Aggregating health and future people

Argument: There are clear parallels between common sense intuitions about cases involving a large number of people each with small amounts of welfare have the same intuitive cause. If one aims to construct a theory defending these common sense intuitions, it should plausibly be applicable to these different cases. Some theories fail this test.


What ought you to do in the following cases?

Case 1. You can bring into existence a world (A) of 1 million very happy people or a world (B) of 100 quadrillion people with very low, but positive welfare.

Case 2. You can cure (C) James of a terminal illness, or (D) cure one quadrillion people of a moderate headache lasting one day.

Some people argue that you ought to choose options (B) and (D). Call these the ‘repugnant intuitions’. One rationale for these intuitions is that the value of these states of affairs is a function of the aggregate welfare of each individual. Each small amount of welfare adds up across persons and the contribution of each small amount of welfare does not diminish, such that due to the size of the populations involved options (B) and (D) have colossal value, which outweighs that of (A) and (C) respectively. The most notable theory supporting this line of reasoning is total utilitarianism.

Common sense dictates the ‘non-repugnant intuitions’ about cases 1 and 2: that we ought to choose (A) and (C). Philosophical theories have been constructed to defend common sense on this front, but they usually deal with cases 1 and 2 separately, in spite of the obvious parallels between them. In both cases, we face a choice between giving each of a massive number of people a small amount of welfare, and giving large amounts of welfare to each of a much smaller number of people. In both cases, the root of the supposed counterintuitiveness of the aggregationist moral view is that it aggregates small amounts of welfare across very large numbers of people to the extent that this outweighs a smaller number of people having large welfare.

Are there any differences between these two cases that could justify trying to get to the non-repugnant intuitions using different theoretical tools? I do not think so. It might be argued that the crucial difference is that in case 1 we are choosing between possible future people, whereas in case 2 we are choosing how to benefit groups of already existing people. But this is not a good reason to treat them differently, assuming that one’s aim is to get the non-repugnant intuitions for cases 1 and 2. Standard person-affecting views imply that (A) and (B) are incomparable and therefore that we ought to be indifferent between them and are therefore permitted to choose either. But the non-repugnant intuition is that (A) is better than (B) and/or that we ought to choose (A). Person-affecting views don’t get the required non-repugnant conclusions dictated by common sense.

Moreover, there are present generation analogues of the repugnant conclusion, which seem repugnant for the same reason.

Case 3. Suppose that we have to choose between (E) saving the lives of 1 million very happy people, and (F) saving the lives of 100 quadrillion people with very low but positive welfare.

Insofar as I am able to grasp repugnance-intuitions, the conclusion that we ought to choose F is just as repugnant as the conclusion that we ought to choose B, and for the same reason. But in this case, future generations are out of the picture, so cannot explain differential treatment of the problem.

In sum, the intuitive repugnance in all three cases is rooted in the counterintuitiveness of aggregating small amounts of welfare, and is only incidentally and contingently related to population ethics.


If the foregoing argument is correct, then we would expect theories that are designed to produce the non-repugnant verdicts in these cases to be structurally similar, and for any differences to be explained by relevant differences between the cases. One prominent theory of population ethics fails this test: critical level utilitarianism (CLU). CLU is a theory that tries to get a non-repugnant answer for case 1. On CLU, the contribution a person makes to the value of a state of affairs is equal to that person’s welfare level minus some positive constant K. A person increases the value of a world if her welfare is above K and decreases it if it her welfare level is below K. So, people with very low but positive welfare do not add value to the world. Therefore, world B has negative value and world A is better than B. This gets us the non-repugnant answer in case 1.

CLU has implications for case 2. However, it is interesting to explore an analogue critical level theory constructed exclusively to produce non-repugnant intuitions about case 2. How would this theory work? It would imply that the contributory value of providing a benefit to a person is equal to the size of the benefit minus a positive constant K. So, the contributory value of curing Sandra’s moderate headache is the value of that to Sandra – let’s say 5 utils – minus K, where K>5. In this case, curing Sandra’s headache would have negative contributory value; it would make the world worse.

The analogue-CLU theory for case 2 is crazy. Clearly, curing Sandra’s headache does not make the world worse. This casts doubt on CLU in general. Firstly, these theories both try to arrive at non-repugnant answers for cases 1 and 2, and the non-repugnant intuition for each case has the same explanation (discussed above). Thus, it needs to be explained why the theoretical solution to each problem should be different – why does a critical level make sense for case 1 but not for case 2? In the absence of such an explanation, we have good reason to doubt critical level approaches in general.

