reasonable disagreement about identifed vs. statistical victims

January-February 2012 HASTINGS CENTER REPORT 35

People tend to contribute more—and thinkthey have stronger obligations to contributemore—torescuinganidentifiedvictimrather

thanastatisticalone.Indeed,theyareoftendisposedtocontributemoretorescuingasingleidentifiedvic-timthanagreaternumberofstatisticalones.Byan“identifiedvictim,”ImeanTerryQ.,lyinginjuredinthepassengerseatofthewreckedautomobileonthecornerofMainStreetandBroadway,orJessicaMc-Clure,thechildwhofellintotheTexaswellin1987andwhose familywas sent$700,000 indonations

for her.We need not know their names, however,andwecanacceptaveryminimalformofidentifi-cation.1Bya“statisticalvictim,”Imeanthepersonwho, extrapolating from traffic records, will be ina similar, serious car accident tomorrow (and maythenbeidentified),orthechildrenwhowillfallintowellsnextyearifwedonotcapthembetterthanwedidthewellthattrappedJessica.

Does this disposition (or perceived obligation)have anynormative force? I initially thought therecouldbeno suchnormative force,but consequen-tialist andnonconsequentialist arguments,pro andcon,haveconvincedmethatreasonablepeoplecandisagreewitheachother.Thisdisagreementposesaproblemforpoliticalphilosophy:howshouldpolicy

Identified vs. Statistical

V I C T I M S

By NORMAN DANIELS

People are more likely to rescue an identified person we know is being harmed than a “statistical”

victim—the person who might be harmed if we don’t take steps to prevent it. Some think the identified

victim bias makes for unethical public policy; others accept it. The disagreement cannot be entirely resolved.

Reasonable Disagreement

about

Norman Daniels, “Reasonable Disagreement about Identified vs.StatisticalVictims,”Hastings Center Report42,no.1(2012):35-45.DOI:10.1002/HAST.13

36 HASTINGS CENTER REPORT January-February 2012

choices take such disagreement intoaccount?

Throughout thispaper, Ihave inmind the disposition to give moreweight to rescuing one identifiedvictim than to rescuing one statisti-calvictim.Ifwegivemoreweighttorescuing one identified victim thanto rescuing more than one statisti-calvictim,weareclearlygivingmoreweighttoone identifiedvictimthanto one statistical one. We might,however, givemoreweight to rescu-ing one identified victim than onestatistical victim but not think thatone identified victim will outweighseveral statistical victims.2 I want toseparatetheidentifiedversusstatisti-cal victim problem from the aggre-gation problem, which I shall notconsider,althoughthetwoareoftenconflated.

The Problem Illustrated

Thomas Schelling first labeledthe problem in a hypothetical

case by sardonically noting that thesame people who flood the post of-ficewithcontributionstopayforanexpensive operation that will keep“a six-year-oldgirlwithbrownhair”alive “till Christmas” will show nointerestinsupportingasalestaxthatfunds hospital improvements thatwillsavemanymorestatisticallives.3Arguably, Schelling picks out a realproblem(thoughhecombinestheag-gregationproblemwiththeidentifiedvictimproblem),evenifotherfactors(suchasanaversiontohighertaxes)mayconfoundtheparticularcasehediscusses.

Journalists learned to exploita related phenomenon. We neverread,hear,orseeastoryaboutanis-sue—whether it isbankruptcy, fore-closure, job loss, trafficaccidents,orcancer—that does not use the hookofanamedvictimwithaspecificnar-rativetoengagethereader.Engagingreadersorviewersinthisway,whichwemayassumeisimportantinjour-nalism, manipulates the audience,butonlytrivially,sincethestakesareinsignificant—perhaps a moment of

the readers’ or viewers’ time. Sincelives are involved in the identifiedvictimproblem,thestakesarehigherin it. In addition, as we shall see, afactor other than vivid engagementwiththevictimmaybeatworkintheidentified victim problem, for weakidentifiability(withnopersonalizinginformation)sufficestoincreasecon-cernabouttheidentifiedvictim.4

Realexamplesofthebiasinfavorofidentifiedvictimsareeasytofind.In the late 1980s, then-president oftheOregonSenate (and later gover-nor) John Kitzhaber, an emergencyroom physician, had the idea thatmore lives couldbe savedperdollarspent in the Oregon Medicaid sys-temifexpensivebonemarrowtrans-plants for childrenwithcancerwerereplaced with an expanded prenatalmaternalcareprogram.Atthispoint,Kitzhaberwasweighing some statis-tical victims (children who will de-velop certain cancers) against others(childrenwhowillnotsurvivecertaintroubled pregnancies). An identifiedvictimimmediatelyappearedtochal-lenge thecalculation:CobyHowardwasanappealingeight-year-oldchildwithcancerwhosefamilywentpublicwhenOregonMedicaiddeniedcov-erageforthebonemarrowprocedure.(Thepublicwasnot told thatCobywasineligibleforatransplantbecausehiscancerwasnotinremission.)Thepublicoutcryproducedprivatedona-tionsfortheprocedure,butCobydiedanyway. Similarly, public demandsforunproven“last chance therapies”foridentifiedvictimsoftenderailat-temptstosavemorestatisticallivesbylimitingcareto“proven”treatments.5ThepublicreactiontotheidentifiedvictimforcedKitzhaberandOregontobegintheworld-famousprocessofrationalizingthestateMedicaidben-efitpackage.

The identified victimbiaswas inplayadecadeagowhenadvocatesofscaling up antiretroviral treatmentsfor HIV/AIDS patients providedphotos and video of specific AIDSpatients, first showing them priorto antiretroviral treatment and closeto death, then showing them after

treatment, far more robust and ableto support their children. Appealstostatisticswerenotaspersuasiveinmoving people to support arguablymorecost-effectivepreventiveefforts.Advocates also argued that donorswouldcontributemoretotreatmentof real victims than they would toprevention that sparedmore statisti-cal lives from the disease. Similarly,physician advocates asserted that inwealthy developed countries, physi-cians are not expected to turn theirbacks on AIDS victims who walkinto their offices (and are thereforeidentified),6sowhyshouldphysiciansin developing countries have to doso? Advocates for identified victimsprovedrightthatmoreresourcesweremobilized to help identified victimsthan would ever have been donatedforpreventivemeasuresalone.7

The disposition to favor identi-fied victims over statistical ones cancombine with the law’s traditionalfocusonindividualsandtheirrights.Through a tutela, a special lawsuitpossible in Colombia, a patient canarguethatadeniedserviceisonethatrightfully should be included in aninsuranceplanbecauseitismedicallynecessary(asdeterminedbythetreat-ing physician) for a dignified life.8Significantresourcesarededicatedtomeeting the medical needs of theseidentified victims, whereas used dif-ferently,theymighthavesavedmorestatistical lives.The bias in favor ofidentified victims also makes envi-ronmental lawharder touse topro-tectthehealthandsafetyofstatisticalvictims.9Identifiedvictims,suchasaworkerwholosesherjob,canweighmoreheavilyinthelawandthelegis-lationthatestablishesthelawthandothe statistical lives thatmaybeben-efitedbythelaw.10

Despitetherealityofthedisposi-tion to favor identified over statisti-calvictimsandthebroadscopeoftheproblem, there is good reason to becautious about the relationship be-tween the identified victimproblemandothercontraststhatareoftenas-sociatedwithit,suchastheproblemof treatment versus prevention. As


Paul Menzel argues, the identifiedversusstatisticalvictimproblemdoesnotdirectlymapontothetreatmentversus prevention problem;11 sometreatments are in fact aimed at sta-tistical victims, and somepreventiveservicesinvolveidentifiedindividuals.Thus (asMenzel claims),wecannotuse the former distinction to estab-lishpriorityamongeithertreatmentsor preventions. If, however, there issome normative force to the identi-fied victim bias, then it may justifygivingsomeprioritytothoseformsoftreatmentoverpreventiveprotectionof equal numbers of statistical liveswherethecontrastbetweenidentifiedandstatisticalvictimsapplies.

