Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a (...) low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off. (shrink)

It is generally accepted that morally justified healthcare rationing must be non-discriminatory and cost-effective. However, given conventional concepts of cost-effectiveness, resources spent on disabled people are spent less cost-effectively, ceteris paribus, than resources spent on non-disabled people. Thus, it is reasonable to assume that standard cost-effectiveness discriminates against the disabled. Call this thedisability discrimination problem.Part of the disability discrimination involved in cost-effectiveness stems from the way in which health-related quality of life is accounted for and measured. This paper offers and (...) defends a patient-sensitive account of health-related quality of life, which can effectively make cost-effectiveness less discriminatory against the disabled and thus more morally justified. (shrink)

Experimental ethicists investigate traditional ethical questions with non-traditional means, namely with the methods of the empirical sciences. Studies in this area have made heavy use of philosophical thought experiments such as the well-known trolley cases. Yet, the specific function of these thought experiments within experimental ethics has received little consideration. In this paper we attempt to fill this gap. We begin by describing the function of ethical thought experiments, and show that these thought experiments should not only be classified according (...) to their function but also according to their scope. On this basis we highlight several ways in which the use of thought experiments in experimental ethics can be philosophically relevant. We conclude by arguing that experimental philosophy currently only focuses on a small subcategory of ethical thought experiments and suggest a broadening of its research agenda. (shrink)

This paper discusses “impartiality thought experiments”, i.e., thought experiments that attempt to generate intuitions which are unaffected by personal characteristics such as age, gender or race. We focus on the most prominent impartiality thought experiment, the Veil of Ignorance (VOI), and show that both in its original Rawlsian version and in a more generic version, empirical investigations can be normatively relevant in two ways: First, on the assumption that the VOI is effective and robust, if subjects dominantly favor a certain (...) normative judgment behind the VOI this provides evidence in favor of that judgment; if, on the other hand, they do not dominantly favor a judgment this reduces our justification for it. Second, empirical investigations can also contribute to assessing the effectiveness and robustness of the VOI in the first place, thereby supporting or undermining its applications across the board. (shrink)

The allocation of healthcare resources takes place at two distinct levels. At the macroeconomic level, policymakers decide on budgets, staffing, cost‐effectiveness thresholds, clinical guidelines and insurance payments; at the microeconomic level, healthcare professionals decide on whom to treat, what the appropriate treatment is, how much time and effort should each patient receive and how urgent the need for care is. At both levels, there is a constant social need for just allocation. Policymakers are mostly guided by abstract principles of justice, (...) thinking in terms of groups of patients, epidemiological data, impersonal statistics and economic costs. On the other hand, healthcare professionals understand the need for justice at a more personal level, as they interact with patients and, in a sense, put theory into practice. Nurses hold a unique position in healthcare systems, as, traditionally, they are closer to patients than other health professionals. This means that they have a firsthand view of the effect that their decisions have on specific patients and, therefore, nurses tend to get more influenced by their personal feelings, values and beliefs at the microeconomic level. This presentation shall examine the gap between abstract macroeconomic and concrete microeconomic health resources allocation decisions, with a particular emphasis on the role of the nurse. (shrink)

The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it (...) is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify. (shrink)

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that all (...) are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

One of the strongest objections to the development and use of substantially life-extending interventions is that they would exacerbate existing unjust disparities of healthy lifespans between rich and poor members of society. In both popular opinion and ethical theory, this consequence is sometimes thought to justify a ban on life-prolonging technologies. However, the practical and ethical drawbacks of banning receive little attention, and the viability of alternative policies is seldom considered. Moreover, where ethicists do propose alternatives, there is scant effort (...) to consider their merits in light of developing world priorities. In response to these shortcomings, I distinguish four policy options and, on the basis of a plausible intuition about fairness, evaluate their implications for a fair distribution of healthy lifespans. I claim that even in developing nations it would be fairest to favor policies that promote equal access to at least one promising category of substantially life-extending intervention: calorie restriction mimetics. (shrink)

