Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as “beneficial,” “effective,” or even “futile,” the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient (...) Greek philosophical conundrum known as the “sorites paradox.” I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing). (shrink)

Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be determined by assessing whether differences in (...) coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior relative to those belonging to other national insurance schemes. The paper further contends that these determinations of fairness should involve the people covered by different insurance schemes. Key universal health coverage questions to involve the public in answering are: Do the sum of differences between the schemes in your country generate feelings of unequal moral worth and/or mean enrolees struggle to achieve sufficient health or normal functioning? Which specific differences between health insurance schemes generate the greatest feelings of unequal moral worth in individuals? Which specific differences generate the greatest barriers to individuals achieving sufficient health or normal functioning? Rather than identifying which services to extend coverage to first, answering these questions will identify which disparities in services and benefits are the most morally urgent to address. Finally, some initial thoughts are offered on who from the public should be involved in making these decisions and how they might be involved as a matter of justice. (shrink)