Suppose you have a single pill at your disposal and that pill will extend any person’s life by 10 years. You have to choose to give it to one of the following tow individuals:
a 20‐year‐old patient, who will live for 10 more years if she gets the drug, and then she dies;a 70‐year‐old patient, who will live for 10 more years if she gets the drug, and then she dies.
The person who does not get the drug will die immediately. Who would you give it to?
Under a QALY-based framework, you would be indifferent between giving it to either individual; in both cases, life extension is 10 years and (assuming identical quality of life) there would be now difference in how QALYs gained are valued.
Many people, however, will prefer to give it to the 20 year old. The 20 year old has only lived a short life whereas the 70-year old already has lived a life near the average life expectancy. People who make this argument are making a “Fair Innings” argument.
Adler et al. (2021)–building on Bognar 2008 and Bognar 2015–use the following definition:
as between a policy that produces a given gain in expected lifetime well‐being for a younger person, and an otherwise‐identical policy that produces the same gain in expected lifetime well‐being for an older person, it is ethically better for society to undertake the first policy.
The Fair Innings approach is justified theoretically using a prioritarian social welfare function approach, whereby an increasing, concave, and continuous transformation is applied to individual lifetime utilities.
Another question is, do individuals actually believe in the “Fair Innings” rationale? fair
To answer this question, a paper by Adler et al. (2025) survey general population individuals in France to not only to see if the Fair Innings hypothesis holds, but also how much age matters in prioritization (i.e., formally how concave the lifetime utility function is). They find:
…about half (41.4–56.2%) of the respondents choose to provide the treatment to the younger patient; in contrast, the fraction that would treat the older patient never exceeds one quarter. Importantly, about one‐third of participants are indifferent between giving the treatment to either the younger or the older patient.
The authors ask for patients age based on various comparisons of individuals aged 20, 40, 60 and 80. Of note, they do not ask about Fair Innings related to children (the youngest age scenario was 20); it is unclear if the Fair Innings hypothesis would be stronger if children were also included as one of the comparison groups. Not that that the share that would choose the younger group was 41.4% – 46.6%, except when comparing 60 vs. 80 year-olds in which case 56.2% preferred to give the treatment to the younger (60 year old) individual.
Additional background on the Fair Innings literature and analysis from the survey can be found in the paper here.
