I said something like "They quantify health through QALYs, which evaluate the burdensomeness of health states on a scale from 0 to 1, to prioritize potential treatments according to how many QALYs they produce per dollar. Or sometimes they use a threshold: a specific cost-per-QALY value -- say, $30,000 per QALY. Treatments producing too few QALYs per dollar won't be funded."
My partner, being an interesting person and not a philosopher, said "Hold on, who is 'they?'"
And I said, "Oh, well in the UK it's N.I.C.E." The National Institute for something something. Care and Excellence. Or something."
"Did you say "N.I.C.E"? Because N.I.C.E. is also the name of the dystopian evil utilitarian organization in C. S. Lewis's That Hideous Strength."
Wait. What? Are you telling me that an actual utilitarian U. K. organization founded in the late 20th century has the same acronymic name as a fiction evil utilitarian organization in a 1945 book by a famous U.K. author? How is that possible?
At the time we had this conversation, I had never read That Hideous Strength, but it had long figured in our family imaginary. For my partner and his daughter, it occupied a space in the overlap zone between "brilliant" and "problematic" -- problematic because sexist, homophobic, and shot through with imperialism. Despite their warnings, of course I had to read the book immediately.
The author, C. S. Lewis, is the British Christian fantasy writer who also produced the Narnia chronicles. So when I say that N.I.C.E. in Lewis's book is "evil," that's not an exaggerating synonym for "committing bad acts." They're literally evil.
In the novel, N.I.C.E. -- "The National Institute of Coordinated Experiments" -- is publicly a scientific and social planning agency weaning us from sentimental attachments to usher in an era of objective social improvements. Behind the scenes, N.I.C.E. is furtively pursuing its evil program for the exploitation of nature and the annihilation of humanity.
If you've ever encountered the arguments utilitarians use to defend their idea that the right action is the one that rationally brings about the best consequences, passages from (fictional) N.I.C.E.'s representatives will sound eerily familiar. Their aim is "the scientific reconstruction of the human race in the direction of increased efficiency." Other value judgments based on justice, beauty, or love are "essentially subjective and instinctive." Ethical beliefs turn out on inspection "to be simply an expression of emotion."
Readers of Peter Singer's 1995 "Ethics and Intuitions" may be reminded of his idea that common moral judgements conflicting with utilitarian outcomes are a "biological residue of our evolutionary history." We evolved to have "intuitions" about justice only because punishing wrongdoers was an evolutionary success.
As Singer explains, the status of moral judgments -- especially those reflecting justice -- is significant because these judgments have long been used to discredit utilitarianism. "H. J. McCloskey, writing at a time when lynchings in the U.S. South were still a possibility, thought it a decisive objection to utilitarianism that the theory might direct a sheriff to frame an innocent man in order to prevent a white mob lynching half a dozen innocents in revenge for a rape" (Singer 343-345). That is, our judgment is that framing an innocent person is wrong, regardless of the consequences, because it is unjust. But "bringing about the best consequences" seems to entail that preventing the riot could be the right thing to do. Thus judgments based on justice seem to undermine utilitarianism.
But Singer says not so. Unlike utilitarian judgments like "five deaths is worse than one," which is "rational," our justice-based "intuitions" should have no standing in our figuring out what is right. As with the fictional N.I.C.E., Singer urges that they reflect an "instinctive" sense of reciprocity -- and should be discarded.
In retrospect, it's not surprising that Lewis would put into the mouths of N.I.C.E.'s representatives talking points familiar from utilitarianism. The rough idea Singer is presenting goes back at least to the British philosopher Sidgwick in the late 19th century. And it's obvious why a Christian ethics would be deeply at odds with utilitarian thinking and why Lewis would be tempted to depict utilitarianism as a manifestation of evil.
The U.K.'s actual real life N.I.C.E. isn't exactly utilitarian, but it does use the utilitarian principles of Cost-Effectiveness Analysis to decide which treatments should be publicly funded. Proposed treatments are evaluated according to how many QALYs they are likely to produce per unit cost: decisions are thus based on bringing about aggregated good consequences.
Like utilitarianism, CEA leads to outcomes conflicting with our moral judgments. The process can lead to discrimination against people with disabilities, as people with disabilities are often judged to have a lower quality of life than non-disabled people; thus interventions extending their lives may be seen as less effective. Since "a QALY is a QALY," the process is insensitive to distribution and equity, with no priority for younger people or the worse off, and no amelioration of existing health inequities. Because of aggregation, low-cost interventions that benefit many people may be more cost-effective than those bringing enormous benefits to small numbers of people: in one famous example, the state of Oregon carried out a large-scale CEA that resulted in part in the conclusion that paying for capping teeth would be more cost-effective than paying for appendectomies.
How to respond to these problems with CEA is part of my current research project on Cost-Benefit Analysis and its offshoots, but this post isn't about that, it's about ACRONYMS. Who thought it was a good idea for an actual utilitarian U. K. organization promoting social progress and rationality to have the same name as a fictional evil utilitarian organization promoting social progress and rationality?
Did no one on the original board of directions pipe up and say "Hey, I know we're not the evil kind of utilitarians. But don't you think it's going to look weird if we say we're N.I.C.E, for progress, science, and rationality, and that other N.I.C.E. also says it's for science, progress, and rationality -- and the other one is EVIL?"
The only discussion of the acronym issue I could find on the internet was from "LifeSite," describing the case of Leslie Burke, a man with degenerative motor neurone disease who sued the UK government for the right not to be denied nutrition and hydration when his illness rendered him unable to swallow or communicate. The U.K. government appealed an initial ruling in his favor, with a representative for the government explaining that N.I.C.E. guidelines combine considerations of efficacy, quality of life judgments, and economics. "If the principle that "clinicians should be able to follow NICE guidelines without being obliged to accede to patient demands" were undermined, the government argued, then "there would be considerable risk of inefficient use of NHS resources."
Describing the principles of the fictional, evil N.I.C.E. as "a mechanistic and ultra-utilitarian, anti-life philosophy that regards human beings as merely a disposable means to an end," LifeSite says "it seems beyond a coincidental irony that a real-life, government-funded organization that bases its decisions on the same utilitarian principles, could be known by the same acronym: N.I.C.E." With this last part, I agree. It does seem beyond a coincidental irony.
As to the broader question of the status of moral judgments or "intuitions," in his article Singer doesn't say what he thinks about framing an innocent person to prevent a riot -- whether he thinks there is some way that contrary to first appearances framing the innocent person actually doesn't produce the best consequences, or whether he thinks framing an innocent person could be the ethical right action.
As a non-utilitarian, I can say more simply that framing an innocent person is wrong, because it's unjust, and I think that is true partly because moral judgments reflect what we care about, which can include values like justice.
In the spirit of this post you may be wondering: could you modify CEA so that instead of measuring QALYs it quantifies and takes into account these other values and thus becomes a new and improved decision-making method? I am so glad you asked! That is what I am working on. It's complicated, but the short answer seems to be "no."