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Dan Brock has argued that in judging distributions of health-say, life years or life expectancy-prioritarianism and egalitarianism may sometimes judge distributions differently. 1 In particular, Brock argues that a principle of "equality of outcomes will not always support improving the position of the worst off". He also argues that equality in 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 it deserves more attention. 2
This paper follows Brock and argues that (a) prioritarianism and egalitarianism may sometimes judge distributions differently; and (b) when understood, both prioritarianism and egalitarianism-properly combined with concerns for average health-are not open to the levelling down objection.
Brock's example
Brock asks us to consider the following distribution ( table 1 ). 1
Distribution | Patient | ||
A | B | C | |
1 | 10 | 20 | 20 |
2 | 11 | 15 | 25 |
A, B and C are individuals, and two possible distributions of health are shown.
I suggest, although Brock does not say so, that we should assume we are dealing with the distribution of life years. Moreover, we could assume that the initial distribution is, say, that all three persons will die at age 50 if not provided with either policy 1 or 2.
Policy 1 will provide 10 additional life years to person A, 20 life years to person B and 20 to C. Policy 2 will provide 11, 15 and 25 life years to persons A, B and C, respectively. As noted by Brock, distribution 1 is more equal than 2, while the position of the worst off, A, is better in 2 than in 1. This is a case where equality of outcomes will not support improving the position of the worst off. Notice that Brock does not claim that egalitarianism will never support the position of the worst off, but that it will not always do so. Notice also that Brock appeals to an "intuitive" judgement of equality, namely that at face value, distribution 2 "looks" more unequal than distribution 1. The differences in outcomes between A, B and C are smaller under 1 than 2 (B-A=10;...