According to the widely accepted principles of beneficence and distributive justice, I argue that healthcare providers and facilities have an ethical duty to reduce the ecological footprint of the services they provide. I also address the question of whether the reductions in footprint need or should be patient-facing. I review Andrew Jameton and Jessica Pierce’s claim that achieving ecological sustainability in the healthcare sector requires rationing the treatment options offered to patients. I present a number of reasons to think that (...) we should not ration health care to achieve sufficient reductions in a society’s overall consumption of ecological goods. Moreover, given the complexities of ecological rationing, I argue that there are good reasons to think that the ethical duty to reduce the ecological footprint of health care should focus on only nonpatient-facing changes. I review a number of case studies of hospitals who have successfully retrofitted facilities to make them more efficient and reduced their resource and waste streams. (shrink)

After witnessing extraordinary scientific and regulatory efforts to speed development of and access to new COVID-19 interventions, patients facing other serious diseases have begun to ask “where’s...

BackgroundIn the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing.Main textThe distribution of scarce resources for testing: We emphasize the (...) use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society’s interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory.ConclusionIn summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing. (shrink)

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

The use of single-use items is now ubiquitous in medical practice. Because of the high costs of these items, the practice of reusing them after sterilisation is also widespread especially in resource-poor economies. However, the ethics of reusing disposable items remain unclear. There are several analogous conditions, which could shed light on the ethics of reuse of disposables. These include the use of restored kidney transplantation and the use of generic drugs etc. The ethical issues include the question of patient (...) safety and the possibility of infection. It is also important to understand the role of informed consent before reuse of disposables. The widespread practice of reuse may bring down high healthcare costs and also reduce the huge amount of hospital waste that is generated. The reuse of disposables can be justified on various grounds including the safety and the cost effectiveness of this practice. (shrink)

Waiting time is widely used in health and social policy to make resource allocation decisions, yet no general account of the moral significance of waiting time exists. We provide such an account. We argue that waiting time is not intrinsically morally significant, and that the first person in a queue for a resource does not ipso facto have a right to receive that resource first. However, waiting time can and sometimes should play a role in justifying allocation decisions. First, there (...) is a duty of fairness prohibiting line-cutting where a sufficiently just queue exists. Second, waiting time has several morally attractive features that can justify its incorporation into allocation schemes. Where candidates are in relevantly similar circumstances, allocating by waiting time is relatively efficient, maximizes distribution equality relative to other Pareto efficient distributions, and treats candidates fairly. The claim that allocation using waiting time is fair is controversial. Some have claimed that formal lotteries are a fairer way to select among equal beneficiaries. We argue that lotteries are no fairer than allocation based on waiting time when it is equiprobable how a prospective queue will be ordered. In practice, lotteries share many of the disadvantages of queues; which is fairer will depend on contingent features of the allocation scenario. The upshot is that first-come, first-served is in fact a just way to allocate resources in many of the cases where it seems pre-theoretically compelling, and waiting time has unique normative properties which frequently justify its incorporation into resource allocation schemes. (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)

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; (...) whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward. (shrink)

Patients have received experimental pharmaceuticals outside of clinical trials for decades. There are no industry-wide best practices, and many companies that have granted compassionate use, or ‘preapproval’, access to their investigational products have done so without fanfare and without divulging the process or grounds on which decisions were made. The number of compassionate use requests has increased over time. Driving the demand are new treatments for serious unmet medical needs; patient advocacy groups pressing for access to emerging treatments; internet platforms (...) enabling broad awareness of compelling cases or novel drugs and a lack of trust among some that the pharmaceutical industry and/or the FDA have patients’ best interests in mind. High-profile cases in the media have highlighted the gap between patient expectations for compassionate use and company utilisation of fair processes to adjudicate requests. With many pharmaceutical manufacturers, patient groups, healthcare providers and policy analysts unhappy with the inequities of the status quo, fairer and more ethical management of compassionate use requests was needed. This paper reports on a novel collaboration between a pharmaceutical company and an academic medical ethics department that led to the formation of the Compassionate Use Advisory Committee. Comprising medical experts, bioethicists and patient representatives, CompAC established an ethical framework for the allocation of a scarce investigational oncology agent to single patients requesting non-trial access. This is the first account of how the committee was formed and how it built an ethical framework and put it into practice. (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)