What Concerns Are at Work?

Karen Jenni andGeorge Loewen-

stein’s seminal study at-tempts to identify thesourcesofbiasthatleadspeopletofavoridentifiedvictims.12 They considerfourfactorsthataregen-erallypresent in all identified versusstatisticalvictimissues:(1)thevivid-nessoftheidentification;(2)thecer-taintyof the threat to the identifiedvictim and the probabilistic natureofthethreattostatisticalvictims;(3)theproportionofthereferencegroupthat can be saved; and (4) the con-trastbetweenevaluatingtheharmbe-fore itoccursversusafter.Realcasesofidentifiedversusstatisticalvictimswill include a mix of these factors,andperhapsallofthem.Findingoutwhetheroneoranotheristhebestex-planation of responses thus requiresdescribing hypothetical choices thatcontrol for the various factors. Theinquirydoesnotpresupposethatthebiasinfavorofidentifiedvictimsisanerror thatneedsanexplanation.

Jenni and Loewenstein men-tion three factors that convey vivid-ness:thestorymustbeemotional,itmustuse visual images, and itmustbe unfolding in “real time.”13Thereis marketing and other research on

“vividness” focusing on the impor-tanceofconcreteexamples.14Never-theless, in their study, vividness didnot explain the disposition to favoridentified victims. Jenni and Loew-enstein tested the impact of vivid-ness, and the other possible causalmechanismslistedabove,bypresent-ing research participants with briefdescriptions of different scenariosinvolvingvictims.Theyaskedpartici-pantstoratetheimportanceofreduc-ingtheriskofharmtothesevictims,varyingthedescriptionstofiteachofthefourpotentialcausalfactors.

Theyhadexpectedvividnesstobeanexplanatoryfactor,andtheyweresosurprisedthatvividnessdidnotex-

plain respondent’s answers that theyranfurtherstudiestoconfirmthere-sults.Inthelaterstudies,thereisevi-denceofanidentificationeffectevenwhen there is no information aboutthe victims.15This identification ef-fect works on emotions other thansympathy,16anditispresentinchoic-esbesidesthoseinvolvingrescue.Forexample, identified wrongdoers arepunished more than unidentifiedones even when there is no “vivid”informationprovidedaboutthem.17

The second and fourth possiblefactorswerealsosetaside.Theidenti-fiedvictimwascertain to faceharmwithoutrescueortreatment,butthedangertostatisticalvictimsisproba-bilistic. We know from other workthat people fear a certain loss morethantheydesireacomparablebenefitorgain,18andasaresultmaytakeriskstoavoidthelossevenwhentheriskshavethesameorworseexpectedpay-offs than the certain loss represents.(Thisbehaviorislabeled“riskseeking

with regard to losses.”)But this fac-toralsodidnotexplaintheidentifiedvictimbias.Neitherdid thedistinc-tionbetweenevaluatingtheactafterthevictimappearsinsteadofbefore.19

The explanatory factor forwhichJenni and Loewenstein find supportis the third factor, which representsanother general propensity amongpeople: we tend to be more con-cernedaboutrisksconcentratedinageographicalareaorpopulationthanequivalent risks that are spread overabroadergroup.Sinceidentifiedvic-timsare100percentofthereferencegroup that can be saved, they standat one extremeof a continuum, theotherendofwhichconsistsofstatis-

tical victims randomlyspreadthroughabroaderpopulation. As Jenniand Loewenstein note,the relationshipbetweenwhat people are willingtopaytoavoidariskofdeathisnotamonotonicfunction of the risk ofdeath—that is, a highbaseline risk of deathmeans that people will

paydisproportionatelymoretoavoidthat risk. Similarly, if an identifiedvictimfacesahighriskofdeath,thenconcerntoavoidherlosswillleadtowillingnesstopayanamountthatismuch greater than what people arewilling to pay to save an equivalentnumberofstatisticallivesspreadoverabroaderpopulation.

The alternative explanations mayhave different normative implica-tions. For example, had vividnessbeenexplanatory,JenniandLoewen-steinclaim,thenitwouldberelevanttoprivatedecisionsaboutactionbutnot to public policy, for we shouldnot make media attention justifica-tory of policy (I believe the pointmistakenbutwillnotargueagainstithere).20 In contrast, theyput the ef-fectsofcertaintyinamoralgrayarea,along with the distinction betweenex ante and ex post evaluation andconcerns about the reference groupand concentrations of risk. In con-trast,Ilaterarguethatconcentration

IFANidentifiedvictimfacesahighriskof

death,manypeoplewillpayanamount

muchgreaterthantheywouldpaytosave

anequivalentnumberofstatisticallives

spreadoverabroaderpopulation.


of risk—their favored mechanism—may have some moral relevance. Inmuchof thediscussionthat follows,however, I keep open the range ofmechanismsthatmaybeinvolved.

Consequentialist Arguments, Con and Pro

Ethicaltheoriesofrightandwrongdivide into consequentialist ac-

counts,whichjudgetherightnessofactionsentirelybytheirconsequenc-es,andnonconsequentialisttheories,which judge the rightnessofactionsby considerations that may includetheirconsequencesbutconsideroth-er things as well.Within each view,there are reasonable disagreementsaboutourproblem.

Consequentialist arguments forand against giving some norma-tive force to the identified victimbiasdifferinthescopeoftheconse-quencestheytakeintoaccount.Theargumentsagainstitassumethatthepolicy options—rescuing an identi-fied victim (or victims) versus pre-venting similar peril to some set ofstatisticalvictims—capturealloftherelevant consequences to be consid-ered. In contrast, the arguments infavorbroadenthescopeoftheconse-quencesbyassumingthatadditionalcausalmechanismsandeffectsareatplayinadditiontotherescueorpre-ventionthemselves,suchas“external-ities”thatincreasethewelfareofthepopulationormotivatethemtosavemore lives. Because of questionableassumptions that reasonable peoplecanneverthelessaccept,bothsidesofthe consequentialist argument seeminconclusive.

Consequentialist objections to the identified victim bias. Anaturalstart-ingpointistheconsequentialistclaimthatwhenlivesareatrisk,weoughtto save as many as possible withoutsacrificing comparable goods. In hisseminaldiscussion,CharlesFriedat-tributes such a “rational” or “maxi-mizingstrategy”to“theeconomist.”21(Thoughhe seems in this argumentto embrace the economist’s views,theattributionmay leavehimroom

to reject consequentialism in favorofanonconsequentialistformoflib-ertarianism that underlies many ofhis views. Arguably, some noncon-sequentialistscouldalsosubscribetothe versionof themaximizing strat-egyhe formulates,but I ignore thatpoint.)The economist’s maximizingstrategy,whichtakesuncertaintyintoaccount,22requiresustosetupa“life-savingbudget”aimedatmaximizingexpectedlivessaved.Sucha“neutral”budgetfavorstherescueofidentifiedindividuals when the calculation ofexpectedpayoffsfavorsthem,butinother cases it favors statistical lives.Being“neutral,”wevaluealllivesthesame,whether theyare identifiedorstatistical. Any disposition to favoridentified victims would underminetheefficientpursuitofthemaximiz-inggoal.