Summary measures of health, such as the quality-adjusted life year and disability-adjusted life year, have long been known to incorporate a number of value choices. In this paper, though, I show that the value choices in the construction of such measures extend far beyond what is generally recognized. In showing this, I hope both to improve the understanding of those measures by epidemiologists, health economists and policy-makers, and also to contribute to the general debate about the extent to which such (...) measures should be adjusted to reflect ethical values. (shrink)

The mission of public health is to assure the conditions in which people can be healthy and to reduce the occurrence of death and disability attributable to disease and injury. From the distinctive perspective of public health, the target is the health of the population as a whole, with a particular concern for vulnerable populations within the whole. Although public health is grounded in science, the mission and perspective of the field are shaped by the ever-evolving values of the society. (...) Ethics and law are therefore constituent disciplines of public health policy and practice. One of the major challenges confronting contemporary practitioners of public health is the need to broaden and deepen their understanding of legal and ethical aspects of their work. This special issue of the Joumal of Law, Medicine & Ethics responds to this challenge. This article describes how the mission of public health has come to encompass the prevention and treatment of injury and highlights some of the political and ethical controversies now confronting the field. (shrink)

The dominant rule of economic evaluation within health care posits that resources are distributed in order to maximize health benefit. There are instances, however, where the public has demonstrated that they do not prefer such an allocation scheme, particularly in the context of life-saving interventions. Objectives Deviations from preferences of maximizing health benefit have important implications on both financial and distributive levels. This study sought to specify the circumstances in which respondent preferences are inconsistent with maximizing health benefit. Methods Ninety (...) respondents recruited from the London School of Economics and Political Science completed a questionnaire comprised of a series of paired profiles involving various combinations of life-saving or quality-of-life enhancing interventions. Results The results indicate that saving a life holds value beyond that captured by traditional health benefit measurement and that the value of saving a life is not consistent across ages. More specifically, the value of saving a life was age-dependent and markedly attenuated for older-age patients. Conclusions Many respondents were willing to overlook maximizing health benefit in order to rescue a life in immediate peril, and showed a diminished sense of moral imperative to rescue older-age patients. In light of difficulties related to the implementation of larger-scale policies incorporating Rule of Rescue concerns, the most realistic approaches will likely involve adopting smaller-scale policies that address issues such as do not resuscitate and living wills. Potential policy solutions such as age or monetary thresholds for life-saving interventions may be favoured in a research context; however, their overall social feasibility is questionable. (shrink)

Bioethicists often present ‘saving lives’ as a goal distinct from, and competing with, that of extending lives by as much as possible. I argue that this usage of the term is misleading, and provides unwarranted rhetorical support for neglecting the magnitudes of the harms and benefits at stake in medical allocation decisions, often to the detriment of the young. Equal concern for all persons requires weighting equal interests equally, but not all individuals have an equal interest in ‘life-saving’ treatment.

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style reasoning are commonly combined (...) in an ethically acceptable fashion. (shrink)

This book addresses these three issues: What is discrimination?; What makes it wrong?; What should be done about wrongful discrimination? It argues: that there are different concepts of discrimination; that discrimination is not always morally wrong and that when it is, it is so primarily because of its harmful effects.

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

In QALY-thinking, an activity that takes N people from a bad state (including 'dying') to the state of healthy for X years should have priority over an activity that takes N other people from the same bad state to a state of moderate illness for the same number of years (given equal costs). An empirical study indicates that this view may not be shared by the general public in Norway. Subjects tended to emphasise equality in value of life and in (...) entitlement to treatment rather than level of health after treatment. The relevance of costs per QALY in prioritising between different health care programmes in Norway is thereby brought in to doubt. While the sample in the study is too small to support firm policy conclusions, the results should contribute to an increased interest among health economists in actually measuring people's ethical preferences in matters of prioritising, rather than taking it for granted that their own values are shared by the general public. (shrink)

