Philosophy 955 Health, Welfare and Preference
Revised, but Still Under Construction!
Health is obviously of great importance. It seems to be both a component and cause of well-being. Yet both health and well-being are elusive concepts. Clarifying such important concepts is obviously of philosophical interest. Furthermore, the way in which health and well-being are conceptualized influences methods of measuring health, and measurements of health in turn influence the allocation of billions of dollars of health-related resources. Philosophical analysis has at least the potential to be of enormous practical importance.
The "orthodox" contemporary view is that health is a "vector" with a number of dimensions, such as mobility, pain, cognitive functioning, affect, vision, hearing, and so forth. There is a conventional level of "full health" in which individuals are free from pain and possess normal mobility, affect, cognitive functioning, sensory performance, and so forth. Those whose functioning along any dimension is above normal do not possess more than full health. There are a large number of dimensions of health and many gradations along each dimension, and so practical systems of health classification have to simplify. They do so by limiting the number of dimensions and specifying a limited number of "steps" along each dimension. The EuroQol or EQ-5D system, for example, has only five dimensions and only three steps along each dimension. One of the dimensions of the EQ-5D is mobility, and the three steps along that dimension correspond to unrestricted mobility, limited mobility, and essentially no mobility. Even with such severe simplification, the EQ-5D distinguishes 243 health states. Notice that health classification systems distinguish health states by function or symptom, not by disease. The past significance of a disease is measured by its effects at changing a person's health state for a period of time. The current significance of a disease depends on its expected consequences for a person's health states.
If one wants to be able to compare the health benefits of two policies, one needs to assign numbers or "quality" weights to different health states, which can be added up across individuals. So, for example, Policy 1 might extend the lives of 10,000 people whose average quality of life is at .95 (with 0 = death and 1 = full health) by 10 years for a benefit of 95,000 "quality-adjusted life years" (QALYs), while another policy has no effect on the average life expectancy of the 100,000 people it benefits and improves the average quality of life from .95 to .97. If the average life expectancy of the beneficiaries is 50 years, the gain is 100,000 x 50 x .02 = 100,000 QALYs.
Though there are a number of complexities, the basic idea is straight-forward. It is, however, also deeply problematic in two regards. The first, about which we will have relatively little to say, concerns the relevance of QALYs (or "cost-effectiveness" measures such as "dollars per QALY") to policy. Selecting policies that maximize QALYs seems to be unfair, since saving the life of someone who is diabled produces fewer QALYs than saving the life of someone who is not disabled. The second problematic aspect, which is central to this course concerns the weights or quality adjustments. Just how is one to determine whether the weight to be assigned to a state of perfect health apart from a mobility limitation is .8 or .95 or .99999? How is one even able to compare a health state involving a mobility limitation to a health state involving moderate pain or a cognitive limitation? How can health be measured or evaluated?
It is at this point that the third concept in the name of this seminar needs to be discussed, because the orthodox view maintains that health states should be evaluated in terms of preferences. One compares a health state involving a mobility limitation to a health state involving moderate pain or a cognitive limitation by asking people which health state they prefer. On some theories of well-being, preferences also play a crucial role in determining which states of affairs make people better off or worse off.
Though "preferences" play a role in folk psychology, philosophers and economists employ technical notions of preference in theorizing about well-being and in developing methods of evaluating health states. So in understanding contemporary views of health and well-being (and in figuring out how to do better), we shall also need to study contemporary preference theory.
1. Re well-being: At a minimum I hope that members of the seminar will come to understand the possible roles of theories of well-being within ethics along with main contemporary theories of well-being and the difficulties they face. An ideal outcome would be if members of the seminar came to have a clear view of what role they believe well-being should play in ethics and what well-being is.
2. Re health: At a minimum I hope that members of the seminar will come to understanding the main theories of health and the main systems for measuring health along with the virtues and difficulties of these theories and systems.
3. Re preference: At a minimum I hope that members of the seminar fully grasp the contemporary theory of preferences, its relationship to informal notions of preference and desire, its virtues and its difficulties, and why it is so tempting to look to preferences to specify well-being and to measure health.
4. What I'd really like to accomplish -- though this is absurdly over ambitious -- is for us collectively to figure out a better way of conceptualizing health, welfare and preferences, which will lead to a more defensible yet still feasible way of evaluating health states.
Note: Students are encouraged to discuss problems concerning the teaching of this course with the instructor and/or the TAs. If students wish to pursue a complaint with someone else, they should contact James Anderson, Assistant to the Chairperson, Philosophy Department, 5185 H.C. White Hall, 263-5162.