Akeyassumptionbehindthisar-gument against an identified victimbiasisthattherearenofurthercausalconsequencesofthechoicetorescueortopreventotherthantherescueorthe prevention—a questionable as-sumption that other consequential-istsmayreasonablyreject.

Consequentialist arguments in favor of an identified victim bias. Consequentialist arguments in fa-vor of an identified victim bias, incontrast, point to additional causaleffectsofthechoicetorescueorpre-vent risks. For example, the “sym-bolic value” argument, which FriedattributestoSchellingandtoGuidoCalabresi,23 claims that “we demon-strate the value we place on humanlife” if we give some preference torescuing identified victims, whereasfailingtodosounderminesthesym-bolic value of human life.24 Friedrejects that argument as “confused,wrong, or morally repugnant,” pri-marilybecausehethinksitisincom-patiblewithvaluinglifetosavefewerlives.Butifwetaketheargumenttobeclaimingthatpeopleactuallycare moreaboutsavingidentifiedlivesandsogeneratemorewelfarebydoingso,or that the symbolic valueof savingidentifiedvictimsmotivates themtosavemorelivesinthelongrun,then

the argument anticipates two moreexplicit consequentialist argumentsin favorofan identifiedvictimbias.Bothversions suggest that there is againfromthebias.Thereissomeem-piricalevidenceforsuchaview.Deb-orahSmall,GeorgeLoewenstein,andPaul Slovic have shown in field ex-perimentsinvolvingcharitabledona-tionsthateducatingpeopleaboutthebiastowardidentifiedvictimsreducescharitabledonationstotheidentifiedvictimswithout leading to increasedgiving to statistical victims.25 In ef-fect, reducing thebiasmakes thingsworse.

One of these more explicit argu-ments supposes that the benefits oflifesavingrescuesgobeyondthelivessaved. If people are greatly troubledby failing to save identified victimsand much less troubled by the fail-ure to save statistical victims, thentheseadditionalconsequences—these“externalities” of the policy choicesthatalsoaffectthewelfareofpeople—should also be included in thecalculationaimedatmaximizingthenet goodnessofour actionsorpoli-cies.JohnMcKieandJeffRichardsonarticulatethiskindofconsequential-istargument in favorof the“ruleofrescue”—thebelief thatwemustdowhateverisrequiredtorescuepeopleinimmediateperil.26Theruleofres-cueisnotidenticalwiththeidentifiedvictimproblemwehavefocusedon,but it is at least afirst cousin, ifwesuppose that the people in peril areidentified victims—that is, that riskisconcentratedinthesespecificindi-viduals.Theruleofrescueturnstheidentifiedvictimbiasintoapurport-ed rule aboutwhatwe shoulddo (Iignorethecontroversyaboutwhetheritisreallyarule).

TheMcKieandRichardsonargu-mentfacesafamiliarproblem:whichprevalent externalities should wecount?Unfilteredbutprevalentatti-tudes,likeracismorgenderbias,mayend up justifying morally unaccept-able practices. If we are in a societycomposed of a majority of sadists,racists, religious bigots, misogynists,or homophobes, then maximizing


outcomesinawaythattakestheirat-titudesasagivenlocksusintosadistic,or racist, or antifemale policies andactions. This view seems unaccept-able—notallexternalitiesarecreatedequal,wewanttoobject.Alongtheselines,RonaldDworkinarguesthatweshouldcountonlyself-regardingandnot other-regarding attitudes whenwe are considering consequences.27But Dworkin’s move against “dou-ble-counting” seems problematic. Ifmaking someone’s child better offalso makes other family membersandfriendsbetteroffbecauseoftheirconcernsforthechild,thenignoringthose other consequences seems in-tuitivelysuspectandnotinthespiritoftheconsequentialistprogram.

Allan Gibbard sug-gests another way to bemore discriminatingabout the attitudes wewanttocountorexcludeinourproblem.Supposewecansavemorelivesofminers if the whole ofanygivensafetybudgetisput into prevention andeasy rescues, with noth-ing allowed for heroicor very expensive rescues.28 Still, wemightfindit“dehumanizing,”inthesense that it “interferes with the di-rectpsychologicalrewardsofhumanfellowship,”29tosimplystandbyanddonothingifamoreheroicorexpen-sive rescue had a significant chanceof saving lives. Although Gibbardrightly expresses some skepticismabout whether policies that ignorethe identified victim bias generallylead todehumanization,30 theworryis that standingby anddoingnoth-ingmay sogo againstnormal, sym-patheticimpulses(thoughweobserveunsympatheticpeopleandbehaviors)thatitfetterstheirfreeexpression31orremovesusfromthenormalrewardsofhumanfellowship,especiallyifthedisposition is not amatter ofweak-nessinthefaceofdanger,butofcon-sciouspolicy.32Arguably,thisconcernaboutdehumanizationdoesnotgen-eralizetomoreproblematicattitudes(provided we ignore the fact that

someracistsormisogynistsmaynotbedehumanizedbyfailurestorescueblacksorwomen).

Gibbard argues that our bestpolicy for maximizing “intrinsic re-ward”—the worth to a person ofleadingthelifeheleads,anotiontowhich Gibbard himself raises someobjections33—is through a risk-cost-benefit analysis, that is, a “sophisti-catedintrinsicrewardmaximization.”Suchananalysisnotonlycountslivessavedor lost and injuriesprevented,butalsocountsthe“deeppsychologi-cal effects,” like dehumanization, ofpolicies.

Suppose, however, that turningour backs on less efficient rescues isnotfullydehumanizing,butthatover

time, it still undermines our com-mitment to rescuing people. Thissupposition is the basis for anotherconsequentialistargumentinfavorofthe identified victim bias—namely,that we can save more lives in thelong run by preserving this com-mitment than we can by ignoringit.This, too, could be considered aversion of the symbolic value argu-mentthatFriedrejected,onlyinthiscase the additional premise is aboutmotivations, not about the welfarebenefits of caring. Jenni and Loew-enstein conclude that the identifiedvictimbiasmightcorrectlyinfluence“private”decisionsbyindividuals,butnot public policy.34 In contrast, thepoint thatemergeseither fromGib-bard’s argument or from the “morelivesinthelongrun”argumentisthatpublicpolicymusttaketheidentifiedvictimbiasintoaccountbecausethesustainability of public policy de-pendsonsupportingthemotivations

thatpeoplehavetoaidothers.Ifwepursueoverlyrationalpoliciesthatdonotadequatelyconsiderwhatpeopledeeplycareabout,ourpursuitmaybeself-defeating.