This article tries to present a broad view on the values and ethicalissues that are at stake in efforts to rationalize health policy on thebasis of economic evaluations (like cost-effectiveness analysis) andrandomly controlled clinical trials. Though such a rationalization isgenerally seen as an objective and `value free' process, moral valuesoften play a hidden role, not only in the production of `evidence', butalso in the way this evidence is used in policy making. For example, thedefinition of effectiveness of medical treatment or (...) health care serviceis heavily dependent on dominant individual or social views about thegoals of the particular treatment or service. There is also a concernthat a reliance on EBM in health policy will occur at the expense ofwidely shared social values like equity and solidarity. Moreover, thereis a concern that when economic considerations and rational proceduresbecome more influential, various `outside' groups third parties likeinsurance companies and policy makers will get a stronger influence onmedical practice which may lead to a change in the patient-providerrelationship. The authors conclude that social values and patientpreference should be explicitly addressed when health policy making isbased on economic and other scientific evidence. (shrink)

A principle claiming equal entitlement to continued life has been strongly defended in the literature as a fundamental social value. We refer to this principle as ‘equal value of life'. In this paper we argue that there is a general incompatibility between the equal value of life principle and the weak Pareto principle and provide proof of this under mild structural assumptions. Moreover we demonstrate that a weaker, age-dependent version of the equal value of life principle is also incompatible with (...) the weak Pareto principle. However, both principles can be satisfied if transitivity of social preference is relaxed to quasi-transitivity. Footnotes1 The authors are grateful to Luc Bovens, Kristian Schultz Hansen, Søren Holm, Franz Huber, Wiebke Kuklys, Gabriella Pigozzi, and two anonymous referees for detailed and very helpful comments on earlier versions of this paper. Any errors and shortcomings are the responsibility of the authors alone. (shrink)

The worst possible way to resolve this issue is to leave it up to individual choice. There is no known social good coming from the conquest of death (Bailey, 1999). - Daniel Callahan Dramatically extending the human lifespan seems increasingly possible. Many bioethicists object that life-extension will have Malthusian consequences as new Methuselahs accumulate, generation by generation. I argue for a Life-Years Response to the Malthusian Objection. If even a minority of each generation chooses life-extension, denying it to them deprives (...) them of many years of extra life, and their total extra life-years are likely to exceed the total life-years of a majority who do not want life-extension. This is a greater harm to those who want extended life than the Malthusian harms to those who refuse extended life, both because losing an extra year of life is worse than enduring a year of Malthusian conditions, and because the would-be Methuselahs have more life-years at stake. Therefore, even if life-extension seems likely to cause severe overcrowding and resource shortages, that threat is not sufficient to justify society in restricting the development or availability of life-extension. (shrink)

Algorithm-assisted decision procedures—including some of the most high-profile ones, such as COMPAS—have been described as unfair because they compound injustice. The complaint is that in such procedures a decision disadvantaging members of a certain group is based on information reflecting the fact that the members of the group have already been unjustly disadvantaged. I assess this reasoning. First, I distinguish the anti-compounding duty from a related but distinct duty—the proportionality duty—from which at least some of the intuitive appeal of the (...) former illegitimately derives. Second, I distinguish between different versions of the anti-compounding duty, arguing that, on some versions, uses of algorithm-assisted decision procedures rarely clash with the anti-compounding duty. Third, drawing on examples of algorithm-assisted decision procedures, I present three objections to the idea that there is a reason not to compound injustice. The most important of these is that one can compound injustice in a non-disrespectful way, and that the wrongfulness of non-disrespectfully compounding injustice is fully explained by the proportionality duty. (shrink)

Knowing how to be good, or knowing how to go about trying to be good, is of immense theoretical and practical importance. And what goes for trying to be good oneself, goes also for trying to provide others with ways of being good, and for trying to make them good whether they like it or not. This is what is meant by 'moral enhancement'. John Harris explores the many proposed methodologies or technologies for moral enhancement: traditional ones like good parenting (...) and education; newer ones like chemical or biological intervention; modifying the environment to make bad outcomes of all sorts less likely; experimentation with political and social systems. The issue of whether and to what extent moral enhancement is possible is the subject of this book. (shrink)

Early announcements of this special journal issue solicited authors interested in contributing articles on the subject of “costs at the end of life.” Those who replied were then informed the title was being changed, on the basis of early subscriber interest, in “rational end-of-life treatment.” Because that seemed a still inadequate reflection of the authorial concerns of responding potential contributors, the editors again changed the title, two months later, to “Making Treatments More Rational and Compassionate for the Chronically Critically Ill.” (...) At that point the editors gave up and decided this issue’s final title would be determined only after the papers were submitted and reviewed. (shrink)

