The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

In this book Larry Temkin examines the concepts of equality and inequality, and addresses one particular question in depth: how can we judge between different sorts of inequality? When is one inequality worse than another? Temkin shows that there are many different factors underlying and influencing our egalitarian judgments and that the notion of inequality is surprisingly complex. He looks at inequality as applied to individuals and to groups, and at the standard measures of inequality employed by economists and others, (...) and considers whether inequality matters more in a poor society than a rich one. The arguments of non-egalitarians are also examined. Temkin's book presents a new way of thinking about equality and inequality which challenges the assumptions of philosophers, welfare economists, and others concerned with these notions on a practical as well as a theoretical level. (shrink)

In "Equality, Priority, and Compassion," Roger Crisp rejects both egalitarianism and prioritarianism. Crisp contends that our concern for those who are badly off is best accounted for by appealing to "a sufficiency principle" based -- indirectly, via the notion of an impartial spectator -- on compassion for those who are badly off" (p. 745). A key example of Crisp's is the Beverly Hills case (discussed below). This example is directed against prioritarianism, but it also threatens egalitarianism. In this article, I (...) respond to the Beverly Hills case. I also challenge the wide person-affecting principle and Crisp's welfarist restriction, which some believe underlie the Levelling Down Objection against egalitarianism. My aim in this article is to defend egalitarianism by illuminating both its nature and appeal. (shrink)

Objective: To provide an ethical analysis of whether the Ethiopian and Tanzanian national HIV/AIDS treatment guidelines can be considered legitimate and fair rationing tools.Method: Qualitative study and ethical analysis involving guideline documents and interviews with nine key members involved in the development of the guidelines. The analysis followed an editing organising style. The theoretical framework was a guideline-specific framework based on theories of just resource allocation in healthcare and conditions that ensure fair processes in guideline development. According to this framework, (...) legitimate rationing requires reasons for patient selection to be explicit, public and relevant, and decisions must be open to question and revision.Results: The only explicit rationing criteria that both guidelines recommended were clinical antiretroviral treatment indications. Explicit non-clinical rationing criteria were expressed in a separate Ethiopian implementation guideline. Neither of the guideline development processes fully satisfies minimal requirements of procedural fairness. There is a lack of transparency. The reasons for decisions are rarely given and are not publicly available. This reduces the opportunity for public questioning, debate and revisions. The guidelines were based on expert opinion and consensus. Recommendations from the WHO were copied without much discussion, disagreement or adjustment.Conclusions: The two national HIV treatment guidelines discussed are de facto mechanisms for rationing but were developed using methods that do not fully satisfy the requirements of fair processes. (shrink)

Next SectionBackground International and national agencies play a major role in setting HIV care-and-treatment priorities in low-income-countries. Little is known about priority setting at lower health-system levels. The objective of this article is to explore experiences of HIV priority decisions, at what levels these decisions are made and how they might influence the distribution of health benefits in a high-endemic region in Tanzania. Methods This is a qualitative study using observations, key documents and semistructured focus-group and individual interviews (43) with (...) health workers, patients and administrators at one regional and one district hospital. The analysis was based on an editing analysis style. Results Health workers did not perceive themselves as bedside rationing agents and they reported following national recommendations and felt they have little impact on important priority decisions. Health benefit distributions were largely determined by priority decisions made at a national level. External factors, such as eligibility criteria, inadequate funding and barriers to access seemed to play a major role in the actual distribution of health services and benefits in the region. Patient groups who were actually given high priority were the sickest patients, those living near a facility and those who could afford long journeys and frequent visits. Low-priority groups were those experiencing other co-morbidities or treatment failure, children, asymptomatic patients and the poorest. Conclusions/significance The interaction of priority setting across health-system levels and their impact on distribution of health outcomes in the population has been underestimated. The distributional pattern of health outcomes calls for further normative assessment. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

This is the text of The Lindley Lecture for 1996, given by T.M. Scanlon, an American philosopher.

Temkin presents a new way of thinking about equality and inequality that challenges the assumptions of philosophers, welfare economists, and others, and has significant implications on both a practical and theoretical level.