In a recent article, Michael Otsuka and Alex Voorhoeve present an argument against the so-called ‘Priority View’ of distribution.Footnote 1 According to that view, as stated by Derek Parfit, ‘benefiting people matters more the worse off these people are’, by virtue of the fact that a person's utility has ‘diminishing marginal moral importance’ the better off she is.Footnote 2 Otsuka and Voorhoeve claim that, because this view fails to reflect a significant difference between the intrapersonal and the interpersonal, it should be rejected.
Their initial counter-example (pp. 171–4) asks us to imagine a young adult who is told that she is going to develop a mobility-affecting condition and has a 50 per cent chance of developing each of the following:
Slight impairment: a condition that renders it difficult for one to walk more than 2 km.
Very severe impairment: a condition that leaves one bedridden, save for the fact that one will be able to sit in a chair and be moved around in a wheelchair for part of the day if assisted by others.
There is a treatment available for each condition, but it must be taken before she knows which impairment she will suffer. Only one treatment can be taken. That for the slight impairment would prevent her disability entirely; that for the very severe impairment would improve her position to that of:
Severe impairment: a condition in which one is no longer bedridden; rather, one is able to sit up on one's own for the entire day but requires the assistance of others to move about.
Assume that this young adult is herself indifferent between the two treatments. According to Otsuka and Voohoeve, if you are in a position to provide her with one of the treatments, it would be reasonable for you also to be indifferent between them – that is, on various plausible assumptions, to maximize the expected increase in her utility. This, then, is the intrapersonal case.
Now consider the interpersonal case, in which you are confronted with a group of individuals. You know that half of them are going to develop the slight impairment and the other half the very severe impairment, and you can identify the individuals in each half. The individuals themselves have the same preferences as the young adult in the intrapersonal case, and we can assume, therefore, that the expected utilities are the same. You can offer treatment only to one or the other half of the group. In this case, Otsuka and Voorhoeve suggest, the only reasonable decision is to treat those who are going to develop the very severe impairment. In other words, our attitudes towards giving priority change dramatically when we move from the intrapersonal to the interpersonal case. According to the Priority View, however, in the intrapersonal case we should not be indifferent between the two treatments, because ‘the treatment for the very severe impairment will have a higher expected moral value simply by virtue of the fact that the initial state from which her utility would be increased would be at a lower absolute level’ (p. 178). The Priority View, that is to say, fails to give weight to ‘the moral significance of the separateness of persons’ (p. 183).
The fact that this initial example features a young adult introduces unnecessary worries about the relation between the Priority View and respect for autonomy. As Otsuka and Voorhoeve themselves point out (p. 187), their argument should work equally well if the individual concerned is not a young adult but a child, too young to have rational preferences regarding the two treatments. They then offer an illustrative example, adapted from Thomas Nagel. Imagine that a parent has a child with a 50 per cent chance of a disability. The parent must decide whether to move to the city (where the disability could be catered for more effectively) or to the suburbs (where an able-bodied child would have a better life than in the city). (Let us assume that the utilities mirror those in the original case of the young adult.)
In Nagel's original example, the decision concerned two children, one disabled, the other able-bodied. Because of the significance of the separateness of persons, they suggest, ‘one should give less weight to benefiting this child should he end up with a disability (by moving to the city) than the weight one would give to benefiting the child with a disability in Nagel's two-child example’ (p. 188). Indeed it seems that, according to Otsuka and Voorhoeve, one should give no special weight to benefiting the child should he end up with a disability, since, if the parent decides to move to the suburbs and the child turns out to be disabled, the parent can ‘justify [her] decision . . . on the grounds that [she] was looking after that very same child's interest in flourishing in the event that he had turned out able bodied’ (p. 188).Footnote 3 If she should have given some weight to benefiting the child should he end up with a disability, this justification would be unavailable.
I suspect that many people will share my view that the parent should move to the city, and that parental indifference exemplifies an indefensible disregard for the possibility of the child's disability. If the parent moves to the suburbs and the child becomes disabled, one can imagine the child (presumably when he has grown up a little) complaining as follows: ‘I accept that the expected utility of each move was the same for me. But you should have paid greater attention to the fact that I had two possible futures: one in which I was disabled, and one in which I was not. You should then have asked yourself which possible future person should be given priority to the other – and the answer would have been clear: the one who is worse off.’
The one-child case, then, supports the Priority View against cost– benefit analysis – and suggests, incidentally, that people's intuitions in the young adult case are being led astray by issues of autonomy. The essence of the Priority View is that one should seek to bring about outcomes in which the worse off do better, regardless of whether the case in question is an intra- or an interpersonal one. The plausibility of the Priority View here can be further demonstrated by considering iterations of intrapersonal cases involving children. Imagine that you are an official charged with providing treatments for orphaned children, whose diagnosis is similar to that of the young adult in the original case. Let us assume that you have to make a decision on treatment for one child per day, for five hundred days. According to Otsuka and Voorhoeve, you should be indifferent between the treatments.Footnote 4 So there is no reason why, if you wish, you should not always offer the treatment which will cure the slight impairment. The upshot, of course, is likely to be something like the following: 250 children who would have suffered from the slight impairment will suffer no impairment, while 250 children who might have suffered only the severe impairment in fact suffer from the very severe impairment. Most people, I believe, would strongly prefer the serial application of the Priority View in this example, even though each time it is applied intrapersonally.
In a ‘group’ case in which the disabilities each child will develop are already known, Otsuka and Voorhoeve will be ready to give priority to the worse off. Given that the outcomes that arise from serial application of the Priority View to intrapersonal cases and from single application of the Priority View to a group with identifiable members are exactly the same, the distinction Otsuka and Voorhoeve seek to draw between the intrapersonal and the interpersonal is very hard to defend.Footnote 5