This study used fMRI to investigate the neural substrates of moral cognition in health resource allocation decision problems. In particular, it investigated the cognitive and emotional processes that underpin utilitarian approaches to health care rationing such as Quality Adjusted Life Years. Participants viewed hypothetical medical and nonmedical resource allocation scenarios which described equal or unequal allocation of resources to different groups. In addition, participants were assigned to 1 of 2 treatments in which they either did or did not receive advanced (...) instructions about the principles of utilitarianism. In all cases, participants were asked to judged the proposed allocations as “fair” or “unfair.” More brain activity was observed within the superior parietal lobe, angular gyrus, middle temporal gyrus, and bilateral caudate nucleus when participants viewed scenarios depicting equal divisions of resources. Conversely, unequal resource divisions were associated with more activity in the inferior frontal gyrus and insula cortex. Furthermore, instructions about the principles of utilitarianism led to significant activation differences within the inferior frontal gyrus and the middle frontal gyrus. Significant differences in activity were also found within the inferior frontal cortex and anterior insula between medical and nonmedical scenarios. The implications for cognitive control mechanisms and the cognitive and neural bases of utilitarian ethical judgment are discussed. (shrink)

Disability might be relevant to decisions about life support in intensive care in several ways. It might affect the chance of treatment being successful, or a patient’s life expectancy with treatment. It may affect whether treatment is in a patient’s best interests. However, even if treatment would be of overall benefit it may be unaffordable and consequently unable to be provided. In this paper we will draw on the example of neonatal intensive care, and ask whether or when it is (...) justified to ration life-saving treatment on the basis of disability. We argue that predicted disability is relevant both indirectly and directly to rationing decisions. (shrink)

Many questions concerning health involve values. How well is a health system performing? How should resources be allocated between the health system and other uses or among competing healthrelated uses? How should the costs of health services be distributed among members of a population? Who among those in need of transplants should receive scarce organs? What is the best way to treat particular patients? Although many kinds of expertise bear on these questions, values play a large role in answering them. (...) These values are of many kinds – judgments about how health states contribute to the well-being of individuals depend on views about what is good for a person, whereas judgments about how to share the costs of health care or about how to distribute scarce organs among those in need of transplants depend on theories of fairness. The value judgments that need to be made are not only multifaceted and heterogeneous; they are also controversial. Both the understanding of the questions and the substance of the answers may vary widely from individual to individual and among different groups within countries and across national boundaries. How are these many complicated, difficult and controversial evaluative questions to be answered? This could be a question about who should answer them as well as a question about how they should be answered. There are various possible mechanisms, and there is no reason why the same method should be employed to answer every question. Among the possible methods are (1) moral argument, (2) political deliberation and (3) eliciting preferences or judgments from some group. Included in the third method lie many different techniques of elicitation. For example, one could study attitudes by the use of deliberative (focus) groups, by permitting individual choice in some sort of market or quasi-market, by polling or by voting. These methods of answering evaluative questions are not always incompatible with one another. Moral argument can play a role within political deliberation, deliberation by focus groups, individual market choice, or voting.. (shrink)

In a recent article in this journal, Kowalik argues that compulsory vaccination unjustifiably infringes on the autonomy of vaccine refusers. While accepting Kowalik’s central premises, we argue that, when appropriately expanded in scope, autonomy considerations do not undermine the justifiability of compulsory vaccination. Vulnerable individuals—including the very old, the very young and those with compromised immune systems—face an omnipresent risk of contracting a potentially fatal vaccine-preventable illness and are thus prevented from accessing public goods by coercive pressure. Consequently, when we (...) consider an appropriately broad scope of autonomy constraints, autonomy considerations do not undermine the case for mandating vaccination. (shrink)