We will be reading mainly articles and book chapters. In a few cases we will be reading fairly sizeable chunks of books, and in several other cases we will be reading portions of really wonderful books which you may want to purchase. I have prepared a course reader which will be on sale at the Underground Textbook Exchange, which is temporarily located in the basement of The Varsity building (401 N. Lake St.) on the Northeast corner of Lake St. and University Ave. In addition to the course reader, I have ordered What Is Disease? ed. by James Humber and Robert Almeder.
Course Web Site:
A variety of material, including the syllabus will also be available on the web. Some of it will be on a public web page: http://philosophy.wisc.edu/hausman/955Spring2006/default.htm. Other resources (such as access to grades and discussion forums) will be available via the Learn@UW web site: https://learnuw.wisc.edu/.
Those enrolled for credit will be expected to write a substantial seminar paper, to lead discussion of one of the seminar topics and to post discussion questions on that topic, to post a brief and careful response each week to a discussion question, and (of course) to participate actively in discusion in the seminar. The seminar paper will count for 70% of your semester grade. Your presentation in seminar will count for 10% of the semester grade. Participation in discussion in seminar and via the discussion postings will count for 20% of the semester grade.
SEMINAR PAPERS These should be substantial, though there is no specific length limit. Unless brilliantly conceived, a paper of less than ten pages will likely not be sufficiently substantial. Papers over 20 pages will typically be too ambitious or unfocused, and I'm not keen on reading a 30-page seminar paper whose arguments could have been expressed in 15 pages without loss of content. The seminar paper will be due at the last meeting of the seminar, Tuesday, May 2. A paragraph description of the topic for your seminar paper is due no later than Tuesday April 4. The topic description can be emailed to me or brought to seminar on the 4th.
PRESENTATIONS AND POSTINGS OF DISCUSSION QUESTIONS In the first class I will distribute a schedule for presentations and ask you to think about your preferences and email me before the second meeting of the seminar. My plan is for presentations to begin with the third seminar (January 31), but if anybody would like to give a presentation during the second seminar, that can be arranged. Seminar presentations involve the following tasks:Complete the readings for the seminar and post between three and six discussion questions on the learn@uw web discussion page no later than noon on the Friday before the seminar meets. Prepare and duplicate a one to three page written outline of the points you want to emphasize in your presentation. Where possible you should make references to issues and questions raised at previous seminars and to points raised by seminar members in their discussion postings. Print out and duplicate copies of responses to discussion questions posted by members of the seminar so that we can all refer to them during seminar. If uninterrupted, your seminar presentation should last about 20 minutes. Since you will typically be interrupted, your presentation is likely to last for most of the seminar.
POSTING DISCUSSION RESPONSES
Every week by noon on the Friday before the seminar meets, a half-dozen discussion questions will be posted by the seminar's discussion leader. All members of the seminar will be expected to post a single brief (250 word maximum) and polished response to one of the posted questions. Responses should be posted no later than 6 p.m. the night before the seminar. Once or twice during the semester I will grade your posting pedantically and mercilously, fussing about your punctuation, wording, grammar, and style (as well as content), and the expectation is that the postings will be extremely clear, well-written, perceptive, and of interest to everybody in the seminar. You should compose your discussion responses using a word processor on your own computer and paste them on to the discussion page only after you have carefully revised and rewritten them. The briefer, clearer, and better written are the postings, the more valuable they will be for everyone. Though it goes without saying, the postings should show the same courtesy, kindness, and gentleness that discussion within the seminar shows. With the exception of the first seminar and the seminar immediately after Spring break, I will expect everybody to post responses every week.
Tuesday, January 17: Introduction:
Derek Parfit, Reasons and Persons, Appendix I "What Makes Someone's Life Go Best?"
Erik Nord, "Values for Health States in QALYs and DALYs: Desirability versus Well-Being and Worth"
Tuesday, January 24: Mental state theories of welfare
Henry Sidgwick, Ultimate Good
Richard Layard, Happiness
Robert Nozick, The Experience Machine
Tuesday, January 31: Rationality, Preference, and desire theories of welfare
Dan Hausman and Michael McPherson, Rationality, Welfare
James Griffin, Part I of Well-Being, chapters 1-2
Tuesday, February 7: From informed desire to objective-list views
James Griffin, Part I of Well-Being, especially chapters 1-3
Thomas Scanlon, Well-Being, esp. sections 1-3.
