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)

There are three broad ethical issues related to handling public health emergencies. They are the three R's - rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough estimates. What ethical (...) principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

Financing innovative and costly treatments in various therapeutic fields entails a number of problems in countries where costs are covered by public services. Providing these drugs is forcing actors to define the maximum sums of money society is willing to spend for given health improvements. This raises the question of whether maximum financing should vary according individuals’ circumstances, such as the rareness of a disease, lifestyles, social inequalities experienced over a life time, etc. This article examines a particular priority, namely (...) that given to the youngest patients, such prioritising usually refers to the “fair innings argument”. We question what could justify such a prioritization criterion. Three arguments are considered. At first we consider that FIA could be justified by the objective of equalizing the opportunities of well-being. Next, we proposed justifying the fair innings argument with the aim of equalizing the time provided to individuals to achieve their plan of life, in accordance with Rawls’s theory of justice as fairness. Finally, we proposed considering the FIA as being justified because of the goal of equalizing the time provided to individuals to accept death. These three arguments, of course, have many limitations, some of which we have highlighted. This article doesn’t aim to convince about the superiority of one argument over the other ones. We seek to contribute to the discussions which could happen on prioritization criteria regarding health care, by making explicit what could justify one specific criterion: the age criterion. (shrink)

BackgroundIn precision medicine biomarkers stratify patients into groups that are offered different treatments, but this may conflict with the principle of equal treatment. While some patient characteristics are seen as relevant for unequal treatment and others not, it is known that they all may influence treatment decisions. How biomarkers influence these decisions is not known, nor is their ethical relevance well discussed.MethodsWe distributed an email survey designed to elicit treatment preferences from Norwegian doctors working with cancer patients. In a forced-choice (...) conjoint analysis pairs of hypothetical patients were presented, and we calculated the average marginal component effect of seven individual patient characteristics, to estimate how each of them influence doctors’ priority-setting decisions.ResultsA positive biomarker status increased the probability of being allocated the new drug, while older age, severe comorbidity and reduced physical function reduced the probability. Importantly, sex, education level and smoking status had no significant influence on the decision.ConclusionBiomarker status is perceived as relevant for priority setting decisions, alongside more well-known patient characteristics like age, physical function and comorbidity. Based on our results, we discuss a framework that can help clarify whether biomarker status should be seen as an ethically acceptable factor for providing unequal treatment to patients with the same disease. (shrink)

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)

We review methods for economic evaluation recently developed in health economics by focusing on the epistemic and non-epistemic values they embody. The emphasis is on insights into valuing health,...

The aim of this study was to describe the reasoning of people aged 60 years and over about prioritization in health care with regard to age and willingness to pay. Healthy people (n = 300) and people receiving continuous care and services (n = 146) who were between 60 and 101 years old were interviewed about their views on prioritization in health care. The transcribed interviews were analysed using manifest and latent qualitative content analysis. The participants' reasoning on prioritization embraced (...) eight categories: feeling secure and confident in the health care system; being old means low priority; prioritization causes worries; using underhand means in order to be prioritized; prioritization as a necessity; being averse to anyone having precedence over others; having doubts about the distribution of resources; and buying treatment requires wealth. (shrink)