The issue of how to set health-care priorities fairly (or justly, or ethically) is one of the most pressing normative issues of our time. Many health-care resources are scarce, and we need some way of systematically assessing different prioritizations. There is also a growing and already very rich literature that addresses the topic, from different perspectives and with contributions from a variety of disciplines. Health economists have for decades worked on outlining summary measures of health that can be used to evaluate distributions of health-related resources and decision tools that can help guide practical priority-setting decisions such as decisions about which treatments to include in insurance plans (e.g. Nord Reference Nord1999; Cookson Reference Cookson2015). Philosophers have developed normative theories designed specifically for the topic (e.g. Daniels Reference Daniels2008; Fleck Reference Fleck2009; Segall Reference Segall2010). Several research groups have also explored approaches that combine philosophy with empirical studies, presenting normative principles that are grounded both in philosophy and in public opinion (e.g. Petrou et al. Reference Petrou, Kandala, Robinson and Baker2013; Ottersen et al. Reference Ottersen, Maestad and Norheim2014). In Setting Health-Care Priorities: What Ethical Theories Tell Us, Torbjörn Tännsjö sets out to explore what ethical theories can tell us about the issue without engaging much with the existing literature.

The book has two main parts. In the first part, Tännsjö claims that there are only three ethical theories that can be relevant to priority-setting, outlines these theories and presents his own view of how plausible each theory is (without claiming that the reader should necessarily agree with him). In the second part, he attempts to apply the theories to priority-setting problems in real life. What I take to be the main argument of the book is that the ethical theories converge when they are applied to practical priority-setting problems, and they all recommend fairly radical re-thinking of health-care policy. More precisely, Tännsjö argues that at a highly general level the most plausible ethical theories all say that, at least in the industrialized world, resources should be diverted from end-of-life care to other more impactful kinds of health-care interventions. Whereas I am quite sympathetic to this proposal, and in particular to the view that treatment of mental illnesses has been largely neglected and should receive significantly more resources, Tännsjö’s general argument is unconvincing.

In the preface, Tännsjö claims that his ‘point of departure is the most widely held and most plausible theories about how to distribute scarce resources’ (vi). The theories that Tännsjö refers to are utilitarianism, ‘the maximin/leximin theory’ and egalitarianism. These are the theories that he applies to problems in real life in the second part of the book. It is also noteworthy that Tännsjö makes it clear already in the beginning of the book that when addressing the theories and thinking about them, he relies on an assumption that rules out pluralism (the idea that, for instance, both utilitarianism and egalitarianism capture something that matters).

Tännsjö, who is himself a utilitarian, offers a good description of utilitarianism that is conventional and well-grounded in the literature. He describes it as an impartial view according to which we ought to maximize the sum total of happiness in the universe (although he also recognizes there are alternative views of how to cash out ‘utility’ and sets aside this issue, something I will also do in this review). In the priority-setting context, utilitarianism consequently says that we ought to set health-care priorities so that they maximize the sum total of happiness. For instance, when choosing between giving a heart to, and saving the life of, a patient who is 30 years old and a patient who is 50 years old, utilitarianism says we should save the younger patient (since they will enjoy the heart longer, and thereby derive more happiness from it).

The second theory that Tännsjö introduces is ‘the maximin/leximin theory’. According to Tännsjö, this is a theory that says that:

It is important for Tännsjö’s argument that this theory focuses on entire lives as opposed to how well off people are during specific periods of their lives such as the present. According to Tännsjö, the reason the maximin/leximin theory assesses who is worst off by focusing on entire lives is that the rationale behind the theory is the separateness and integrity of persons, something which he in turn ties to John Rawls’s famous critique of utilitarianism: ‘Utilitarianism does not take seriously the distinction between persons’ (Rawls Reference Rawls1971: 27). If we are to care about the separateness of persons, we ought to care about individuals’ whole lives, not just how well off they are at certain times, or so Tännsjö thinks. This means that the theory would say that when choosing between giving a heart to, and saving the life of, a patient who is 30 years old and a patient who is 50 years old we should save the younger patient. The reason is that if the younger person gets the heart the worst off person would die at 50, while if the person who is 50 gets the heart the worst off person would die at thirty. A life where one dies at 30 is worse than a life where one dies at 50, so priority should be given to saving the young person.

Tännsjö does not show that anyone has defended the maximin/leximin theory. He refers to Rawls, and the maximin/leximin theory of course has some resemblance with Rawls’s difference principle. However, Rawls certainly did not intend the difference principle to reflect a monistic ethical theory which is the way in which Tännsjö presents the maximin/leximin theory. Furthermore, if any theory of health-care priority-setting is associated with Rawls it is Norman Daniels’ theory, which focuses on Rawls’s views on the value of equality of opportunity and public reason (e.g. Daniels Reference Daniels2008).

It is unfortunate that Tännsjö does not engage more with the literature that more directly defends views that are closer to his maximin/leximin theory. In the contractualist tradition, for instance, Tännsjö could have found defences of views that come close to the view he speaks about. For example, he could there have found the idea that an action is wrong if and only if it is impermissible according to a principle that no one can reasonably reject in conjunction with the ‘minimax complaints model’ of what grounds a reasonable rejection, which says:

This comes close to Tännsjö’s maximin/leximin theory and a discussion of these views could have given some credence to the idea that this is a popular theory. However, had he engaged with this literature, he would also have discovered that defenders of this view tend to also defend other grounds for reasonably rejecting a principle (e.g. Kumar Reference Kumar2015), something which makes one wonder about whether those willing to give strong priority to the worst off really have views that converge as neatly with utilitarianism as Tännsjö’s maximin/leximin theory does in the context of setting health-care priorities.