A further argument in favor of abias for identified victims also turnson the additional consequences of apolicy choice. Suppose that peopleencountering identified victims cor-rectly believe that they have a dutyto aid them, whether they are pri-vate citizens confrontedwithpeoplein peril, or people with professionalor contractual obligations to rescuepeople in peril. Further, these du-tiesneednotbegrounded inbeliefsabout the maximization of good ef-fectsortheminimizationofharmful

ones(thedutyitselfmaybe nonconsequentialistinorigin).Specifically,ifrescue squads or hospi-talemergencyroomsarefundedsothatonly“easyrescues” or inexpensivetreatments are budgetedfor(callthis“thestrictlyrationalbudget” since itmaximizeslivessavedperdollar spent), then the

personnelinthesesettingsmay(cor-rectly)believetheyareshirkingtheirmoraldutiesiftheyhaveasignificantchanceofhelpingpeoplewithrescuesthataremoredangerousorexpensivethanthosethatarebudgetedfor.Thestrictlyrationalbudgetthenpreventsthese people from carrying out theduties they believe they have. Per-suadingthemthattheirdutyextendsonly as far as the budget proposesstrainscredulity.

Like the consequentialist argu-ments against an identified victimbias, none of these consequentialistarguments supporting such a bias isconclusive. Each rests on question-able empirical premises—claimsaboutthemagnitudeoftheexternali-ties, the likelihood and force of de-humanization,theextinguishingofacommitment to invest in lifesaving,orperformancedeficitsinresponders.Nevertheless, reasonable consequen-tialistsmaybelievesomeofthemand

IFREASONABLEpeoplecandisagree

onwhetherconcentrationofriskacross

apopulationmattersmorally,thenthe

argumentforrulingouttheidentifiedvictim

biasalsoremainsinconclusive.


rejectthealternativeassumptionthatno other consequences are involvedthan the rescueofonegroupor thesavingoftheother.

nonconsequentialist Arguments, Con and Pro

Just as reasonable consequential-ists can disagree about whether

the identified victim bias has nor-mativeforce,so, too,canreasonablenonconsequentialists. Disagreementsacross the consequentialist/noncon-sequentialist divide count as reason-able,too,butIshallnotdiscussthatobviousbasisforreasonabledisagree-menthere.

Nonconsequentialist objections to the identified victim bias. To start,consider the requirement that wetreat people with equal respect as aresult of their status as persons. Anidentifiedvictimisworthyofsuchre-spect,butsoarepeoplewhoareonlyreferred to as statistical lives—theyareno lesspeopleworthyof respectjustbecausewedonotyetknowwhotheyare.Variationsonthisideainsistwearediscriminatingagainststatisti-calvictimsinamorallyobjectionablewayifwegiveintoourpsychologicalresponses of increased sympathy orempathy for identified victims.Oneinterpretation of this equal respectviewisthatweshouldgiveidentifiedandstatisticalvictimsequalchancesatrescue,thusavoidingdiscrimination.

Somewhat surprisingly, Friedseemstoaffirmtheviewthatfairnessrequiresustovaluepeopleequallybygivingthemequalchancesatrescue.35The claim is surprising because hiseconomist would insist that peoplewhoarelessefficientlysavedbyeitherrescueorpreventionshouldnot haveequalchanceswithpeoplewhoselivesaremoreefficientlysaved.Weshouldbeefficientaboutusingourlifesavingbudgettosavelives,evenifweaban-don those inefficiently saved.Fried’seconomist iscommittedto“neutral-ity” within an efficiently pursuedbudget,not to equal chancesof res-cue.TheveryfairnessobjectionthatFried makes against the identified

victimbiasseemsalsotoapplytothemaximizingstrategy.

I note in passing that those whooppose the identified victim bias,whetherconsequentialistsornoncon-sequentialists,shouldprovideanerrortheorytoexplainwhysomanypeo-plearedisposedtothebiasandthus“get it wrong.” For example, ShellyKaganstatesthatpeopleform“vivid”or“pale”ideas,respectivelyrepresent-ing strong and weak response moti-vation,36 andourbias (“blind spot”)towardidentifiedvictimsisrootedinthe fact that theyare representedbymore vivid ideas.37 Kagan’s accountrequires, however, a strong empiri-cal claim that people typically havethe capability—and motivation—toeliminate their blind spots. Other-wise,notbeingbiasedtowardidenti-fiedvictims ispartofan“extremist”morality that is feasible for only averyfewunusualpeople.

Nonconsequentialist arguments in favor of an identified victim bias. Buttheequalchancesviewisnottheonlyreasonable interpretation of the re-quirementforequalrespect.Onewayfor a nonconsequentialist to defendtheideaofequalrespectwhilereject-ingthecommitmenttoequalchancesistoclaimthereisamorallyrelevantdifferencebetweenidentifiedandsta-tisticalvictims.Thedooristhenopentoanonconsequentialistargumentinfavor of identified victims.To showthat the distinction between identi-fied and statistical victims is reason-ably viewed as morally relevant, weneed either a justifiable and generalaccount of moral relevance,38 or weneedamethodology,suchasFrancesKamm’s appeal to intuitions about“fully equalized cases” and theprin-ciples that support them.39 In lightof either, Fried’s nonconsequential-ist appeal to the fairness of treatingpeople equally is inconclusive as anargument against the identified vic-timbias.

Before turning to the generalquestion of morally relevant traits,consider briefly a nonconsequential-istargumentthatbeinganidentifiedvictim is such a trait. Anticipating

inpartwhat later came tobe calledagent-relative prerogatives,40 Friedconsiders whether our potentialfriendships with identified victimscan justify devoting more resourcesto helping them. “Personalists,” asFriedlabelsthem,arguethatencoun-terswithidentifiedindividualswhoselivesareinperilcreateanopportunityforfriendshipthatjustifiesadditionalresources for rescuing them becauseof the special value of their (poten-tial) friendship,which ismissingforstatistical victims. Fried rejects thepersonalist argument, and for goodreason.Sincemanyof those statisti-calliveswillturnouttobeidentifiedvictimsforsomeoneorother,wecan-notusethepotentialforfriendshiptodistinguishidentifiedfromstatisticalvictims in a general way. Moreover,therelationshipbetweenrescuerandidentifiedvictimisnotreallyafriend-shiporkinshipthatmightbethoughttoconfirmspecialpermissions.Thesepoints seem fatal to the personalistclaim that the potential for friend-shipmarksamorallyrelevantdiffer-encebetweenidentifiedandstatisticalvictims.

But consider a more plausiblenonconsequentialist argument in fa-vor of a morally relevant differencebetween identified and statisticalvictims—namely, the concentrationof risk that Jenni and Loewenstein’sstudysuggestedwasthebestexplana-tion of the identified victim bias.41Let’s suppose they are right aboutthe factor thatbestexplains thebiaspeoplehave.Couldthatfeaturemat-termorally?