This brings me to the second point. In my view, the most compelling explanation for why a critical level approach clearly fails in one case but not the other is that the critical level approach to case 1 exploits our tendency to underrate low quality lives, but that an analogous bias is not at play in case 2.

When we imagine a low quality life, we may be unsure what its welfare level is. We may be unsure what constitutes utility, how to weight good experiences of different kinds, how to weight good experiences against bad experiences, and so on. In light of this, assessing the welfare level of a life that lasts for years would be especially difficult. We may therefore easily mistake a life with welfare level -1, for example, for one with welfare level 2. According to advocates of repugnant intuitions, the ability to distinguish such alternatives would be crucial for evaluating an imagined world of low average utility: it would be the difference between world B having extremely large positive value and world B having extremely large negative value.[1]

Thus, it is very easy to wrongly judge that a low positive welfare life is bad. But one cannot plausibly claim that curing a headache is bad. The value of curing a day-long moderate headache is intuitively easy to grasp: we have all experienced moderate headaches, we know they are bad, and we know what it would be like for one to last a day. This explains why the critical level approach is clearly implausible in one case but not the other: it is mistaken about case 2 because it underrates low quality lives, but this bias is not at play in case 1. Thus, we have good reason to doubt CLU as a theory of population ethics.

The following general principle seems to follow. If our aim is to theoretically justify non-repugnant intuitions for cases 1 and 2, then one theory should do the job. If the exact analogue of one theory is completely implausible for one of the cases, that should lead us to question whether the theory can be true for the other case.


[1] Huemer, ‘In defence of repugnance’, Mind, 2008, p.910.

Where should anti-paternalists donate?

GiveDirectly gives out unconditional cash transfers to some of the poorest people in the world. It’s clearly an outstanding organisation that is exceptionally data driven and transparent. However, according to GiveWell’s cost-effectiveness estimates (which represent a weighted average of the diverse views of GiveWell staffers), it is significantly less cost-effective than other recommended charities. For example, the Against Malaria Foundation (AMF) is ~4 times as cost-effective, and Deworm the World (DtW) is ~10 times as cost-effective. This is a big difference in terms of welfare. (The welfare can derive from averting deaths, preventing illness, increasing consumption, etc).

One prima facie reason to donate to GiveDirectly in spite of this, suggested by e.g. Matt Zwolinski and Dustin Moskovitz, is that it is not paternalistic.[1] Roughly: giving recipients cash respects their autonomy by allowing them to choose what good to buy, whereas giving recipients bednets or deworming drugs makes the choice for them in the name of enhancing their welfare. On the version of the anti-paternalism argument I’m considering, paternalism is non-instrumentally bad, i.e. it is bad regardless of whether it produces bad outcomes.

I’ll attempt to rebut the argument from anti-paternalism with two main arguments.

(i) Reasonable anti-paternalists should value welfare to some extent. Since bednets and deworming are so much more cost-effective than GiveDirectly, only someone who put a very high, arguably implausible, weight on anti-paternalism would support GiveDirectly.

(ii) More importantly, the premise that GiveDirectly is much better from an anti-paternalistic perspective probably does not hold. My main arguments here are that: the vast majority of beneficiaries of deworming and bednets are children; deworming and bednets yield cash benefits for others that probably exceed the direct and indirect benefits of cash transfers; and the health benefits of deworming and bednets produce long-term autonomy benefits.

Some of the arguments made here have been discussed before e.g. by Will MacAskill  and GiveWell, but I think it’s useful to have all the arguments brought together in one place.

It is important to bear in mind in what follows that according to GiveWell, their cost-effectiveness estimates are highly uncertain, not meant to be taken literally, and that the outcomes are very sensitive to different assumptions. Nonetheless, for the purposes of this post, I assume that the cost-effectiveness estimates are representative of the actual relative cost-effectiveness of these interventions, noting that some of my conclusions may not hold if this assumption is relaxed.


  1. What is paternalism and why is it bad?

A sketch of the paternalism argument for cash transfers goes as follows:

  • Anti-malaria and deworming charities offer recipients a specific good, rather than giving them the cash and allowing them to buy whatever they want. This is justified by the fact that anti-malaria and deworming charities enhance recipients’ welfare more than cash. Thus, donating to anti-malaria or deworming charities to some extent bypasses the autonomous judgement of recipients in the name of enhancing their welfare. Thus, anti-malaria and deworming charities are more paternalistic than GiveDirectly.

