but hopefully there are always others who receive a greater benefit. It is the task of ethics to help us make these trade-offs in ways that are acceptable to all, or at least are based on good reasons. If there was no scarcity, ethics would be largely unnecessary.

My objection to many of these views is that they are too simplistic. There must be less crude ways to make such trade-offs than to set a strict threshold at 70.

3:AM: But some of those advocating such an approach to allocating health care go further and prioritize 15 to 40-year-olds. This again seems morally repugnant. What’s wrong with it?

GB: Many things… But here’s just one: I think it’s a mistake to try to come up with some age limit over or below which you are not eligible for certain forms of medical care. We should ask the question differently: how much value should societies give to additional years of life at different ages? Should we hold, for example, that it’s equally valuable to spend on medical research that promises to extend the life of octogenarians and to spend on medical research that enables more people to reach that age? I don’t think we shouldn’t spend on research or treatment that increases life spans at all — but I do think we have to make tradeoffs, and that it’s not indefensible to hold that an additional year of life has relatively smaller value when you are eighty compared to when you’re forty.

Accepting this would have far-reaching practical consequences. We would have to rethink a lot of our social policies. But it does not follow that we would have to abandon old people.

Actually, the fact that you find these views morally repugnant may indicate how unwilling we are to think about scarcity. We’d like to believe we don’t have to make painful trade-offs anymore. That’s sadly just not true. But, in a way, it’s a good thing that there’s scarcity: a few generations ago we didn’t have to face such questions, since there was very little we could do to prolong life. It’s only because of the amazing progress in medicine that we now have to grapple with them.

3:AM: But doesn’t this mean that we have to give up on equality? For instance, on
equality between the young and the old?

GB: To some extent, yes. But I don’t think that equality in itself is valuable. We should care about inequalities, but we shouldn’t try to deal with them by making people more equal; rather, we should help those who are worse off. In philosophical terms, that makes me a prioritarian rather than an egalitarian. A prioritarian holds that a unit of benefit has more value when it goes to a worse off person, and the worse off the person is, the greater its value; but she does
not think it’s worth pursuing equality for its own sake. In practical terms, an egalitarian and a prioritarian would often make the same policy recommendations, but they would justify their recommendations in different ways.

There is, however, one kind of equality that is important: equality of opportunity. And with respect to this kind of equality, intergenerational inequalities abound. Consider the chronic unemployment and underemployment of young people in some countries, or the fact that young people in some places cannot afford to live in cities where the best jobs are, or that they can’t be certain that they’ll have the same quality of life as their parents when they retire. In many countries, young people don’t have the same opportunities as their parents did at their age. We should think much more about the political implications of these trends, and what they might mean for the intergenerational cooperation that every society needs to survive.

3:AM: It seems a lot of what you write about is informed by demography.

GB: Absolutely. One reason intergenerational justice is such a fascinating topic is demographic trends. Many of the most affluent societies are aging rapidly; in a few decades, the over-60s will make up more than a third of their population. This will have profound social and economic consequences — rising health care and pension costs are just the most obvious. Social resources usually flow from the old to the young, but this has already started to reverse in some countries. We’re really sailing into uncharted waters here; no one knows what such an old society will look like. This is unprecedented in human history.

3:AM: What do we know about people’s moral views about justice between the old and the young? And, more generally, how should ethicists use empirical data? Carefully I guess is one answer — but it raises the bigger issue about whether armchair ethics is better than ethics using empirical findings. What do you think?

GB: There is the view that all you need for moral philosophy is a good armchair — what people’s actual moral beliefs are is irrelevant for ethics. My impression is that this view was much more prevalent when I started out in philosophy. I remember being asked at job interviews why we should care about what the average Joe or Jane believes. (Those job interviews usually didn’t go well.) These days, it’s much less common to dismiss empirical ethics out of hand.

So why should we care about the moral beliefs of average Joe and Jane? One reason is purely practical: by keeping up with the work social scientists do on moral beliefs, you can discover new questions or new angles to approach old philosophical questions. It’s a goldmine of ideas, if you take the trouble to explore it a bit.

More controversially, you can make the argument that you can’t do ethics without starting from some moral beliefs. A lot of ethics is about clarifying, justifying, and systematizing moral beliefs. One part of that is to work towards what is called “reflective equilibrium” — making your moral beliefs cohere with your moral principles, by using the moral beliefs you are unwilling to give up to test candidate moral principles, and using moral principles to assess your moral beliefs. At the end of this process, you hope to have a set of principles that is coherent with your moral beliefs, while also using those principles to filter your moral beliefs. Then you might have a theory that’s as coherent as can be.

So moral beliefs are a bit like a fairly poor data set. You want to develop a “hypothesis” (a principle) that fits the data best, while knowing that you have to throw out some — and perhaps most — of the data you have.