WecanconsiderthatquestionbyadoptingthemethodKammemployswhen she considers whether near-ness matters morally.42 Three meth-odological constraints are centralto her discussion of nearness: 1) wemustconsider“fullyequalized”casesin examining our intuitions aboutwhatmattersmorally;2)wemustbesensitivetocontextualinteraction,asfeaturesthatmatterinsomecontextsmaynotinothers;and3)intuitionsalonecannotdeterminewhatmattersmorally,forweneedtosupportthose


intuitions with some relevant theo-retical considerations. Thus, Kammrejects Peter Singer’s effort to showthatnearnessismorallyirrelevantbydrawingananalogybetweenrescuingsomeonefromapondat thecostofruining$500shoesandsending$500overseas to save a starving child.43Thecasesdifferinmanyways—theyare not fully equalized—and so donotconstitutea testofwhether it isnearness thatmatters in them.Also,Kamm argues, there are importantcontextual considerations: nearnessmightnotmatteriftherescueiscost-less(say,itinvolvedflippingaswitch)butmightmatterifthereisasignifi-cantcost.44And inorder to supportthe intuitions, Kammsuggests that the plausi-bilityofleavingroomforagent-relative preroga-tivesinanethicaltheorymeans we may reason-ablyalsothinkthatindi-vidualshavesomespecialresponsibilities for whathappensnearthem.45

Toseeiftheconcentrationofriskmight matter morally, consider twoequalized cases where only the con-centrationofriskvaries.Supposewehave only five tablets of a medicinethat can be used either as an effec-tivetreatmentforaterminaldisease,providedthatallfivetabletsaregiventothepersonwhohascontractedthedisease, or as an effective vaccina-tion,giveninone-tabletdosestofivepeopleexposedtothedisease.With-outvaccination,thereisa20percentchance of contracting the diseaseonceexposed.Sothetwocases looklikethis:

Treatment: Alice has the disease.Wecangiveherthewholedose—allfivetablets.

Vaccination: Betty, Cathy, Dolly,Ellie, and Fannie have been ex-posed to Alice. We can vaccinateallofthembygivingeachone-fifthofthedosewecangiveAlice.

In both cases, we can supposethat one expected life is saved (thusavoiding issues about aggregation).Inaddition,thepeopleatriskinthevaccination case are identified withregardtowhowillreceivepreventivetreatment, though we do not knowwhich of them will get the diseaseif they arenot vaccinated.Does theconcentration of risk in the treat-ment case matter morally? Do wehave a greater obligation to treat orvaccinate?

Ibelievewehaveastrongerobliga-tion to treat Alice than to vaccinatethefiveothers.(Iknowfromconve-nience samples of students and col-leaguesthatsomeothersdonotshare

my intuitive judgment about thiscase,apointIreturntoshortly.)Ofcourse,thereisacontextualfact—thescarcity of the medicine. But giventhat context, the concentration ofriskmattersmorally.

To see that it does, suppose wemodify the vaccination case so thatthere are one hundred named indi-viduals,friends,classmates,andrela-tivesofAlice,allofwhomhavebeenexposed to her; there is a 1 percentchance of infection; and one one-hundredthofthetreatmentdosecanwork as a vaccination. Again, oneexpected life will be saved by vac-cinating, just as one expected life issavedbytreating.Itnowseemsevenlessplausibletoreducetheoneinonehundred chance of contagion anddeathforeachpersonratherthansavetheonepersonalreadyinfected.(Ig-noretheissueoffurthertransmissionbysupposingthatwecanquarantineeachpersonatrisksuccessfullyinanyscenario.)

Wemightdismissa1percentriskasinsignificant,whereasa20percent

riskgivesrisetoarealclaimforassis-tance.Nevertheless,whatweseefromthese cases is that the concentrationofriskmattersatsomepointorothertothebeliefthatwehavesomedutytorescue.Disagreementaboutwhendifferent risks should be treated asgivingrisetoequalclaimsmeanswemighthave toflipcoins—or,better,flip weighted die—to decide. Obvi-ously, the issues change if more ex-pectedlivesarelostbyforegoingthevaccination of her friends than aregainedbyfavoringtreatmentofAlice,butthatconvertsourfullyequalizedcases into an aggregation probleminwhichmoreandfewerlivesareatstake. Risk concentration might be

such a weak factor thatit matters morally onlyinbreakingties,butthisconclusion would needcarefulexamination,andmy argument has notclaimed more force foritsmoralrelevance.Nev-ertheless,wemightthinkthe moral relevance in

thiscontextissimilartothewayweconsidertheconcentrationofriskinother contexts. For example,Kammsuggeststhatwemightnothirefourworkers to construct a bridge if thework carries a 25 percent risk ofdeath,butwemightbuildthebridgeifwecanspreadthatriskovermanymore workers, albeit with the sameexpectedoutcomeindeaths.46

Toseethatthereisanissueofdis-tributivefairnessthatisatworkhere,consider that Alice arguably has thestronger claim on assistance: she isworse off than the other five at thetime we are deliberating about howtousethemedicine.Shefacescertaindeath ifnothing isdoneor ifothersgetthevaccination,whereastheyface“only”a20percentchanceofdeathifnothingisdoneorifAliceisrescued.Sinceherclaimonassistanceisstron-ger,itwouldbeunfairtohertofavortheothers,whohaveweakerclaims.(If thefirst versionof the treatmentversus dilemma is not compelling,then something closer to the one-hundred-pill version should clarify

THEISSUEforpublicpolicyiswhatweight

togivetheviewsofthemajorityinfavor

ofidentifiedvictimsdespitethepowerof

argumentsagainstthatoutcomebyothers.


that not all risks give rise to equalclaims.)

I earlier noted there is disagree-ment at the intuitive level, at leastin my convenience samples, aboutthe strength of our obligations inthe original two cases. If we cannotresolve such disagreement by usingour intuitions about hypotheticalcasesinaccordancewithKamm’sfirsttwomethodologicalconstraints,thenwemayneedtofindanotherwaytoarriveata fairchoiceaboutwhat todo,suchasaccountabilityforreason-ableness.47Andevenifweallagreeattheintuitivelevelthatconcentrationofriskmattersmorallyinsomecon-texts,Kamm’sthirdrequirementsaysthat we need some theoretical sup-porttoexplainwhyconcentrationofriskmatters.

Suppose, asKammdoes, thatweinclude room in our ethical viewfor agent-relative prerogatives.Thenwhat happens near an agent maymatter morally because of the im-portance of granting agent-relativespacetothem,sothatagentsmaybemore accountable for what happensnearthem.48Similarly,agentsmaybemoreaccountable for addressing theconcentrated risks encountered bythosepeoplearoundthemthantheyareformoredispersedones.Weknowfromvariousstudiesthatpeopletreatlosses asmore important than com-parablegains.Thisjudgmentendsupmattering morally because it affectshowpeopleevaluatetheirprojectsinlife.Beingcommittedtoavoidingsig-nificantlosses(Alice’slife)ratherthangainingcomparableexpectedbenefits(thesafetyoffivepeopleatlessrisk)thusiscompatiblewithgrantingpeo-pleagent-relativeprerogatives.

But these suggestions—Kamm’sregardingnearnessandmineregard-ing concentrationof risk—areplau-sible, but not overwhelming. Myadaptation of Kamm’s treatment ofnearness to the caseof concentratedrisksisnotconclusiveinpartbecauseofthedisagreementaboutintuitionsI noted earlier. I conclude that rea-sonablepeoplemight think that theconcentrationofriskmattersmorally,

andothersreasonablymightnot.Butif reasonable people can disagreeabout this, then the nonconsequen-tialist argument that treating peopleequallymeans rulingout the identi-fied victim bias also remains incon-clusive:itcannotruleoutthisreasonfordifferentialtreatment.

Legitimacy and Fairness in Public Policy

Howcanpolicydecisionsachievelegitimacyandarguablyfairness

when there is ongoing ethical dis-agreement,asinthecaseofidentifiedandstatisticalvictims?Foradecisionabout ethically contested matters ofpublic policy to be legitimate, I as-sumeitmustnotonlybemadebyap-propriateauthorities,butalsoitmustbemade in an appropriateway.Myaccountcanbestatedinthreepoints:

1)Reasonablepeoplewilldisagreeethically about the strength ofcommitments to assist identifiedversusstatisticalvictims.

