Though the revised edition of A Theory of Justice, published in 1999, is the definitive statement of Rawls's view, so much of the extensive literature on Rawls's theory refers to the first edition. This reissue makes the first edition once again available for scholars and serious students of Rawls's work.

This essay seeks to characterise the essential features of an equitable health care system in terms of the classical Aristotelian concepts of horizontal and vertical equity, the common language of “need” and the economic notion of cost-effectiveness as a prelude to identifying some of the more important issues of value that policy-makers will have to decide for themselves; the characteristics of health that can cause policy to be ineffective ; the information base that is required to support a policy directed (...) at securing greater equity, and the kinds of research that are needed to underpin such a policy. (shrink)

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care (...) left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. (shrink)

Background:Previous research has linked missed nursing care to nurses’ work environment. Ethical climate is a part of work environment, but the relationship of missed care to different types of ethical climate is unknown.Research objectives:To describe the types of ethical climate in adult in-patient cancer care settings, and their relationship to missed nursing care.Research design:A descriptive correlation design was used. Data were collected using the Ethical Climate Questionnaire and the MISSCARE survey tool, and analyzed with descriptive statistics, Pearson’s correlation and analysis (...) of variance.Participants and research context:All nurses from relevant units in the Republic of Cyprus were invited to participate.Ethical considerations:The research protocol has been approved according to national legislation, all licenses have been obtained, and respondents participated voluntarily after they have received all necessary information.Findings:Response rate was 91.8%. Five types identified were as follows: caring ; law and code ; rules ; instrumental ; and independence. Reported overall missed care was M = 2.51, and this was positively related to instrumental and independence types and negatively related to caring, rules, and law and code.Discussion:The reported levels of missed care and the types of ethical climates present similarities and differences with the relevant literature. All types of ethical climate were related to the reported missed care.Conclusion:Efforts to reduce the influence of instrumental and independence types and fostering caring, law and code, and rules types might decrease missed nursing care. However, more robust evidence is needed. (shrink)

Although most theorists of healthcare rationing argue that rationing, including rationing that takes place in the physician–patient relationship is unavoidable, some health professionals strongly disagree. In a recent essay, Vegard Bruun Wyller argues that bedside rationing is immoral and thoroughly at odds with a sound view of the physician–patient relationship. We take Wyller to be an articulate exponent of the reluctance to participate in rationing found among some clinicians. Our essay attempts to refute the five crucial premises of his argument (...) yet build on his genuine insights. In our analysis, Wyller’s critique of bedside rationing is instructive both for harbouring some very common misconceptions that must be exposed and refuted, but also for offering important words of caution. In particular, bedside rationing must be performed in ways that do not harm the physician–patient relationship. Read irenically, Wyller’s critique is a reminder of what must not be lost in our painful endeavour to update the ethics of medicine to encompass the unavoidability of rationing. (shrink)

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of prioritisation of the resources (...) available for healthcare or of rationing such resources must be governed by this principle. -/- This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational ‘reasons based consequentialism’ is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended. (shrink)