Approaches relying on fair procedures rather than substantive principles have been proposed for answering dilemmas in medical ethics and health policy. These dilemmas generally involve two questions: the epistemological (factual) question of which benefits an intervention will have, and the ethical (value) question of how to distribute those benefits. This article focuses on the potential of fair procedures to help address epistemological and factual questions in medicine, using the debate over antidepressant efficacy as a test case. In doing so, it (...) employs concepts from social epistemology such as testimonial injustice (bias resulting from the exclusion of evidence) and hermeneutical injustice (bias resulting from a prevailing discussion framework’s conceptual limitations). This article also explores the relevance of scientific consensus to determinations regarding medical evidence. (shrink)

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional rather than a residual system. They argue that the concept contradicts the idea of comprehensiveness; leads to unsustainable expenditures; is too indeterminate for policy; and supports only a prioritarian distribution. I argue that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and that UHC is a (...) solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy are not transparent about the source of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option. (shrink)

Critical-care decision making is highly complex, given the need for health care providers and organizations to consider, and constructively respond to, the diverse interests and perspectives of a variety of legitimate stakeholders. Insights derived from an identified set of ethics-related considerations have the potential to meaningfully inform inclusive and deliberative policy development that aims to optimally balance the competing obligations that arise in this challenging, clinical decision-making domain. A potential, constructive outcome of such policy engagement is the collaborative development of (...) an as-fair-as-possible dispute resolution process that incorporates an appropriated-justified, defensible critical-care obligation threshold. (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.

The purpose of this essay is to show how, on a wide variety of issues, Rabbi Moshe Feinstein broke new ground with the established Orthodox rabbinic consensus and blazed a new trail in Jewish medical ethics. Rabbi Feinstein took power away from the rabbis and let patients decide their treatment, he opened the door for a Jewish approach to palliative care, he supported the use of new technologies to aid in reproduction, he endorsed altruistic living organ donation and recognized brain (...) death (thus laying the groundwork for Orthodox Jewish acceptance of heart transplantation), he downplayed the value of social worth in triage decisions, and was a fierce defender of the rights of the fetus. I develop broader theological principles from Rabbi Feinstein's ethical positions and compare them to those of his Jewish and Christian contemporaries. (shrink)

Are there some newborn infants whose short- and long-term care costs are so great that treatment should not be provided and they should be allowed to die? Public discourse and academic debate about the ethics of newborn intensive care has often shied away from this question. There has been enough ink spilt over whether or when for the infant's sake it might be better not to provide life-saving treatment. The further question of not saving infants because of inadequate resources has (...) seemed too difficult, too controversial, or perhaps too outrageous to even consider. However, Roman Catholic ethicist Charles Camosy has recently challenged this, arguing that costs should be a primary consideration in decision-making in neonatal intensive care. In the first part of this paper I will outline and critique Camosy's central argument, which he calls the ‘social quality of life (sQOL)’ model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal ‘quality of life’ and Camosy's ‘sQOL’ should factor into these decisions, and I outline two practical proposals. (shrink)

In “Conceptions of Care,” Tove Pettersen discusses and articulates select ways in which care can be comprehended. Several difficulties related to an altruistic understanding of care are examined before the author presents the case for a more favorable concept: mature care. Mature care is intended to take into account the interests of both parties to the caring relationship. This understanding of care facilitates the expression of the relational and reciprocal aspects of caring while emphasizing the equal worth of all involved. (...) Also attended to is the embeddedness of care in wider cultural and political contexts. (shrink)

Introduction Hundreds of thousands of premature neonates born in low-income countries are implicitly denied treatment each year. Studies from India show that treatment is rationed even for neonates born at 32 gestational age weeks (GAW), and multiple external factors influence treatment decisions. Is withholding of life-saving treatment for children born between 28 and 32 GAW acceptable from an ethical perspective? Method A seven-step impartial ethical analysis, including outcome analysis of four accepted priority criteria: severity of disease, treatment effect, cost effectiveness (...) and evidence for neonates born at 28 and 32 GAW. Results The ethical analysis sketches out two possibilities: (a) It is not ethically permissible to limit treatment to neonates below 32 GAW when assigning high weight to health maximisation and overall health equality. Neonates below 32 GAW score high on severity of disease and efficiency and cost-effectiveness of treatment if one gives full weight to early years of a newborn life. It is in the child's best interest to be treated. (b) It can be considered ethically permissible if high weight is assigned to reducing inequality of welfare and maximising overall welfare and/or not granting full weight to early years of newborns is considered acceptable. From an equity-motivated health and welfare perspective, we would not accept (b), as it relies on accepting the lack of proper welfare policies for the poor and disabled in India. Conclusion Explicit priority processes in India for financing neonatal care are needed. If premature neonates are perceived as worth less than other patient groups, the reasons should be explored among a broad range of stakeholders. (shrink)

