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Submitted by Nir Eyal on

Highly original stuff, Adam!

In my own view, ex ante distributions lack intrinsic worth, whether positive or negative. But even those who believe that they intrinsically matter would have to reject this modest proposal, for two reasons:

1. The difference between the most cost effective and the least cost effective interventions is enormous. As Toby Ord points out in similar contexts, Disease Control Priorities 2, perhaps our most authoritative source on the cost effectiveness of interventions in the developing world, shows 10,000 times differences between them. Even if you think that giving a chance to someone with a complicated condition is worth something, do you really think that it is worth 10,000 lives?

2. The people who will one day have complicated needs that require expensive solutions are not as yet identified. That could be ensured by including a “time-release” clause in UHC legislation, such that reforms would kick in only after a waiting period. Therefore, the real ex ante perspective is where we are now—unidentified. Behind the current veil of ignorance about future health needs, rational egoists would prefer maximizing their expected health or expected utility by opting for the reform that funds the most cost-effective interventions. They would not want their prospects compromised just so that some people, later to be identified as having expensive needs, then get a chance too. They are focused on the real ex ante perspective, and not on what is from their current vantage ex post.

So even from an ex ante perspective—which I reject—Adam’s (tongue in cheek?) modest proposal is anything but modest.