2) In the face of such disagree-ments,publicpolicyrequirespro-ceduraljustice—specifically,afair,deliberativeprocessinwhichcon-flicting views are considered andrationales are developed for poli-cies that reston themostaccept-ableprinciples;

3)Afullytransparentprocessthatinvolves appropriate stakehold-ers who broaden the deliberationaboutwhatreasonsshouldbecon-sidered, and that allowsdecisionstobe revised in light ofnew evi-denceandarguments,canenhancethe legitimacyof thedecisions; itcan also produce an outcomethat is “defeasibly fair” (tobe ex-plained); and it can thus providefeedback intobroaderdemocraticprocessesthatcanreconsiderboththe fairness of the outcome andappropriatenessoftheprocess.49

Is the disagreement about theweightofcommitmentstoidentified

versus statistical victims a disagree-ment among reasonable people, asthefirstpointasserts?Itseemstobe.First, inaminimalsense, it isadis-agreement in which people can ad-ducereasonsforholdingtheirviews.Ultimately, the reasons may not bepersuasive, but they are not clearlyuntenable, incoherent, or in someobviousway irrational.Thinkingweshouldbeneutralbetweenidentifiedand statistical victims because theyaretoberespectedequallyaspersonsprovides a reason that is relevant totheissue.Similarly,peoplewhofavoridentified victims because their mo-tivation to help those in immediateneed isgreateraregivingacoherentreason, one arguably connected tomaintainingsocialstability.

Peoplearereasonableinasecond,more robust sensewhen the reasonstheygive for theircommitmentsareintendedtopersuadepeople seekingmutually justifiable bases for theirjointactions.Thekindsofconsider-ationsjustnotedaboutrespectingallpeople equally or the naturalness ofmotivationtoassistthoseinimmedi-ateperilseemtofitthismorerobustsense as well. Both kinds of reasonscouldbesubmittedtoadeliberationaimedatfindingmutuallyacceptablegroundsforaction.

A third, more specialized senseof reasonableness is the one JohnRawls and Joshua Cohen affirm intheir accounts of justification basedon“publicreason,”asthatnotionisunderstood in political liberalism.50The reasons citedmustbepartof apublic democratic culture and notreasonsaccessibleonlytopeoplewhoare in the grip of a comprehensiveworld view, such as a religious per-spectiveoraphilosophicaltheory.Itissomewhatcontroversialwhatkindsof reasons might then be excludedfromthisspecializedsense,51butthereasons noted here—equal respectforpersonsorthenaturalnessofcer-tain empathetic responses to identi-fied victims—would be difficult todismiss as belonging to the privatedomain of a comprehensive worldview,sinceoneiswidelysharedacross


variousviews,andtheothermaybeabasicfactabouthumanresponsive-nesstopeopleinperil.

It is worth nothing that the rea-sons people give in support of anidentified victim bias are sometimesaboutthecausesofbehaviorandnotthemselvesstrictlymoralreasons:thesocial fabricdependson strong feel-ingsofempathyofthesortthatiden-tified victims better stimulate; these“naturally aroused” motivations torescue identified victims more read-ily produce a commitment to helpstatisticalvictims;feelingsofregretorguiltwouldbegreaterifpeoplewereneutralbetweenidentifiedandstatis-tical.Butwhether trueornot, theseclaims are reasonableand relevant to moraljustification, since theysuggest how individualsorgroupscan sustainorcreatebehaviorsthatmo-ralitywouldjustify.

Inshort,thedisagree-ment about an identi-fied victim bias seemsreasonable in all threeof these senses. It fallsshort if reasonable means ultimately justifiable, but that is a very narrowunderstanding.

Does a fair, deliberative processhelpmakepublicpolicydecisionsfairand legitimate? I take legitimacy toinvolveboththequestionofwhohasthemoralauthoritytomakethede-cisionandquestionsabouthowit ismade.Ifthefair,deliberativeprocessis democratically approved, eitherdirectlyorthroughdelegationbyap-propriateauthorities,thenthe“who”part is acceptable. The “how” partinvolves, for example, transparency,abroad rangeof stakeholders to vetreasons, and appropriate proceduresforrevisionandenforcement.Ithinkthat improvingtheprocessenhancesthe legitimacy of the outcomes—makesdecisions“morelegitimate”—thoughjusthowwemeasurewhetherthishappensisamorecomplexissueIcannotaddress.

Consider now whether the fairprocess yields fair outcomes. Where

we have clear consensus on whatcounts as just, we do not need toappeal toa fair,deliberativeprocess,exceptwhenweneedsuchaprocess(suchasacriminaltrial)toassureusthat we are applying the principlesunderlying the consensus correctly.For example, discrimination againstblacks or women would be cases inwhichwehaveaclearconsensusanddonotneedtoappealtofair,deliber-ativeprocess.Wereservetheprocessfor cases where reasonable disagree-ment remains about what counts asjust or fair. If we had consensus onthe injustice of thewidelyheldbiasinfavorofidentifiedvictims,thenin-sistingondeliberationaboutitwould

be just as wrongheaded as insistingondeliberationaboutdiscriminationagainstsomegroups,suchasminori-tiesorwomen.

The lack of consensus on prin-ciples that resolve the disagreementabout the identified victim biasmakes this problem similar to other“unsolved rationing problems” thatarefamiliarinhealthpolicy.52Amongthesearetheprioritiesproblem(howmuchpriority togive thosewhoareworse off ), the aggregationproblem(whentoallowaggregationsoflesserbenefits to larger numbers to out-weigh significant benefits to fewerpeople), and the best outcomes/fairchancesproblem(whentogivepeo-ple fair chancesat a significantben-efitratherthanfavorbestoutcomes).Because all of theseproblems lack apriorconsensusondistributiveprin-ciples,afair,deliberativeprocessthatyields agreements about what to doregarding them strongly resembleswhat Rawls called pure procedural

justice.Ifweacceptthisanalogy,thenweshouldviewtheoutcomeofafairprocessasfair.

Nevertheless,therearealsoimpor-tant disanalogies to Rawls’s uncon-tested example of pure proceduraljustice—gambling.53 The fairnessof gambling outcomes is not con-strainedbyotherprinciplesofjustice,but some disagreements about whatcounts as the just treatment of in-dividuals are (in this sense, they are“interstitial,” not foundational54).The fairness of gambling outcomesisalsonot“defeasible,”meaningthatwecannotconceiveofaprinciplewemightdiscover thatwould showtheoutcomeofthefairspinofaroulette

wheel is not really fair,butadeliberativeprocessmeant to resolve a dis-agreement about an un-solvedrationingproblemwould be—we cannotrule out the possibil-itythatwemayarriveatconsensusonsomeprin-ciple that would “solve”the problem, whether itis the priorities problem

or the weight we should give to anidentified victim bias. This disanal-ogy means there will be some con-troversy about whether we shouldtakea (conceivably)defeasible claimaboutfairnessastantamounttofair-nessuntilthegroundsfordefeatingitareagreedupon.Still,thatapproachseemsreasonabletome.

In the identified versus statisticalvictim problem, some would insistthatwealreadyhavewhatshouldbepersuasiveconsequentialistandnon-consequentialist arguments in favorof not giving priority to identifiedover statistical victims, as describedearlier.Butthisisneverthelessacasewherepersistentreasonabledisagree-mentwill be encountered, as Ihaveargued.Theissueforpublicpolicyiswhatweighttogivetheviewsofthemajority in favor of identified vic-timsdespitethepowerofargumentsagainstthatoutcomebyothers.

