Paradigms

Health Capability Paradigm

In this area of our research, we not only challenged existing paradigms but developed and empirically assessed a novel paradigm, the health capability paradigm (HCP), of health promotion that forms the basis for healthy public policies, beginning with two 2004 papers published in Lancet, one of which was later cited by United Nations High Commissioner for Refugees and United Nations Education, Scientific and Cultural Organization (UNESCO).

The HCP is an innovative interdisciplinary theoretical framework integrating diverse sources of information in economics, political science, and ethics, creating new theoretical concepts and methods and producing findings unavailable from the application of only one discipline. We developed the HCP by questioning, indeed critiquing, the conventional health economic approach, challenging economic theory’s foundational principles of rational behavior and expected utility theory.

Standard theory suggests that rational decisions have three qualities: internal consistency of choice, maximization of objectives and pursuit of self-interest. Paul Samuelson’s (1947) Foundations of Economic Analysis defined preference as a binary relation underlying consistent choice revealed through consistency of choices taken.  Choice functions also require contraction consistency (chosen alternative, X, must continue to be chosen even if the set of possible options from which X is chosen contracts) and expansion consistency (chosen alternative, X, must continue to be chosen even if the set of possible options from which X is chosen expands). However, choices in health and health care, individual or social, cannot be represented by transitive binary relations, and in fact they are proved to be intransitive. Thus, linking choice to preference is a flawed basis for health economics. Numerous health care and public health choice examples illustrate the problem with these conditions, which fail to account for external objectives, values, or norms, which matter for decision-making.  Internal consistency of choice axioms fails to illuminate real behavior in the real world and fail to understand why people make the choices they make; these axioms lack descriptive and predictive reliability and validity in health. Rather, we needed to extend rationality to include external criteria such as norms, values and principles.

A wider set of motivations is included in the HCP as described in two later papers, one of which gained recognition by the U.S. government, Obama Administration, and was cited in multiple US government briefs to support the constitutionality of the individual mandate in the Affordable Care Act litigation in the Supreme Court and lower federal courts in California, Florida, Virginia and Michigan (relying on our paper in support of the argument that healthcare markets are unique and therefore minimum coverage provisions are a necessary and proper means of government regulation). Moreover, the puzzle of uncertainty, as demonstrated by the Ellsberg paradox (people prefer risk in situations where they know probabilities than when they do not) and the Allais paradox (expected utility theory is mistaken in not including mental magnitudes, processes, and counterfactuals) poses a particularly problematic roadblock for expected utility theory because health and health care are replete with uncertainly and incompleteness. A plural evaluative framework was needed, which is what the HCP provides, having a ground-breaking impact on the field.

 Selected Publications

Ruger JP. “Aristotelian Justice and Health Policy:  Capability and Incompletely Theorized Agreements. PhD Dissertation, Harvard University.

Ruger JP. “The Moral Foundations of Health Insurance,” Quarterly Journal of Medicine, 2007; 100(1): 53-7.