Building on work by Peterman, Aas, and Wasserman (2021), we modify their prospective benefit analysis to include only medically-relevant information about patients as persons without reference to their broader lives. Because patients (not their lives) must be treated equally, we argue that patients are the appropriate targets of allocative justification. We go on to challenge some of our current data-collection practices on this basis.

During the recent debates on whether to prioritize health care workers for COVID-19 vaccines, two main lines of arguments emerged: one centered on maximizing health and one centered on reciprocity. In this article, we scrutinize the argument from reciprocity. The notions of fittingness and proportionality are fundamental for the act of reciprocating. We consider the importance of these notions for various arguments from reciprocity, showing that the arguments are problematic. If there is a plausible argument for reciprocity during the pandemic, (...) this is most likely one that centers on the risk that health care workers take on while working. We argue that the scope of this argument is not plausibly extended only to health care workers. Other essential workers at risk are in the position to make the same arguments. We also argue that there is no compelling argument from reciprocity that makes reciprocating with vaccines, rather than by other means, necessary. Furthermore, allocating vaccines based on reciprocity will conflict with utility-maximizing. Given the weak state of the arguments, overriding concerns for utility seem unreasonable. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory of justice in (...) health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures to allocate scarce life-saving resources. In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims (...) to these resources rather than use RAND to allocate such resources. (shrink)

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving (...) the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

Volume 20, Issue 2, February 2020, Page 20-22.

Transplantation programs commonly rely on clinicians’ judgments about patients’ social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its (...) reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients’ personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation. (shrink)

This study aimed to determine if people would use social usefulness as a criterion when allocating a kidney to potential recipients. Participants ranked hypothetical patients in order of priority to receive the kidney, using only information on the patients’ volunteering record, intelligence, emotional intelligence, and attractiveness. The results showed that volunteers were prioritized over nonvolunteers, highly intelligent patients over those with average intelligence, patients with high emotional intelligence over those with average emotional intelligence, and good-looking patients over average-looking patients. There (...) was little evidence of personal favoritism. Implications and limitations are discussed. (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)

BackgroundResuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit, meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people regarding resource allocation decisions in the NICU.MethodsThe study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were (...) 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.ResultsThe majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival, life expectancy, and cost of treatment. In the classic ‘lifeboat’ scenario, all but two respondents were utilitarian.ConclusionsThis survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two (...) distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the types of (...) moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses’ moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care. (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)

In this paper, we point out that explainability is useful but not sufficient to ensure the legitimacy of algorithmic decision systems. We argue that the key requirements for high-stakes decision systems should be justifiability and contestability. We highlight the conceptual differences between explanations and justifications, provide dual definitions of justifications and contestations, and suggest different ways to operationalize justifiability and contestability.

Drawing on Ezekiel Emanuel’s controversial piece ‘Why I hope to die at 75,’ I distinguish two types of concern in ethical debates about extending the human lifespan. The first focusses on the value of living longer from prudential and social perspectives. The second type of concern, which has received less attention, focusses on the value of aiming for longer life. This distinction, which is overlooked in the ethical literature on life extension, is significant because there are features of human psychology (...) and the structure of a life that should give pause when considering how long one should aim to live, but which do not neatly coincide with considerations about how valuable additional life is likely to be. I argue that, while Emanuel’s case for hoping to die at 75 is unconvincing, he nonetheless provides weak pro tanto considerations in favour of taking a moderate life span as a prudential aim around which to base at least some significant life plans. (shrink)

In this Commentary, I propose an ethical framework for ethical discussions around the allocation of scarce resources in COVID-19 response. The framework incorporates four principles: beneficence (benefiting people by saving lives or years of life), equality, remedying disadvantage, and recognizing past conduct. I then discuss how the framework interacts with ethical constraints against using people as a mere means and against causing death. The commentary closes by criticizing the equation of deontological ethics with random or first-come, first-served allocation and of (...) allocation that aims to save more lives or years of life with utilitarianism.. (shrink)

Volume 20, Issue 3, March 2020, Page 65-68.

