• O F Norheim.
• Division for Medical Ethics, Department of Public Health and Centre for International Health, University of Bergen, Kalfarveien 18, Bergen 5018, Norway. ole.norheim@isf.uib.no
• J Med Ethics. 2009 Sep 1; 35 (9): 565-9.

AbstractThe moral philosopher Dan Brock has argued that equality of health outcomes "even if achievable" is problematic as a goal in its own right-because it is open to the levelling down objection. The levelling down objection to egalitarianism has received surprisingly little attention in the bioethics literature on distribution of health and healthcare and deserves more attention. This paper discusses and accepts an example given by Brock showing that prioritarianism and egalitarianism may judge distributions of health outcomes differently. We should accept that levelling down is never a good thing, all things considered, but that equality often is. By discussing variants of Brock's example, it is demonstrated that if equality, prioritarianism and aggregation are combined, as in a population-wide summary measure of health, such as the health achievement index, this combined set of principles is not open to levelling down. The paper suggests-although a more thorough investigation of the properties of the achievement index is needed-that this measure (a) is always sensitive to inequality in health, (b) is always sensitive to average health, (c) can assign priority to those with lowest health outcomes and (d) is not sensitive to levelling down. Levelling down is not an embarrassment for egalitarians if they adopt a pluralist theory that integrates fairness with goodness. Equality is not the only value egalitarians promote. But equality is so important that we should not reject it.

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