You could of course do this without looking any empirical research at all. You could just rely on your own moral beliefs — or moral intuitions — and use them as your data. Some philosophers do this, and they seem to discover astonishingly complex moral intuitions by considering imaginary cases that they construct. But the danger is that relying on your own moral beliefs will just lead you to conclusions you are already won’t to accept. Your data set is likely to be especially poor, especially if you already have theoretical commitments.

Consider people’s beliefs about the moral relevance of age. It turns out that the people asked in empirical studies deeply disagree on this issue. Roughly half of them say age should never be a criterion in priority setting; the rest think it’s obvious that more priority should be given to younger people. Since you said you found that idea pretty awful and morally repugnant, you seem to belong to the first group. If nothing else, we have learned from these studies that we shouldn’t take our own moral beliefs on this issue granted, since many other people, some of them surely just as reasonable as we are, disagree.

3:AM: The USA is pulling out of the Paris climate change agreement. Many environmentalists believe that climate change policy should be based on the precautionary principle. You have argued against this principle. So first of
all, what is this principle and why is it problematic for climate change policy?

The precautionary principle says, roughly, that policies and regulations should aim to avoid the worst possible outcomes when you lack precise information on the magnitude of the possible harms and their probabilities. The 1992 United Nations Framework Convention on Climate Change called for something like this as the basis for climate change policy. But even though the idea might look reasonable, it’s hard to formulate this principle more precisely. So I suggested that we could borrow the central thought behind prioritarianism, which I described above, to make it more specific. That is, we should design policies and regulations that give more weight to benefits of the worse off — in this case, to improving the situation of the generation that would end up worse off given different policy alternatives. To simplify greatly, this comes down to giving more priority to avoiding the worst outcomes in climate change policy.

Where this matters is this: many philosophers tend to think of the demands of justice between us and future generations in terms of equality. Perhaps this is because they are attracted to the idea of equality when it comes to the distribution of benefits in the present, so they extend it to the future. But I think equality is even less attractive when it comes to our relations to
generations that will come much later in time. I don’t think that future generations should be just as well off as we are; I think they should be better off than we are, and we should make it possible for them to be so. In other words, I think progress is important.

3:AM: What other ethical issues should be part of the discussion on climate change?

GB: Since we’ve already talked about demography, I’ll give an example from there. It’s striking how little attention the problem of overpopulation receives, both in philosophy and in policy. Advocating any form of population policy is a taboo. (Well, except for restricting abortion and access to birth control, which are proposed by some people, while any proposal for population control is off the table.) The standard view is that overpopulation will solve itself as countries complete the demographic transition from high birth rates and high death rates to low birth rates and low death rates. Among other things, this view assumes without argument that the transition will have completed in time before overpopulation leads to irreversible consequences.

The latest IPCC report mentions that the improvements in energy efficiency between 2000 and 2010 almost offset all of the increase in CO2 emissions due to population growth. But that’s not how this piece of data should be read. For what the IPCC really says is that all of the gains in energy efficiency that the world achieved in a decade was more than wiped out by the growth in population. If we had been able to decrease the rate of population growth, we would now be closer to keeping climate change manageable. Yet the problem of overpopulation is simply not part of the discussion. That’s pretty amazing.

The point isn’t to advocate any sort of coercive policy for limiting population growth. There are much better ways. And of course once again there are trade-offs: it would lead to problems if we ended up with societies that have become old before they have become affluent. This is one area where it would be useful to have more interchange between bioethics, climate change ethics, economics, and environmental policy.

3:AM: And finally, for the readers here at 3:AM, are there five books you can recommend that will take us further into your philosophical world?

GB:

One of the first books I ever read in philosophy is Jonathan Glover’s Causing Death and Saving Lives. It’s highly accessible for general readers. Although published over 40 years ago, this is still the book that I recommend to non-philosophers who want to get an introduction to some of the most difficult problems in practical ethics.

Two more specialist books are David Gauthier’s Morals by Agreement

and John Broome’s Weighing Goods. They both have had an enormous influence on me. In particular, I have learned a lot from John Broome over the years about how to do philosophy.

Perhaps I should also mention a book from theoretical ethics. Michael Smith’s The Moral Problem helped me a lot to think about the nature of ethical values and moral judgments.

Finally, a book in political philosophy. Karl Popper’s The Open Societyand Its Enemies is a lot of fun to read, and it’s now timely again for those of us who want to continue to live in open societies.

ABOUT THE INTERVIEWER
Richard Marshall is still biding his time.

Buy his new book here or his first book here to keep him biding!

End Times Series: the first 302

First published in 3:AM Magazine: Saturday, March 17th, 2018.