Zusammenfassung Im Falle von Pandemien können die Kapazitäten auf den Intensivstationen bekanntlich knapp werden. In Deutschland hat dieser Umstand zu einem Urteil des Bundesverfassungsgerichts geführt, in dem vom Gesetzgeber verlangt wurde, Menschen mit Behinderungen für solche Fälle besser vor Diskriminierung zu schützen. Aus ethischer Sicht hängt die Frage nach den Diskriminierungspotentialen von Priorisierungskriterien stark davon ab, worin genau das Übel einer Diskriminierung verortet werden muss – eine Frage, zu der es in der Ethik mehrere konkurrierende Theoriegruppen gibt. In diesem Aufsatz (...) soll gezeigt werden, dass diese Theorien darüber hinaus jeweils einer Ergänzung bedürfen, um dem Phänomen der indirekten Diskriminierung gerecht werden zu können. Wie hier am Beispiel einiger konkreter Triage-Kriterien gezeigt werden soll, ist ein Ansatz mittlerer Breite besonders geeignet, um die Aufmerksamkeit auf den Kern der aktuellen Probleme zu lenken. Dazu zählt insbesondere das Ausmaß, in dem soziale Gepflogenheiten gegenüber Menschen mit bereits zuvor bestehenden konkreten Schwierigkeiten generell Auswirkungen auf die Struktur ihrer sozialen Interaktionen haben. (shrink)

This paper argues that we ought to rethink the harm-reduction prioritization strategy that has shaped early responses to acute resource scarcity (particularly of intensive care unit beds) during the COVID-19 pandemic. Although some authors have claimed that “[t]here are no egalitarians in a pandemic,” it is noted here that many observers and commentators have been deeply concerned about how prioritization policies that proceed on the basis of survival probability may unjustly distribute the burden of mortality and morbidity, even while reducing (...) overall deaths. The paper further argues that there is a general case in favor of an egalitarian approach to medical rationing that has been missed in the ethical commentary so far; egalitarian approaches to resource rationing minimize wrongful harm. This claim is defended against some objections and the paper concludes by explaining why we should consider the possibility that avoiding wrongful harm is more important than avoiding harm simpliciter. (shrink)

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, ‘value’ refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of (...) using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley’s “agential flourishing” theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations. (shrink)

Consider two cases. In Case 1, you must decide whether you save the life of a disabled person or you save the life of a person with no disability. In Case 2, you must decide whether you save the life of a disabled person who would remain disabled, or you save the life of another disabled person who, in contrast, would also be cured as a result of your intervention. It seems that most people agree that you should give equal (...) chances in Case 1: saving the life of the person with no disability would be unfair discrimination against the person with disability. Yet, in Case 2, it appears that many people believe that you are at least permitted to save straightaway the person who would have no disability after your intervention. There would be no unfair discrimination against the other person. I argue that these judgments present a puzzle for theories of resource allocation in normative ethics. The puzzle is straightforward for consequentialists: the two cases have the same outcomes, but the judgments are different. But the puzzle also presents a problem for nonconsequentialist views. After introducing the cases, I show this by reviewing a number of proposals for solving the puzzle. I argue that none of these proposals are successful. I then make my own proposal and conclude by spelling out its implications. (shrink)

Quality improvement mechanisms increasingly use outcome measures to evaluate health care providers. This move toward outcome measures is a radical departure from the traditional focus on process measures. More radical still is the proposal to shift from relatively simple and proximal measures of outcome, such as mortality, to complex outcomes, such as quality of life. While the practical, scientific, and ethical issues associated with the use of outcomes such as mortality and morbidity to compare health care providers have been well (...) rehearsed, the specific concerns associated with the use of quality of life measures in quality of care research have received little attention. As with much research on quality of life there is a tendency to assume that the disadvantages are outweighed by the general virtue of “listening” to patients. In this paper we disagree with this assumption and argue that quality of life is a process, not an outcome. (shrink)

The evaluation of whether an animal has a life worth living (LWL) has been suggested as a useful concept for farm animal policymaking. But there are a number of different ways in which the concept could be applied. This paper attempts to identify and evaluate candidate ethical principles based on the concept. It suggests that an appropriate principle by which to apply the concept is one that (1) is framed in terms of preventing an animal having a life worth avoiding (...) (LWA), rather than ensuring they have LWL, (2) is based on a prospective, rather than retrospective, concept of a life’s worth, and (3) relates to both the perpetuation and creation of an animal at all times during its life. The paper concludes by endorsing an overarching principle that no animal should be unreasonably caused to be, or allowed to remain, in a position of having a prospective LWA. (shrink)