Myproposalhereisthatwecannotignore the persistent disagreement

NOTTRYINGtofindmutuallyacceptable

groundsforpolicywouldexpressinadequate

respectforthecommitmentsofthemajority

andwouldfailtoproduceownershipof

the“correct”ethicalview.


andmust subject it tocarefuldelib-erationinaprocessthatisadmittedlyfair.This may seem to be an unac-ceptable compromise with a viewthat arguably (in the eyes of some)doesnotstanduptocarefulscrutiny,evenifitiswidelyheld.ButIdonotthinkwecanclaimthataconclusionis legitimate or fair solely because itseems “right” to thosemore steepedin some forms of ethical argumentwhen many reasonable people holdan opposite view. Neither view willdemonstrably lead to false conclu-sions.Thereisnoconclusivedemon-strationhere.Therefore,notengaginginanefforttofindmutuallyaccept-ablegroundsforpolicywouldexpressinadequate respect for the commit-mentsofthemajorityandwouldfailto produce ownership or buy-in ofthe“correct”ethicalview.Thepointis not that democratic might makesright. It does not. Rather, it is thatdeliberation under conditions thatare fair toallparties is theonlywaytoproduceaconclusion thatpeoplecan agree rests on considerations allbelievearerelevant.

Why insist that the fair processmeet the conditions specified in thethird point above—that rationalesfordecisionsbefullypublic;thattheyfocusonreasonsallparticipants,ide-allyincludingappropriatestakehold-ers,considerrelevantforthiskindofdecision;andthattheyberevisableinlightofnewevidenceandarguments?Together, these conditions hold de-cision-makers accountable for theirreasonableness.55Insistingthatratio-nalesbefullypublicmeetsarequire-mentofjustice:thatpeoplebemadeaware of the grounds for decisionsthat fundamentally affect theirwell-being. It also contributes tobroadersociallearningaboutthegroundsforsuch decisions and thus improvesbroader democratic processes. Theinsistencethatdecisionsbemadeongroundsthatallcanagreearerelevanttomeetingneeds fairlyderives fromthe assumption that we should seekmutually justifiable decisions. In-cludingabroadrangeofstakeholdersensures that the deliberation covers

ground that different parties see asrelevant, and that vetting all ratio-nales with such stakeholders givesthemanopportunitytoaffirmsomeownership of them, enhancing thelegitimacy of the result. (Includingstakeholdersdoesnotby itselfmaketheprocessmoredemocratic.56)Mak-ing sure decisions can be revised inlightofnewevidenceandargumentsassures everyone that the informa-tioninitiallyavailableisnotgiventoomuchweight,andnewfindingsandbetterargumentswill receiveahear-ingaswell.

Supposewehaveinplaceaprocessthat conforms to the requirementsof accountability for reasonableness.Whatwillhappentopolicydelibera-tionsthatareframedbytheproblemofidentifiedversusstatisticalvictims?Iftheargumentsagainstanidentifiedvictimbiasareasdecisiveassomeoftheirproponentsthink,thenthebiasin favorof identifiedvictims shoulderode. If that happens, then fromboth theperspectiveof thoseethicalargumentsandthatoffairprocess,wearearrivingatmorefairdecisions,andwe do so with enhanced legitimacy.Supposewedonotremovethewholebias, but there remains a significantgroupthatfeelsmoreshouldbeowedtothosewhoseneedismoresalienttothem, in the sense that it motivatesthemtodomore.Theremainingdis-agreementisitselfevidencethat,evenunder good conditions for delibera-tion,the“correct”ethicalarguments(intheeyesofsome)failtopersuadeasignificantgroupofpeoplethatthereis no acceptable rationale for theirview.That becomes a fact we mustaccommodate in arriving at a pub-lic policy, and there seems to be nobetterwaythantoputinplacethoseconditionsfordeliberationandtoac-cepttheiroutcome.Ofcourse,somepeoplewhoclingtopositionsmaydoso because they have a vested inter-estinaparticularoutcomeandhavenothonestlyadoptedtheperspectiveof finding decisions they can justifytoeachother.Noprocesscanassurepurityofheartandmind.Buttheal-ternative—relying only on “experts”

makingnontransparentdecisions,orwaiting forphilosophers to arrive ataconsensus—seemsevenmoreriskysinceit isunlikelythatwecanagreeonwhothevalue-expertsare,andwedo not have time to wait for philo-sophicalconsensus.

There is one important obstacleto the proposal that we rely on fairprocesstoresolvepersistentdisagree-mentsaboutpolicyregardingidenti-fiedandstatisticalvictims.Nosocietyhasaunifiedbudgetorasingle“min-istry”foraddressingthese issuesandmakingthepolicydecisionsinalloftherelevantcontexts.Therearemanyregulatorysettings inwhichwepro-tect statistical victims, and we havequitedifferentcontexts inwhichwemake decisions about funding ser-vicesaimedatidentifiedvictims.TheEnvironmentalProtectionAgencyinthe United States sets standards forclean air and water, and the Secre-tary of Labor and the OccupationalHealth and Safety Administrationsetstandardsfortoxinsinthework-place.Bothmaybeguardingagainstenvironmental carcinogens. It is theCenters for Medicare and MedicaidServices, however, that makes cov-erage decisions for the treatment ofelderly cancer patients. The hodge-podge of levels of expenditures perlife saved may be influenced by theidentified victim bias, but the biasoperatesindifferentcontextsandnotwithin any one agency accountablefor reconciling them. Perhaps theproposalhere—thatdecision-makersbeaccountableforthereasonablenessoftheirdecisions—canhaveaneffectonthelegitimacyandfairnessoftheoutcomes in each context, but pro-ducing coherence among outcomesacrossthesemanycontextsandagen-ciesisunlikelyintheabsenceofsomemechanism, such as regulation, im-posing that coherence. Social learn-ing stimulated by accountability forreasonableness will have difficultyfinding a foothold on such brokenterrain.


references

1.D.SmallandG.Loewenstein,“Help-inga VictimorHelpingthe Victim:Altru-ismandIdentifiability,”Journal of Risk and Uncertainty 26,no.1(2003):5-16.

2. See J.Taurek, “Should the NumbersCount?”Philosophy and Public Affairs6,no.4(1977):293-316.

3.T.Schelling,“TheLifeYouSaveMayBeYourOwn,”inProblems in Public Expen-diture Analysis, ed. S.B. Chase (Washing-ton, D.C.: Brookings Institution, 1968),127-62.

4. Small and Loewenstein, “Helping a VictimorHelpingthe Victim.”

5.N.DanielsandJ.Sabin,Setting Limits Fairly: Learning to Share Resources for Health(Oxford, U.K.: Oxford University Press,2002,2008);seealsoC.HamandS.Pick-ard,Tragic Choices in Health Care: The Case of Child B (London:King’sFund,1998).

6.E.Goemaere,N.Ford,andS.Benatar,“Correspondence: HIV/AIDS PreventionandTreatment,”Lancet 360(2002):86-87.

7. InternationalTreatmentPreparednessCoalition,“MissingtheTarget6:TheHIV/AIDSResponseandHealthSystems:Build-ingonSuccesstoAchieveHealthCareforAll,” July 2008, http://www.aidstreatmen-taccess.org/mtt6_final.pdf.

