The aggregation problem.

Suppose that you had to choose between two medical programs. You could provide flu vaccine to a million people, thereby sparing a quarter of them the virus and adding fifteen years to the lives of four people who would otherwise have developed fatal complications. Or you could offer coronary bypass surgery to twenty others, lengthening their lives by an average of five active years and brightening the days they would have had anyway. Which program should you choose? The benefits I have described are fictitious. But this hypothetical choice illustrates what Norman Daniels terms the aggregation problem--the problem of combining benefits of varying dimensions to different numbers of people in deciding how health care dollars should be spent. By breaking the larger rationing issue into four parts, Daniels has helpfully spotlighted the many distinct moral questions that allocating health care presents. In this essay, I suggest that the aggregation problem, although exceedingly difficult as an abstract philosophical issue, can readily be solved within a large-scale health insurance system. Which services are funded ought to depend on people's informed preferences regarding possible treatments, given the risks they run and the efficacy of available procedures. The hard questions lie in two of the other three quadrants Daniels has marked off. Daniels's democracy problem--the problem of assembling people's ill-informed and often incoherent preferences into one or a few insurance packages that a diverse group of people must all live by--is exceedingly difficult. The most troubling questions, however, are probably those of priority. Justice requires redress for the uncourted ill luck and bad genes that mar some people's lives, though disagreement abounds over what compensation is appropriate. The challenge is to articulate, concretely, those remedial principles that should constrain the best collective expression of people's medical insurance decisions. Isolating the Aggregation Problem In approaching the aggregation problem, I make several important assumptions. Let me state them plainly. First, the choices among people vying for medical services occur within an established system for dispensing care to a sizable population. Think of a government-funded or employer-provided health insurance plan. These decisions are not the nightmare choices among differing numbers of lives and arms and eyes that some imaginary potentate puts to a hapless philosopher. Nor are they unexpected, emergency decisions between injured or imperiled people that some private individual must make. They are predictable choices regarding the rival needs of members of an identified group. Second, those requesting medical attention all have some claim of right to it, and therefore are entitled to a just decision. The medical resources at issue are not charitable gifts, to which possible recipients lack moral or legal tide. Nor may the provider favor any claimant based on ties of affection or association. Third, none of the people whose claims must be balanced is more deserving than the rest. Nobody has precedence on account of youth, unmerited disadvantage, prudence, or urgent need. Accounting for these differences constitutes Daniels's priorities problem, from which I abstract. A Crucial Assumption My final assumption is unavoidably controversial, though I want to beg as few questions as I can. I assume that each person has the same claim to health care resources. By this I do not mean that people with different ailments or fears can demand the same number of dollars' worth of treatment whenever they enter a hospital, or that they have equally powerful rights to some drug or procedure regardless of their prognoses. What I suppose is that all of the people concerned, as individuals, have identical claims in advance of their specific needs to whatever care money can buy, except insofar as those claims are limited by the proper solution to the priorities problem. …