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)

A survey of various candidates shows that there is no defensible moral principle that shows that individuals have an obligation to reduce their greenhouse gas emissions.

Several philosophers claim that the greenhouse gas emissions from actions like a Sunday drive are so miniscule that they will make no difference whatsoever with regard to anthropogenic global climate change (AGCC) and its expected harms. This paper argues that this claim of individual causal inefficacy is false. First, if AGCC is not reducible at least in part to ordinary actions, then the cause would have to be a metaphysically odd emergent entity. Second, a plausible (dis-)utility calculation reveals that such (...) actions have a not-insignificant amount of expected harm. One upshot is that the near-exclusive focus in the literature on AGCC as a collective action problem is too restricted. The paper also provides several moral psychological explanations of why it is so difficult to comprehend individual responsibility with regard to global phenomena, including a reappraisal of Thomas Nagel’s view of the absurd. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

When people use a resource without a co-ordinated plan the result is often a tragedy of the commons in which the resource is depleted. Many environmental resources display the characteristics of a developing tragedy of the commons. Many believe that each person is ethically obligated to reduce use of the commons to the sustainable level. I argue that this is mistaken. In a tragedy of the commons there is no reasonable expectation that individual, voluntary action will succeed. Our obligation is (...) not fruitlessly to reduce individual use, but to support a collective agreement to reduce everyone's use to the sustainable level. (shrink)

Very few moral philosophers have written on climate change.1 This is puzzling, for several reasons. First, many politicians and policy makers claim that climate change is not only the most serious environmental problem currently facing the world, but also one of the most important international problems per se.2 Second, many of those working in other disciplines describe climate change as fundamentally an ethical issue.3.

Walter Sinnott-Armstrong argues, on the relationship between individual emissions and climate change, that “we cannot claim to know that it is morally wrong to drive a gas guzzler just for fun” or engage in other inessential emissions-producing individual activities. His concern is not uncertainty about the phenomenon of climate change, nor about human contribution to it. Rather, on Sinnott-Armstrong’s analysis the claim of individual moral responsibility for emissions must be grounded in a defensible moral principle, yet no principle withstands scrutiny. (...) I argue thatthe moral significance of individual emissions is obscured by this critique. I offer a moral principle, the threshold-contribution principle, capable of withstanding Sinnott-Armstrong’s criticisms while also plausibly explaining what’s wrong with gas-guzzling joyrides and other gratuitous emissions-producing individual acts. (shrink)

In this paper, I explore one way to bring bioethics and environmental ethics closer together. I focus on a question at the interface of health, sustainability, and justice: How well does a society promote health with the use of no more than a just share of environmental capacity? To address this question, I propose and discuss a mode of assessment that combines a measurement of population health, an estimate of environmental sustainability, and an assumption about what constitutes a fair or (...) just share. This mode of assessment provides an estimate of the just and sustainable life expectancy of a population. It could be used to monitor how well a particular society promotes health within just environmental limits. It could also serve as a source of information that stakeholders use when they deliberate about programs, policies, and technologies. The purpose of this work is to focus attention on an ethical task: the need to fashion institutions and forms of life that promote health in ways that recognize the claims of sustainability and justice. (shrink)

This book shows how environmental decline relates to human health and to health care practices in the U.S. and other industrialized countries. It outlines the environmental trends that will strongly affect health, and challenges us to see the connections between ways of practicing medicine and the very environmental problems that damage ecosystems and make people sick. In addition to philosophical analysis of the converging values of bioethics and envrionmental ethics, the book offers case studies as well as a number of (...) practical suggestions for moving health care toward sustainability. (shrink)

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians’ perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell (...) under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians’ rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources. (shrink)

In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the (...) concept is in making ethical decisions about starting or stopping treatment. (shrink)

American doctors in the 1990s are being asked to serve as "double agents," weighing competing allegiances to patients' medical needs against the monetary costs to society. This situation is a reaction to rapid cost increases for medical services, themselves the result of the haphazard development since the 1920s of an inherently inflationary, open-ended system for funding and delivering health care. The answer to an inefficient system, however, is not to stint on care, but rather to restructure the system to remove (...) the inflationary pressures. As long as we are spending enormous resources on an inherently inefficient and inflationary system we cannot justify asking doctors to withhold beneficial care to save money for third-party payers. Doing so serves a largely political agenda and endangers the patient-centered ethic that is central to medicine. (shrink)

Physicians have an ethical responsibility to their patients to offer the best available medical care. This responsibility conflicts with their role as gatekeepers of the limited health care resources available for all patients collectively. It is ethically untenable to expect doctors to face this trade-off during each patient encounter; the physician cannot be expected to compromise the wellbeing of the patient in the office in favour of anonymous patients elsewhere. Hence, as in other domains of public policy where individual and (...) collective interests conflict, some form of collective solution is required. Collective solutions may take the form of placing explicit resource constraints on resources available to physicians, or clinical practice guidelines that recognise cost-effective care as acceptable. Such solutions will be politically and ethically sustainable only if patients as citizens of the larger population accept the need for rationing of limited resources in health care. (shrink)