This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.

Casuistry and principlism are two of the leading contenders to be considered the methodology of bioethics. These methods may be incommensurable since the former emphasizes the examination of cases while the latter focuses on moral principles. Conversely, since both analyze cases in terms of mid-level principles, there is hope that these methods may be reconcilable or complementary. I analyze the role of principles in each and thereby show that these theories are virtually identical when interpreted in a certain light. That (...) is, if the gaps in each method are filled by a concept of judgment or Aristotelian practical wisdom, these methods converge. (shrink)

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five (...) distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

There are some ideas that at first seem simple, but which become more complex and profound the more they are explored. Great art, of course, is like that. When I first saw Vermeer's Girl with a Pearl Earring I was excited by its fresh simplicity. I thought, however, it a painting I would soon understand. I was wrong. It becomes increasingly mysterious with increasing familiarity. It has recently inspired a novel.1The distinction between acts and omissions is one of these simple, (...) complex, ideas. When I first studied philosophy I thought I would rapidly be able to decide once and for all whether the distinction is of moral importance or not. I did in fact come to a decision. The problem is that I have kept revising that decision ever since. The issues raised by the arguments over acts and omissions continue to inspire philosophical discussion. They also continue to haunt doctors and relatives at the bedsides of those near the end of their lives.Donna Dickenson, in this issue of the journal,2 reports the results of a survey of opinions from those taking part in an Open University course on death and dying. She believes that for many bioethicists the acts/omissions distinction has been shown to be wrong as a distinction of moral worth. Her survey suggests, however, that for many health professionals this distinction is seen as morally important. She asks whether the bioethical consensus, as she sees it, against the distinction is a result of clear thinking, or whether the views of practitioners result from their taking into account, in a way bioethicists do not, the richness of reality.There is I believe, less consensus amongst bioethicists than Dickenson suggests. In this issue of the journal, Marc Stauch3 argues in favour of the acts/omissions …. (shrink)