Egalitarianism, as Tännsjö understands it, is the idea that ‘inequalities are of negative value; an unequal distributive pattern is, in one respect at least, better if it is even rather than if it exhibits different levels of happiness among recipients’ (29). He claims that the rationale for this is that it is bad for a person to be worse off than someone else and connects this theory, too, to separateness and integrity of persons. Since Tännsjö thinks separateness and integrity of persons is the rationale behind egalitarianism, he thinks that this theory, too, is concerned with distributions of happiness between entire lives. Thus, for instance, when choosing between giving a heart to, and saving the life of, a patient who is 30 years old and a patient who is 50 years old, Tännsjö’s egalitarianism says we should save the 30-year-old (since if the younger patient gets the heart the inequality between the two lives would be smaller than the inequality between the two if the person who is 50 gets the heart).

This description of egalitarianism is peculiar at best. The only egalitarian Tännsjö cites in the chapter on egalitarianism is Larry Temkin, who most certainly would dismiss as ludicrous the idea that equality is the only thing that matters (Temkin Reference Temkin2003). Furthermore, Temkin has a radically different view of what the rationale behind egalitarianism is (he thinks it is an impersonal ideal; Temkin Reference Temkin2003), and it is not at all obvious that the rationale behind egalitarianism is separateness and integrity of persons. Moreover, there is an ongoing debate among egalitarians regarding how to account for inequalities at specific times, and it is far from obvious that egalitarians would give as strong priority to young people as Tännsjö assumes (Segall Reference Segall2016; Herlitz Reference Herlitz2018a, Reference Herlitz2018b). As a matter of fact, Temkin explicitly dismisses the view that egalitarians should care only about distributions across entire lives (Temkin Reference Temkin1993: Ch. 8).

The general proposition that the three theories are the most widely held theories strikes me as false. By far the most popular theory in this area is Daniels’ already mentioned Rawlsian view that emphasizes equality of opportunity and the importance of making prioritization decisions with an appropriate process (so-called ‘accountability for reasonableness’). Theories that at the very least are more popular than maximin/leximin and egalitarianism (especially if one thinks of them as theories that capture all that matters to the evaluations) include human right to health, relational egalitarianism, needs-based approaches and the capability approach. This undermines the argument of the book insofar as Tännsjö aspires to show that the most widely held theories converge in practice.

The second part of the book aims to show that it does not matter much whether one accepts utilitarianism, the maximin/leximin theory or egalitarianism, i.e. that the recommendations of the theories largely overlap. Tännsjö shows this by discussing what the theories would say about neonatal care, mundane and easily cured diseases, assisted reproduction, abortion, mental illness, cognitive enhancement, radical life extension, fatal diseases among the elderly, dementia, orphan drugs and individualized medicine.

Although the selection of cases is somewhat curious and Tännsjö does not back up his arguments with empirical research (which is available to those who search for it), the second part of the book is interesting in that Tännsjö shows how there is quite significant overlap between seemingly different ethical theories if one sticks to evaluating distributions across entire lives. However, one is left with the worry that Tännsjö has cherry-picked cases to bring his points home. For instance, low back pain is one of the leading causes of disability in the world. What do the theories say about how we should prioritize treatment and prevention of low back pain? Do utilitarianism, the maximin/leximin theory and egalitarianism (as Tännsjö understands these theories) converge in their recommendations? This does not seem obvious to me. It seems plausible that one can prevent significant amounts of low back pain in the future to a fairly low cost, for instance, by educating young people on the importance of workplace habits and the basics of workplace ergonomics. Such a policy would plausibly be strongly favoured by utilitarians. By contrast, Tännsjö’s maximin/leximin theory and egalitarianism would favour, it seems to me, expensive interventions that benefit people with significant low back pain problems.

In brief, the book presents an argument that shows that besides utilitarianism, there are two conceptually possible theories that are different from utilitarianism, which recommend similar priority-setting in certain areas. However, it seems to me quite plausible that it will be true for all ethical theories that there exist two conceptually possible theories that are quite different but recommend similar policies. We should expect more from a book like this. An important contribution to the field would address theories that are representative of the relevant literature and discuss choice situations that are especially pertinent or exhaustive of the kind of priority-setting problems policymakers face. I doubt this book achieves this.

I am uncertain of what the intended audience of the book is. On one hand, the book introduces philosophical ideas at a very basic level, which makes me think the intended audience is people who work on – or are interested in – priority-setting (e.g. health economists, public health officials, medical practitioners). On the other hand, the book introduces and discusses issues that would be very familiar to that audience at a very basic level (e.g. triage, Quality-Adjusted Life-Years), so perhaps the intended audience is other philosophers. I do not believe that the book serves any of these audiences particularly well. I would hesitate to recommend this book to non-philosophers. One reason for this is that Tännsjö misrepresents philosophical theories. A second reason is that although the book introduces philosophical ideas at a basic level, it is also filled with technical philosophical terms which are not explained. I would also hesitate to recommend the book to other philosophers, primarily because the misrepresentation of philosophical theories makes the argument of the book rather peripheral to contemporary philosophical debates and what I think ought to matter to philosophers interested in priority-setting.

Finally, I should note that the book does not live up to the editorial standards I would have expected from Oxford University Press.