Incommensurability and healthcare priority setting

Philosophical Studies https://doi.org/10.1007/s11098-024-02160-4 Incommensurability and healthcare priority setting Anders Herlitz1,2 Accepted: 19 April 2024 © The Author(s) 2024 Abstract This paper argues that accepting incommensurability can be a useful step for developing attractive hybrid theories to how to distribute scarce health-related resources. If one provides opportunity for distributive options to be incommensurable with respect to substantive criteria, one can hold on to substantive criteria while also providing room for decision processes to play a significant role. The paper also argues that the strategy of accepting incommensurability is preferable to the strategy of having substantive criteria establish sets of options that are equally, explains why incommensurability gives us reason to go hybrid, and argues that reasons grounded in decision processes have properties that make them appropriate as “tiebreakers” in choice situations characterized by incommensurability. Keyword Incommensurability · Healthcare rationing · Priority-setting · Distributive theory · Hybrid theories A core topic in population-level bioethics concerns how to distribute scarce healthrelated resources at population-level. In these debates, some have focused on and defended universal substantive normative criteria, e.g., cost-effectiveness ideals, special concerns for the most severely ill, and/or inequality aversion (see, e.g., Johansson, 2014; Cookson, 2015; Cookson et al., 2022; Tännsjö, 2018; Hausman, 2023). Others have focused on the decision process distributors use and typically highlight the importance of deliberation and public reasoning (see, e.g., Rawls, 1993; Gutmann & Thompson 1997; Daniels & Sabin 2002; Daniels, 2008; Friedman, 2008; Fleck, 2009). A combination of substantive and procedural criteria seems desirable, but it is not obvious how they should be combined. This paper shows how accepting that substantive criteria admit of value incommensurability such that two options can be incommensurable with respect to them can be useful in hybrid approaches. In some sense, since value incommensurability (in the technical * Anders Herlitz 1 Department of Philosophy, Lund University, Lund, Sweden 2 Institute for Futures Studies, Stockholm, Sweden 13 Vol.:(0123456789) A. Herlitz sense this paper adopts) can be a consequence of vagueness and/or incompleteness such ideas are already implicitly present in the literature (see, e.g., Daniels, 2008). However, explicitly recognizing that options can be incommensurable with respect to substantive criteria promises to bring clarity to both challenges and opportunities that ensue. It makes it easier to see, understand and solve the decision-theoretical challenges that arise for these hybrid theories and provides a way of understanding the role of the decision process in relation to substantive criteria. The paper is structured as follows. In the next session, I introduce how I will understand value incommensurability and outline its implications in some further length. The section that follows shows how accepting incommensurability can be a way for proponents of procedural approaches to hold on to the idea that decision processes, deliberation and active participation in decision making matter while simultaneously accepting that substantive criteria of what is good determine how scarce resources should be distributed. In the last substantial section, I discuss three objections to the idea that incommensurability is important when developing hybrid theories: (i) the idea that equally as good as—the value relation—is simpler; (ii) the question of why any potential incommensurability should give us reason to go hybrid rather than just introduce an additional substantive criterion to settle a conventional ranking of all items; and (iii) the question of why reasons established with certain decision processes do a better job than substantive, independent reasons at ranking incommensurable options. There is a brief concluding section. 1 Value incommensurability and the scope of choice freedom In a sense, all action-guiding substantive norms restrict the freedom of choice of agents that commit to them. They do not restrict what agents are able to do in a general sense, of course, but what they are able to do without violating the norms. Insofar as someone binds or commits themselves to a norm, this norm will restrict what they can choose without going against their commitments. The norm “distribute health resources in a cost-effective way” restricts what distributors who commit to it can do without violating the norm. Some norms—like “maximize expected Quality-Adjusted Life Years (QALY) per $”—are very restrictive in this way since they often tell decision making agents exactly what to do. Other norms—like “do not discriminate based on sex”— are less restrictive since they only tell decision making agents to avoid certain options. Accepting value incommensurability is a way of reducing the restrictiveness of a normative approach that puts forward substantive norms and expanding what I will call the scope of choice freedom. The more incommensurability one accepts, the more initially justified options decision makers will face. But before developing this argument, some clarifications regarding what I mean with value incommensurability are needed. The recent literature on value incommensurability is riddled with terminological confusion that is partly due to disagreements regarding how to explain the phenomenon (cf. Andersson & Herlitz 2022a). Some use “incommensurability” in a very precise way to describe the phenomenon that a certain value cannot be placed on the same cardinal scale as another (e.g., Chang, 1997, 2015), some use 13 Incommensurability and healthcare priority setting it to describe incomparability (e.g., Anderson, 1993; Raz, 1986), and some use it to describe these phenomena but also vagueness and non-conventional comparative relations such as parity (e.g., Rabinowicz 2022a, b). In this paper, I will use value incommensurability (or incommensurability for short) in a broad sense to cover a wide range of comparability problems: Value incommensurability: two items, x and y, are incommensurable with each other if it is not determinately true that x is better than y, not determinately true that y is better than x, and not determinately true that x and y are equally good. On this definition, incommensurability obtains if some items are incomparable, if it is indeterminate which relation obtains between them or if some non-conventional comparative relation like parity obtains between the items (the term “determinately” is included in the definition in order to cover indeterminacy). Valuetheoreticians debate which of these phenomena best explain incommensurability (see, e.g., Broome, 2022; Chang, 2022), but for this paper those discussions have limited importance (cf. Andersson & Herlitz 2022b). The focus here lies (...truncated)