8. A. Yamin and O. Parra-Vera, “HowDo Courts Set Health Policy? The Caseof the Colombian Constitutional Court,”PLoS Medicine6,no.2(2002):e1000032.

9.S.-L.Hsu,“TheIdentifiabilityBiasinEnvironmentalLaw,”Florida State Univer-sity Law Review 35,no.2(2008):433-504.

10.K.E.JenniandG.Loewenstein,“Ex-plaining the ‘IdentifiableVictim,’” Journal of Risk and Uncertainty 14, no. 3 (1997):235-57.

11. P. Menzel, Medical Costs, Moral Choices: A Philosophy of Health Care Eco-nomics in America (New Haven, Conn.:YaleUniversityPress,1983),159-63.

12.JenniandLoewenstein,“Explainingthe‘IdentifiableVictim,’”237-39.

13. S. Rose suggested this operational-izationofthenotionofvividness;personalcommunication.

14. R.E. Nisbett and L. Ross, Human Inference: Strategies and Shortcomings of Social Judgment (Englewood Cliffs, N.J.:Prentice-Hall, 1980), cited in Jenni andLoewenstein, “Explaining the ‘IdentifiableVictim.’”

15. G. Loewenstein, D. Small, and J.Strnad,“Statistical,Identifiable,andIconicVictims,”inBehavioral Public Finance: To-ward a New Agenda,ed.E.J.McCafferyandJ.Slemrod(NewYork:RussellSageFoun-dation,2006),32-46.

16. Loewenstein, Small, and Strnad,“Statistical, Identifiable, and Iconic Vic-tims,”5ff.

17.D.SmallandG.Loewenstein,“TheDevil You Know: The Effects of Identifi-ability on Punishment,” Journal of Behav-ioral Decision Making 18(2005):311-18.

18.D.KahnemanandA.Tversky,“Pros-pectTheory:AnAnalysis ofDecisionun-der Risk,” Econometrica 47, no. 2 (1979):263-91; D. Kahneman and A. Tversky,eds., Choices, Values, and Frames (NewYork: Russell Sage Foundation, 2000); D.Kahneman,P.Slovic,andA.Tversky,eds.,Judgment under Uncertainty: Heuristics and Biases (Cambridge,U.K.:CambridgeUni-versityPress,1982).

19. D. Small, G. Loewenstein, and P.Slovic, “Sympathy and Callousness: TheImpact of Deliberative Thought on Do-nations to Identifiable and Statistical Vic-tims,”Organizational Behavior and Human Decision Processes 102 (2007): 143-53, at147.

20.JenniandLoewenstein,“Explainingthe‘IdentifiableVictim,’”240.

21. C. Fried, “Value of Life,” Harvard Law Review 82,no.7(1969):1415-37.

22.Fried,“ValueofLife,”1422.23. See Schelling, “The Life You Save

May Be Your Own,” and G. Calabresi,“TheDecisionforAccidents:AnApproachto Nonfault Allocation Costs,” Harvard Law Review78,no.4(1965):713-45.

24.Fried,“ValueofLife,”1425.25. Small, Loewenstein, and Slovic,

“SympathyandCallousness.”26. J. McKie and J. Richardson, “The

RuleofRescue,”Social Science and Medicine 56(2003):2407-2419.

27.R.Dworkin,Taking Rights Seriously (Cambridge, Mass.: Harvard UniversityPress,1977),234-38,275.

28.A.Gibbard,“RiskandValue,”inVal-ues at Risk,ed.D.MacLean(Totowa,N.J.:RowmanandAllanheld,1986),94-112.

29.Ibid.,101.30.Ibid.,102.SeealsoE.SoberandD.S.

Wilson,Unto Others: The Evolution and Psy-chology of Unselfish Behavior (Cambridge,Mass.:HarvardUniversityPress,1998).

31.Gibbard,“RiskandValue,”96.32.Ibid.,102.33. A. Gibbard, “Interpersonal Com-

parisons: Preference, Good, and the In-trinsic Reward of a Life,” in Foundations of Social Choice Theory, Studies in Rational-ity and Social Change, ed. J.Elster andA.Hylland(NewYork:CambridgeUniversityPress,1986;Paris:MaisondesSciencesdel’homme,1986),165-293.

34.JenniandLoewenstein,“Explainingthe‘IdentifiableVictim,”254.

35.Fried,“ValueofLife,”1427.36. S. Kagan, The Limits of Morality

(NewYork:OxfordUniversityPress,1989),283ff.

37.Kagan,The Limits of Morality,288.38. See J. Cohen, “For a Democratic

Society,” in The Cambridge Companion to

Rawls, ed. S. Freeman (Cambridge, U.K.;New York: Cambridge University Press,2003), 224-33; N. Daniels, “Merit andMeritocracy,”Philosophy and Public Affairs 3(1978):206-223;N.Daniels,Just Health Care: Studies in Philosophy and Health Policy (Cambridge, U.K.: Cambridge UniversityPress,1985).

39.F.M.Kamm,Intricate Ethics: Rights, Responsibilities, and Permissible Harm (Ox-ford,U.K.:OxfordUniversityPress,2007),347-63.

40. S. Scheffler, The Rejection of Conse-quentialism: A Philosophical Investigation of the Considerations Underlying Rival Moral Conceptions (Oxford,U.K.:OxfordUniver-sityPress,1982).

41.JenniandLoewenstein,“Explainingthe‘IdentifiableVictim,’”247.

42.Kamm,Intricate Ethics,345-59.43. Ibid., 247-49, andP. Singer, “Fam-

ine, Affluence, and Morality,” Philosophy and Public Affairs1,no.3(1972):229-43.

44.Kamm,Intricate Ethics,348.45.Ibid.,386ff.46.F.Kamm,indiscussionwiththeau-

thor,May2009.47. Daniels and Sabin, Setting Limits,

43-66.48.Kamm,Intricate Ethics,ch.12.49.SeeN.DanielsandJ.E.Sabin,“Lim-

itstoHealthCare:FairProcedures,Demo-cratic Deliberation, and the LegitimacyProblemforInsurers,”Philosophy and Pubic Affairs 26,no.4(1997):303-350;DanielsandSabin,Setting Limits.

50. J. Rawls, Political Liberalism, 2nded.(NewYork:ColumbiaUniversityPress,1993, 1995); J. Cohen, “Procedure andSubstance in Deliberative Democracy,” inDemocracy and Difference: Contesting the Boundaries of the Political, ed. S. Benhab-ib (Princeton, N.J.: Princeton UniversityPress,1996),95-119.

51. N. Daniels, Justice and Justification: Reflective Equilibrium in Theory and Practice(Cambridge, U.K.: Cambridge UniversityPress,1996),157-74.

52. N. Daniels, “Rationing Fairly: Pro-grammatic Considerations,” Bioethics 7,nos.2-3(1993):224-33.

53.J.Rawls,A Theory of Justice,rev.ed.(Cambridge, Mass.: Harvard UniversityPress,1999),75.

54.N.Daniels, “FairProcess inPatientSelection for Antiretroviral Treatment inWHO’sGoalof3by5,”Lancet366(2005):169-71.

55. Daniels and Sabin, Setting Limits,43-66.

56.Ibid.,61-63.

reasonable disagreement about identifed vs. statistical victims

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