This kind of paternalism, the argument goes, is non-instrumentally bad: even if deworming and anti-malaria charities in fact produce more welfare, their relative paternalism counts against them. Paternalism is often justified by appeal to the value of autonomy. Autonomy is roughly the capacity for self-governance; it is the ability to decide for oneself and pursue one’s own chosen projects.

Even if the argument outlined in this section is sound, deworming and bednets improve the autonomy of recipients relative to no aid because they give them additional opportunities which they may take or decline if they (or their parents) wish. Giving people new opportunities and options is widely agreed to be autonomy-enhancing. This marks out an important difference between these and other welfare-enhancing interventions. For example, tobacco taxes reduce the (short-term) autonomy and liberty of those subject to them by using threats of force to encourage a welfare-enhancing behaviour.


  1. How bad is paternalism?

Even if one accepted the argument in section 1, this would only show that donating to GiveDirectly is less paternalistic than donating to bednets or deworming. This does not necessarily entail that anti-paternalists ought to donate to GiveDirectly. Whether that’s true depends on how we ought to trade off paternalism and welfare. With respect to AMF for example, paternalism would have to be bad enough that it is worth losing ~75% of the welfare gains from a donation; with respect to DtW, ~90%.

It might be argued that anti-paternalism has ‘trumping’ force such that it always triumphs over welfarist considerations. However, ‘trumping’ is usually reserved for rights violations, and neither deworming nor anti-malaria charities violates rights. So, trumping is hard to justify here.

Nonetheless, it’s difficult to say what weight anti-paternalism should have and giving it very large weight would, if the argument in section 1 works, push one towards donating to GiveDirectly. However, there are a number of reasons to believe that donating to deworming and bednets is actually attractive from an anti-paternalistic point of view.


  1. Are anti-malaria and deworming charities paternalistic?

(a) The main beneficiaries are children

Mass deworming programmes overwhelmingly target children. According to GiveWell’s cost-effectiveness model, 100% of DtW’s recipients are children, Sightsavers ~90%, and SCI ~85%. Around a third of the modelled benefits of bednets derive from preventing deaths of under 5s, and around a third from developmental benefits to children. The final third of the modelled benefits derive from preventing deaths of people aged 5 and over. Thus, the vast majority (>66%) of the modelled benefits of bednets accrue to children under the age of 15, though it is unclear what the overall proportion is because GiveWell does not break down the ‘over 5 mortality’ estimate.

Paternalism for children is widely agreed to be justified. The concern with bednets and deworming must then stem from the extent to which they are paternalistic with respect to adults.[2]

In general, this shows that deworming and anti-malaria charities do a small or zero amount of objectionable paternalism. So, paternalism would have to be very very bad to justify donating to GiveDirectly. Moreover, anti-paternalists can play it safe by donating to DtW, which does not target adults at all.

This alone shows that anti-paternalism provides weak or zero additional reason to donate to cash transfer charities, rather than deworming or anti-malaria charities.


(b) Positive Externalities

Deworming drugs and bednets probably produce substantial positive externalities. Some of these come in the form of health benefits to others. According to GiveWell, there is pretty good evidence that there are community-level health benefits to bednets: giving A a bednet reduces his malaria risk, as well as his neighbour B’s. However, justifying giving A a bednet on the basis that it provides health benefits to B is more paternalistic towards B than giving her the cash, for the reasons outlined in section 1.

However, by saving lives and making people more productive, deworming and bednets are also likely to produce large monetary positive externalities over the long term. According to a weighted average of GiveWell staffers, for the same money, one can save ~10 equivalent lives by donating to DtW, but ~1 equivalent life by donating to GiveDirectly. (An ‘equivalent life’ is based on the “DALYs per death of a young child averted” input each GiveWell staffer uses. What a life saved equivalent represents will therefore vary between staffers because they are likely to adopt different value assumptions).

What are the indirect monetary benefits of all the health and mortality benefits that constitute these extra ‘equivalent lives’? I’m not sure if there’s hard quantitative evidence on this, but for what it’s worth, GiveWell believes that “If one believes that, on average, people tend to accomplish good when they become more empowered, it’s conceivable that the indirect benefits of one’s giving swamp the first-order effects”. What GiveWell is saying here is as follows. “Suppose that the direct benefits of a $1k donation are x. If people accomplish good when they are empowered, the indirect benefits of this $1k are plausibly >x.” If this is true, then what if the direct benefits are 10*x? This must make it very likely that the indirect benefits >>x.

