Enormous gaps between HIV burden and health care availability in low-income countries raise severe ethical problems. This article analyzes four HIV-priority dilemmas with interest across contexts and health systems. We explore principled distributive conflicts and use the Atkinson index to make explicit trade-offs between health maximization and equality in health. We find that societies need a relatively low aversion to inequality to favor treatment for children, even with large weights assigned to extending the lives of adults: higher inequality aversion is (...) needed to share resources equally between high-cost and low-cost treatment; higher inequality aversion is needed to favor treatment rather than prevention, and the highest inequality aversion is needed to favor sharing treatment between urban and rural regions rather than urban provision of treatment. This type of ethical sensitivity analysis may clarify the ethics of health policy choice. (shrink)

Kerstein and Bognar (2010) and Persad, Wertheimer, and Emanuel (2009) defend specific principles for the allocation of health care resources, but their choice of principles is influenced by the exa...

This chapter examines how social- scientific research on public preferences bears on the ethical question of how those resources should in fact be allocated, and explain how social-scientific researchers might find an understanding of work in ethics useful as they design mechanisms for data collection and analysis. I proceed by first distinguishing the methodologies of social science and ethics. I then provide an overview of different approaches to the ethics of allocating scarce medical interventions, including an approach—the complete lives system—which (...) I have previously defended, and a brief recap of social-scientific research on the allocation of scarce medical resources. Following these overviews, I examine different ways in which public preferences could matter to the ethics of allocation. Last, I suggest some ways in which social scientists could learn from ethics as they conduct research into public preferences regarding the allocation of scarce medical resources. (shrink)

One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’s complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persadet alargue that their system is the product of a successful process of reflective equilibrium—a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we (...) achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persadet alhave failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persadet al’s investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives. (shrink)

In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity is absolute and ongoing; and argue that (...) Kerstein and Bognar are mistaken to base their allocation principles on differences in personhood. (shrink)

This article provides a critical appraisal of the case for healthcare being rationed away from older patients to those who are younger. After sketching a metaphysics of elderliness and reviewing clinical and economic cases for healthcare rationing, the article looks in depth at the most challenging case for age rationing known as the ‘fair innings’ case. This article rejects that case and makes an alternative case that fairness actually dictates against age rationing in favour of allocation on the basis of (...) need. It concludes with a call for a renewed ‘covenant between generations’, founded on the virtue of pietas. (shrink)

Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. In this (...) article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: maximising life-years per personnel time, youngest and robust first, sickest first, first come/first served and instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system. (shrink)

Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being (...) equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. (shrink)

Ruth Tallman has recently offered a defense of the modified youngest first principle of scarce resource allocation [1]. According to Tallman, this principle calls for prioritizing adolescents and young adults between 15–40 years of age. In this article, I argue that Tallman’s defense of the modified youngest first principle is vulnerable to important objections, and that it is thus unsuitable as a basis for allocating resources. Moreover, Tallman makes claims about the badness of death for individuals at different ages, but (...) she lacks an account of the loss involved in dying to support her claims. To fill this gap in Tallman’s account, I propose a view on the badness of death that I call ‘Deprivationism’. I argue that this view explains why death is bad for those who die, and that it has some advantages over Tallman’s complete lives view in the context of scarce resource allocation. Finally, I consider some objections to the relevance of Deprivationism to resource allocation, and offer my responses. (shrink)

PURPOSE: The purpose of this paper is to consider some of the philosophical and bioethical issues raised by the creation of the draft social values framework developed to facilitate data collection and country-specific presentations at the inaugural workshop on "Social values and health priority setting" held in February 2011. -/- DESIGN/METHODOLOGY/APPROACH: Conceptual analysis is used to analyse the term "social values", as employed in the framework, and its relationship to related ideas such as moral values. The structure of the framework (...) (process and content values) is considered in light of current debate in philosophy and bioethics about the political and moral aims served by these kinds of values, and the extent to which they are either suited to, or sufficient for, the policy context. -/- FINDINGS: There is much to be gained by engaging with the arguments presented in the philosophical literature in order to further refine the framework. The framework should remain neutral in respect of the importance of procedural values in different contexts and should be as inclusive as possible in respect of the principles it includes. Further development would be best served by taking a multidisciplinary approach. The framework could provide a valuable space in which future debates about procedural/substantive values can be considered. -/- ORIGINALITY/VALUE: The paper brings philosophical and bioethics perspectives to bear on a new framework proposed for the analysis of social values in health priority setting. It identifies how such a practical, policy-focused framework might be informed by engagement with deeper, and often unresolved, questions or principle around resource allocation in health. (shrink)