This essay seeks to characterise the essential features of an equitable health care system in terms of the classical Aristotelian concepts of horizontal and vertical equity, the common language of “need” and the economic notion of cost-effectiveness as a prelude to identifying some of the more important issues of value that policy-makers will have to decide for themselves; the characteristics of health that can cause policy to be ineffective ; the information base that is required to support a policy directed (...) at securing greater equity, and the kinds of research that are needed to underpin such a policy. (shrink)

BackgroundWhen rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of (...) relative scarcity.MethodsFourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.ResultsParticipants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.ConclusionsWe conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level. (shrink)

Tännsjö’s book Setting Health-Care Priorities defends the view that there are three main normative theories in the domain of distributive justice, and that these theories are both highly plausible in themselves, and practically convergent in their normative conclusions. All three theories point to a somewhat radical departure from the present distribution of medical resources: in particular, they suggest redirecting resources from marginal life extension to the care of mentally ill patients. In this paper I wish to argue, firstly, that prioritarianism (...) should not be considered as an amendment to utilitarianism, as it is in Tännsjö’s view, but as a distinctive fourth option. This can best be appreciated if we focus on a reading of the theory that emphasizes its derivation from egalitarianism and its attempt to develop an intermediate approach between utilitarian and egalitarian intuitions. Secondly, in response to Tännsjö’s central objection to prioritarianism, I will argue that the theory does not apply in intrapersonal cases but is only relevant for decisions regarding the interpersonal distribution of benefits. Finally, I will suggest that a practical convergence of the four theories on specific issues such as artificial reproduction or mood enhancement is far less likely than Tännsjö seems to believe. (shrink)

Vaccines, when available, will prove to be crucial in the fight against Covid-19. All societies will face acute dilemmas in allocating scarce lifesaving resources in the form of vaccines for Covid-19. The author proposes The Value of Lives Principle as a just and workable plan for equitable and efficient access. After describing what the principle entails, the author contrasts the advantage of this approach with other current proposals such as the Fair Priority Model.

It is widely recognized that prioritizing health care resources by their relative cost-effectiveness can result in lower priority for the treatment of disabled persons than otherwise similar non-disabled persons. I distinguish six different ways in which this discrimination against the disabled can occur. I then spell out and evaluate the following moral objections to this discrimination, most of which capture an aspect of its unethical character: it implies that disabled persons' lives are of lesser value than those of non-disabled persons; (...) it constitutes “double jeopardy” or violates Frances Kamm's non-linkage principle; it conflicts with equality of opportunity; it conflicts with fairness, which requires ignoring (some/most) differential impacts of treatment; it wrongly gives lower priority to disabled persons for equally effective treatment; it conflicts with giving all persons an equal chance to reach their full potential; and, it is in conflict with giving priority to the worse off. (shrink)

Around the world, the population is ageing in ways that pose new challenges for healthcare providers. To date these have mostly been formulated in terms of challenges created by increasing costs, and the focus has been squarely on life-prolonging treatments. However, this focus ignores the ways in which many older people require life-enhancing treatments to counteract the effects of physical and mental decline. This paper argues that in doing so it misses important aspects of what justice requires when it comes (...) to older people. (shrink)

There are in two assumptions inherent in this issue's theme, both inimical to the traditional goals of medicine and to the standards of care it proposed. First, the idea that treatment must be limited for some (but not others) on the basis of cost was born in the early literature of bioethics. Second, that there is a quantifiable and diagnostically predictable period at the “end-of-life” where treatment is “futile,” and therefore not worth supporting in a context of scarcity grew out (...) of bioethics's construction of allocative protocols in the 1990s. This paper traces the history of these ideas as constructs grounded in neither natural scarcity nor in firm diagnostic categories. Their relation to issues of care is therefore suspect. (shrink)

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment...