So, given certain plausible assumptions, it’s plausible that the indirect monetary benefits of deworming and bednets exceed the direct and indirect monetary benefits of cash transfers. DtW and AMF are like indirect GiveDirectlys: they ensure that lots of people receive large cash dividends down the line.

As I argued in section 1, providing bednets and deworming drugs is autonomy-enhancing relative to no aid: it adds autonomy to the world. If, as I’ve suggested, bednets and deworming also produce larger overall cash benefits than GiveDirectly, then bednets and deworming dominate cash transfers in terms of autonomy-production. One possible counter to this is to discount the autonomy-enhancements brought about by future cash. I briefly discuss discounting future autonomy in (c).

This shows that anti-paternalists should arguably prefer deworming or anti-malaria charities to GiveDirectly, other things equal.


(c) Short-term and long-term autonomy

Short-term paternalism can enhance not only the welfare but also the long-term autonomy of an individual. For the same amount of money, one can save 10 equivalent lives by donating to DtW vs. 1 equivalent life by donating to GiveDirectly. The morbidity and mortality benefits that constitute these equivalent lives enable people to pursue their own autonomously chosen projects. It’s very plausible that this produces more autonomy than providing these benefits only to one person. Anti-paternalists who ultimately aim to maximise overall autonomy therefore have reason to favour deworming and bednets over GiveDirectly.

Some anti-paternalists may not want to maximise overall autonomy. Rather, they may argue that we should maximise autonomy with respect to some specific near-term choices. When we are deciding what to do with $100, we should maximise autonomy with respect to that $100. So, we should give them $100 rather than using the $100 to buy bednets.

This argument shows that how one justifies anti-paternalism is important. If you’re concerned with the overall long-term autonomy of recipients, you have reason to favour bednets or deworming. If you’re especially concerned with near-term autonomy over a particular subset of choices, the case for GiveDirectly is a bit stronger, but still probably defeated by argument (a).


(d) Missing markets

Deworming charities receive deworming drugs at subsidised prices from drug companies. Deworming charities can also take advantage of economies of scale in order to make the cost per treatment very low – around $0.50. I’m not sure how much it would cost recipients to purchase deworming drugs at market rates, but it seems likely to be much higher than $0.50. Similar things are likely true of bednets. The market cost of bednets is likely to be much greater than what it would cost AMF to get one. Indeed, GiveWell mentions some anecdotal evidence that the long-lasting insecticide-treated bednets that AMF gives out are simply not available in local markets.

From the point of view of anti-paternalists, this is arguably important if the following is true: recipients would have purchased bednets or deworming drugs if they were available at the cost that AMF and DtW pay for them. Suppose that if Mike could buy a bednet for the same price that AMF can deliver them – about $5 – he would buy one, but that they aren’t available at anywhere near that price. If this were true, then giving Mike cash would deprive him of an option he autonomously prefers, and therefore ought to be avoided by anti-paternalists. This shows that cash is not necessarily the best way to leave it to the individual – it all depends on what you can do with cash.

However, the limited evidence may suggest that most recipients would not in fact buy deworming drugs or bednets even if they were available at the price at which deworming and anti-malaria charities can get them. This may in part be because recipients expect to get them for free. However, Poor Economics outlines a lot of evidence showing that the very poor do not spend their money in the most welfare-enhancing way possible. (Neither do the very rich). The paper ‘Testing Paternalism’ presents some evidence in the other direction.

In sum, for anti-paternalists, concerns about missing markets may have limited force.



Deworming and anti-malaria charities target children, probably provide large long-term indirect monetary benefits, and enhance the long-term autonomy of beneficiaries. This suggests that anti-paternalism provides at best very weak reasons to donate to GiveDirectly over deworming and anti-malaria charities, and may favour deworming and anti-malaria charities, depending on how anti-paternalism is justified. Concerns about missing markets for deworming drugs and bednets may also count against cash transfers to some extent.

Nonetheless, even if GiveDirectly is less cost-effective than other charities, there may be other reasons to donate to GiveDirectly. One could for example argue, as George Howlett does, that GiveDirectly promises substantial systemic benefits and that its model is a great way to attract more people to the idea of effective charity.

Thanks to Catherine Hollander, James Snowden, Stefan Schubert, Michael Plant for thorough and very helpful comments.



[1] See this excellent discussion of paternalism by the philosopher Gerald Dworkin.

[2] It’s an interesting and difficult question what we are permitted to do to parents in order to help their children. We can discuss this in the comments.