So in this case extreme progressivism says that is wrong to act as you would if you
were reasonable and moved only by individual concern for each of your patients. It
generates a conflict between reasonable beneficence and morality.
2
Extreme progressivism is a very uncompromising theory. Only the worst off matter.
Few real philosophers accept that. Do less extreme, more plausible versions of progressivism
generate conflicts between reasonable beneficence and morality? This is a tricky question to
answer. Any progressivist theory specifies a certain way in which you should pay special
attention to the less well off. It avoids the conflict if, in situations in which you are uncertain
about who stands to gain or lose from your action (situations like At the Doctor), it would
not be unreasonable for you, when acting out of concern for a particular person, to pay
special attention in just the same way to possibilities in which things go less well for that
person.
3
So, in effect, making a judgment about whether a progressivist theory generates the
2
The example has played an important role in discussions of progressivism. In brief: Parfit (1997) distinguished
two kinds of progressivist theory, welfare egalitarianism, which says that equality of welfare is in itself good, and
welfare prioritarianism, which says that incremental benefits to worse-off people have greater moral significance
than equivalent incremental benefits to better off people. He then pointed out that welfare prioritarianism,
unlike welfare egalitarianism, is not subject to a ‘leveling down objection’ – it does not say, implausibly, that we
can make things in a morally significant way better by making everybody worse off). Rabinowicz (2001) then
pointed out that prioritarianism is subject to a seemingly-similar-in-spirit objection: Though it does not say that
sometimes we should act contrary to the interests of all, it does say that, in cases like At the Doctor, we should
act contrary to the expected interests of all. There has been much subsequent discussion about whether this is a
bad feature of the view. See Otsuka and Voorhoeve (2009), Parfit (2012), Otsuka (2012) and Otsuka (2015).
3
So, for example, a welfare prioritarian can avoid the conflict if she says that 1) acting morally consists in acting
so as to maximize expected total priority-adjusted well-being, and that 2) acting from reasonable concern for a
person consists in acting so as to maximize her expected priority-adjusted well-being. (Though there is then a
question about whether she should really count as a ‘prioritarian’. If these ‘priority adjusted well-being levels’
matter both morally and prudentially then it is unclear why not to call them ‘well-being levels’ and be done with
it.) A welfare prioritarian faces the conflict if she says that incremental benefits to the less-well-off matter much
more, morally, than incremental benefits to the better-off, and that it would be unreasonable to adjust so