Tuesday, February 14: Objective List and perfectionist views
James Griffin, Part I of Well-Being, especially chapters 3-4
James Griffin, The Good Life (chapter 2 of Value Judgement)
Tuesday, February 21: Well-being, excellence, and life plans (I)
Aristotle, Nicomachean Ethics, Book I, and ch. 1-6 of Book X
Joseph Raz, Personal Well-Being
Tuesday, February 28: Well-being, excellence, and life plans (II)
Robert Merrihew Adams, Well-Being and Excellence
Thomas Scanlon, Well-Being
Tuesday, March 7: Capabilities and Functioning
Amartya Sen, Functionings, Capability, Freedom, Agency, and Well-Being
Martha Nussbaum, from Women and Human Development
Tuesday, March 21: Health and Normal Species Functioning
Christopher Boorse, Concepts of Health
Frederik Kaufman, "Disease: Definition and Objectivity" (H&A 269-86)
Michael Ruse, Defining Disease (H&A 135-72)
Tuesday, March 28: Naturalist, normative, and pragmatic views of disease and health
George Agich, Toward a Pragmatic Theory of Disease (H&A 219-46)
K. Danner Clouser, Charles M. Culver, Bernnard Gert, Malady (H&A 173-218)
Christopher Boorse, A Rebuttal on Health (H&A 1-134)
*Tuesday, April 4: Concepts of health and health-state classifications
Ritu Sadana, Development of Standardized Health State Descriptions
David Feeny, Health-Status Classification Systems for Summary Measures of Population Health
Prasanta Mahapatra, Lipika Nanda and K.T. Rajshree, The 6D5L Description System for Health State Valuation
Tuesday, April 11: Measuring Health
John Graham, An Investor's Look at Life-Saving Opportunities
Dennis Fryback, Methodological Issues in Measuring Health Status and Health-Related Quality of Life for Population Health Measures: A Brief Overview of the “HALY” Family of Measures
Patrick Hofstetter and James Hammitt, Selecting Human Health Metrics for Environmental Decision-Support Tools
Tuesday, April 18: On the definition and measurement of health
Christopher Murray, Rethinking DALYs, pp. 1-9, 22-43, 54-63
Erik Nord, The Limitations of Utility Measurement
Tuesday, April 25: Health and well-being
John Broome, Measuring the Burden of Disease by Aggregating Well-Being
Dan Brock, The Separability of Health and Well-Being
*Tuesday, May 2: Health and opportunity
Norman Daniels, Health Needs
If my office hours, (Tuesday 11-12 and Wednesday 12-1) are not convenient, see me after class to arrange another time to meet. My job is to help you to master the skills and material with which this course is concerned, so feel free to come see me.
Feel free to email me at firstname.lastname@example.org with any specific questions you have about assignments or requirements. If the question and answer are relevant to others, I will post them on the course discussion page. If you do not want your question posted, you should let me know. Otherwise I will assume that in emailing me, you’ve given me permission to post your question. You can send me substantive philosophical questions, too, though in most cases it is better to include the whole seminar in discussions of matters of substance.
Though this should obviously go without saying, particularly in a graduate seminar: Plagiarism is a serious offense. All sources and assistance used in preparing your papers must be precisely and explicitly acknowledged. If you have any questions about what constitutes plagiarism, please come talk with me. The web creates special risks. Cutting and pasting even a few words from a web page or paraphrasing material without a reference constitutes plagiarism. If you are not sure how to refer to something you find on the internet, you can always give the URL. It is generally better to quote than to paraphrase from material on the web, because in the absence of page numbers it can be hard to find passages that are paraphrased rather than quoted. When referring to material from the web, specify the date that you accessed the material in addition to the URL, because web pages (unlike books and articles) change.
Some elementary advice, which you probably already know:
On reading philosophy papers:
1. Use your highlighter very sparingly. It is much more useful to pencil in marginal notes summarizing or querying specific points than to highlight passages. Actively engaging the author is much more valuable than merely trying to assimilate the prose. And if you do highlight, only highlight a small percentage of the text. (There is not much point to highlighting everything, apart from adding color to the page!)
2. You should plan on reading the assignments at least twice. During the first reading you should ask yourself:
a. What is the author's position?
b. What is the general structure of the paper? Is it a collection of separate arguments, or does it aim to make one main argument?
c. What are the author's main assumptions? (Where is the author coming from?)
d. Against whom does the author take him/herself to be arguing? What is the context in which the piece was written?
e. What is the main line of argument (or what are the main lines of argument)?
f. What objections does the author address and how successful is the author in answering them?
g. How does the author's position relate to your views? To what extent does the author reinforce or challenge your views?
h. How do the author's arguments relate to the arguments discussed in seminar or in other reading assignments? What criticisms would the author make of arguments developed in seminar or in other readings? To what extent is the position of the author open to criticisms made in seminar or in other readings?
During the second reading of the assigned material, you should proceed more slowly and critically. Rather than asking, as suggested above, questions about what the author's purposes, organization, and argument are, you should try to assess all of these and particularly the author's arguments. Try to study the discussion questions before doing your second reading.