The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight—and (...) as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare. (shrink)

Governmental reactions to crises like the COVID-19 pandemic can be seen as ethics communication. Governments can contain the disease and thereby mitigate the detrimental public health impact; allow the virus to spread to reach herd immunity; test, track, isolate, and treat; and suppress the disease regionally. An observation of Sweden and Finland showed a difference in feasible ways to communicate the chosen policy to the citizenry. Sweden assumed the herd immunity strategy and backed it up with health utilitarian arguments. This (...) was easy to communicate to the Swedish people, who appreciated the voluntary restrictions approach and trusted their decision makers. Finland chose the contain and mitigate strategy and was towards the end of the observation period apparently hesitating between suppression and the test, track, isolate, and treat approach. Both are difficult to communicate to the general public accurately, truthfully, and acceptably. Apart from health utilitarian argumentation, something like the republican political philosophy or selective truth telling are needed. The application of republicanism to the issue, however, is problematic, and hiding the truth seems to go against the basic tenets of liberal democracy. (shrink)

The task of combatting and defeating Covid-19 calls for drastic measures as well as cool heads. It also requires that we keep our nerve and our moral integrity. In the fight for survival, as individuals and as societies, we must not lose our grip on the values and the compassion that make individual and collective survival worth fighting for, or indeed worth having.1.

In intensive care, disputes sometimes arise when patients or surrogates strongly desire treatment, yet health professionals regard it as potentially inappropriate. While professional guidelines confirm that physicians are not always obliged to provide requested treatment, determining when treatment would be inappropriate is extremely challenging. One potential reason for refusing to provide a desired and potentially beneficial treatment is because (within the setting of limited resources) this would harm other patients. Elsewhere in public health systems, cost effectiveness analysis is sometimes used (...) to decide between different priorities for funding. In this paper, we explore whether cost-effectiveness could be used to determine the appropriateness of providing intensive care. We explore a set of treatment thresholds: the probability threshold (a minimum probability of survival for providing treatment), the cost threshold (a maximum cost of treatment), the duration threshold (the maximum duration of intensive care), and the quality threshold (a minimum quality of life). One common objection to cost-effectiveness analysis is that it might lead to rationing of life-saving treatment. The analysis in this paper might be used to inform debate about the implications of applying cost-effectiveness thresholds to clinical decisions around potentially inappropriate treatment. (shrink)

Whose values should count – those of patients or the general public – when adopting the quality-adjusted life year framework for healthcare decision making is a long-standing debate. Specific disciplines, such as economics, are not wedded to a particular side of the debate, and arguments for and against the use of patient values have been discussed at length in the literature. In 2012, Sinclair proposed an approach, grounded within patient preference theory, which sought to avoid a perceived unfair discrimination against (...) people with disabilities when using values from the general public. Key assumptions about general public values that beget this line of thinking were that ‘disabled states always tally with lower quality of life’, and the use of standardised instruments means that ‘you are forced into a fixed view of disability as a lower value state’. Drawing on recent contributions to the health economics literature, we contend that such assumptions are not inherent to the incorporation of general public values for the estimation of QALYs. In practice, whether health states of people with disabilities are of ‘lower value’ is, to some extent, a reflection of the health state descriptions that members of the public are asked to value. (shrink)

The principle that people's lives and fundamental interests are of equal value and that they must therefore be given equal weight has immense intellectual appeal and intuitive force. It is often enough to discredit a theory or proposal simply to show that it violates this principle. When measures are said to be discriminatory or unfair it is this principle which is in play. Recent philosophers of widely differing schools and outlooks give versions of this principle a central role in their (...) theories. (shrink)

In modern representative democracies, much healthcare is publicly funded or provided and so the question of what healthcare systems should do is a matter of public policy. Given that public resources are inevitably limited, what should be done and who should benefit from healthcare? It is a dilemma for policymakers and a subject of debate within several disciplines, but rarely across disciplines. In this paper, I draw on thinking from several disciplines and especially philosophy, economics, and systems theory. I conclude (...) that economist and philosopher John Broome’s writing provides the framework for an answer: a healthcare system in a democracy should do as much good as possible, although sometimes we should sacrifice some overall good for the sake of fairness. This leaves open some detailed questions about what in practice we consider to be good and fair, and about when some good should be traded off in order to be fair. The answers to these questions depend on our values, or as explained by systems theory, our weltanschauung. How policy decisions should be made when citizens’ values differ is a subject of extensive academic debate. However, it is a separate question. Representative democracies have mechanisms for resolving such debates. (shrink)