Ethics Amidst Uncertainty: Essays on Global Health Priority Setting

Abstract

Global health actors must allocate limited resources. For instance, non-governmental organizations must decide which public health interventions to prioritize, research funders must decide what grants to make, and governments must decide what health care to provide to their citizens. These decisions have ethical implications. For example, a decision to prioritize cancer research over dengue research predictably affects which, how much, and how different populations will benefit from research. Making matters more complex, global health actors face uncertainty when setting priorities: they may be unsure about the relevant empirical facts (e.g., what health benefits an intervention will yield), as well as the relevant moral principles (e.g., whether to maximize health benefits or prioritize more disadvantaged groups). In my dissertation, I focus on three kinds of uncertainty global health actors face in setting priorities: uncertainty about the efficacy of different policies and interventions, uncertainty about the future, and uncertainty about what one, morally, ought to do. In the first chapter, I argue that ethicists have tended to sidestep issues related to uncertainty when offering guidance about priority setting, and that this has limited the applicability of their guidance. In the second chapter, I assess when and whether global health actors should prioritize interventions for which there are more reliable cost-effectiveness estimates. In the third chapter, I consider how far into the future research funders should look—and how they should account for changing disease burden—when setting priorities. In the fourth chapter, I consider whether moral uncertainty necessitates a turn towards procedural—rather than substantive—justice in setting priorities. In the final chapter, I identify common themes across the dissertation, consider limitations, assess how future projects might build on this work, and conclude.