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)

Background: Existing ethical guidelines recommend that, all else equal, past receipt of a medical resource (e.g. a scarce organ) should not be considered in current allocation decisions (e.g. a repeat transplantation).DiscussionOne stated reason for this ethical consensus is that formal theories of ethics and justice do not persuasively accept or reject repeated access to the same medical resources. Another is that restricting attention to past receipt of a particular medical resource seems arbitrary: why couldn't one just as well, it is (...) argued, consider receipt of other goods such as income or education? In consequence, simple allocation by lottery or first-come-first-served without consideration of any past receipt is thought to best afford equal opportunity, conditional on equal medical need. There are three issues with this view that need to be addressed. First, public views and patient preferences are less ambiguous than formal theories of ethics. Empirical work shows strong preferences for fairness in health care that have not been taken into account: repeated accessto resources has been perceived as unfair. Second, while difficult to consider receipt of many other prior resources including non-medical resources, this should not be used a motive for ignoring the receipt of any and all goods including the focal resource in question. Third, when all claimants to a scarce resource are equally deserving, then use of random allocation seems warranted. However, the converse is not true: mere use of a randomizer does not by itself make the merits of all claimants equal.SummaryMy conclusion is that not ignoring prior receipt of the same medical resource, and prioritizing those who have not previously had access to the medical resource in question, may be perceived as fairer and more equitable by society. (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)

The American Journal of Bioethics, Volume 11, Issue 12, Page 46-47, December 2011.

During the first wave of the COVID-19 pandemic in Italy, practitioners had to make tragic decisions regarding the allocation of scarce resources in the ICU. The Italian debate has paid a lot of attention to identifying the specific regulatory criteria for the allocation of resources in the ICU; in this paper, however, we argue that deciding such criteria is not enough for the implementation of fair and transparent allocative decisions. In this respect, we discuss three ethical issues: (a) in the (...) Italian context, the treating physician, rather than a separate committee, was generally the one responsible for the allocation decision; (b) although many allocative guidelines have supported moral equivalence between withholding and withdrawing treatments, some health professionals have continued to consider it a morally problematic aspect; and (c) the health workers who have had to make the aforementioned decisions or even only worked in ICU during the pandemic often experienced moral distress. We conclude by arguing that, even if these problems are not directly related to the above-mentioned issues of distributive justice, they can nevertheless directly affect the quality and ethics of the implementation of allocative criteria, regardless of those chosen. (shrink)

We present the perspective of a Bioethics Consultation Service operating in an urban hospital in Dayton, Ohio, USA, as it adapted to treating Sars-CoV-2 patients throughout 2020. Since the first case of COVID-19 was reported in Ohio on 9 March 2020, until 1 January 2021, the Bioethics Consultation Service was consulted 60 times, a 22.5% increase from the same period of 2019. The most common diagnoses requiring consultation included end-stage renal disease requiring dialysis, out-of-hospital cardiac arrest, and sepsis. Only 10% (...) of consultations were for patients hospitalized with COVID-19. This is a qualitative analysis of the cases we saw and a discussion of factors that affected our service while adapting to COVID-19 standards of care. (shrink)

The current public health crisis has exposed deep cracks in social equality and justice for marginalised and vulnerable communities around the world. The reported rise in the number of ‘do not resuscitate’ orders being imposed on people with disabilities has caused particular concerns from a human rights perspective. While the evidence of this is contested, this article will consider the human rights implications at stake and the dangers associated with using ‘quality of life’ measures as determinant of care in medical (...) decision-making and triage assessments. (shrink)

In a crisis, societal needs take precedence over a patient’s best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. (...) But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When “triaging” or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was (...) 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

Medical resource allocation is a controversial topic, because in the end it prioritises some peoples’ medical problems over those of others. This is less controversial when there is a clear clinical reason for such a prioritisation, but when such a reason is not available people might perceive it as deeming certain individuals more important than others. This article looks at the role of social utility in medical resource allocation, in a situation where the clinical outcome would be identical if either (...) person received the treatment. This situation is explored with a focus on the United Kingdom, but its conclusions have wider applications to any system where healthcare is tax-payer funded. The article proposes an experience adjusted life years system, and discusses its strengths and weaknesses. (shrink)