Style and references:
1. You are expected to give references when you cite detailed claims or arguments made in the readings, and your papers should, where appropriate, show familiarity with relevant materials from the seminar or reading for the course. But you are (of course) expected to write essays, not examination answers. So don't introduce irrelevant matters to demonstrate that you have mastered irrelevant material from the seminar. (But you must not ignore relevant supporting arguments and, particularly, objections in the readings.) Cite the readings only when they are relevant. Be sure that your paper is a well organized argument for some clearly articulated thesis.
2. When you quote, paraphrase, or make use of a point made by others, be sure to document the source. We are not particular about what style you use. All that matters is that your references be precise and usable. If you say that Parfit says that contracts are worthless, it should be clear on what page Parfit supposedly says that. The easiest way to give a reference is simply to put the source and page number in parenthesis. Papers without clear references (where needed) will be marked down.
3. Papers must be typed or printed double-spaced with wide margins (at least one inch) on all sides, so that there is plenty of room for marginal comments. Be sure to keep copies of your papers. Please do not use binders.
4. Papers for the course must be essentially correct in their "mechanical" aspects-- spelling, punctuation, grammar, typing, and so forth. Papers with more than 3 or 4 errors per page will be marked down, and if they are very messy, they will not only be penalized, but they will also be returned for correction before they are graded. Obviously spelling and typing are of no intrinsic importance, but messy papers are hard to assess; and it is not unfair to expect you to take responsibility for making sure that your papers are correct in these regards.
Hints on essay writing:
1. The point is to write a well-organized and unified argument for some clearly enunciated conclusion. The task of writing a good essay is virtually identical with the task of thinking out a clear thesis or conclusion that you want to defend and then elaborating and defending it. You should be able to say clearly and precisely not only what your seminar paper is about, but also what your paper maintains or shows. Be sure your seminar paper has both a thesis--that it asserts something definite--and a logical organization. Once it is clear what you what to show, you will have a criterion to decide what is relevant and the basis for organizing your paper. Can you put your main point clearly in a sentence? Can you say clearly in a sentence what your paper shows or proves? Are all the parts of your paper relevant to your main point? Is the structure of your argument clear? No good essay merely summarizes things you have read and then offers your remarks or points of comparison or differences you noticed. Every acceptable essay integrates its remarks into an argument of its own. Exposition of the views of others should always be part of your argument for your thesis.
2. Note that a well-organized paper is not merely orderly. For example, a paper that argues that Parfit argues claims 1, 2, and 3 and that one can defend claim 1 as follows, claim 2 as follows, but not claim 3 is certainly orderly, and it certainly has a thesis. But it would only be well-organized--truly one paper rather than three--if the discussions of the three claims bore some relations to one another and if the paper added up to some unified and substantive statement. Please do not put section headings in your papers.
3. Avoid first paragraphs that say things such as, "First I will discuss the views of Griffin and Sen. Then I will discuss their strengths and weaknesses. Then I will compare their conclusions and formulate my opinion." Passages such as these make it sound as if your argument will begin only on the last page. Exposition of the views of others has to find its place within your argument, not as a preface to your argument. If you think in terms of what you want to establish, and outline your paper in terms of stages in your argument, your essay will be much stronger.
4. Try to say exactly what you mean. Pay careful attention to your language. Sentences such as "Aristotle's happiness is an ancient view" are unacceptably careless. Value your words and use them accurately.
5. To help in organizing your thinking, you should attempt to answer the following three questions:
1. What is your thesis--that is, what is it that you are trying to maintain or show or prove? What is your main argument for your thesis?
2. What is the most important objection to or criticism of your thesis that you need to consider? Formulate that objection or criticism as an argument.
3. What is your argument in response to the objection or criticism mentioned in answer to question 2?
If you cannot answer these questions clearly and easily, then there are serious problems with your paper. Do not regard your papers as finished or acceptable until each clearly implies answers to the above questions. (But an essay is not, of course, a list of answers to any set of questions.) Taking the task of answering these questions seriously can make a big difference in the quality of your paper.
Special considerations in writing philosophical papers:
1. In a philosophical debate or a philosophical paper, the objective is to learn and to express the truth (or some anti-realist substitute). So you should try to make the arguments conflicting with your views as compelling as possible, before you answer them. If there are any objections to what you are maintaining that you cannot answer, then you cannot be sure that you are right. Work hard at trying to see "the other side (s) ".
When working on your seminar papers, feel free to come talk with me. In addition, there are some excellent resources on the web for writing philosophy papers. I particularly recommend:
www.sfu.ca/philosophy/writing.htm This is brief, clear, and helpful.
http://www.princeton.edu/~jimpryor/general/writing.html Excellent, but much lengthier.
www.unc.edu/depts/wcweb/handouts/philosophy.html For those who are serious about philosophy.
www.cofc.edu/~portmord/tips.htm Contains lots of references for further study.
A terrific general source on writing is Strunk and White's The Elements of Style. The first edition is available on the web at http://www.bartleby.com/141/