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)

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)

Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the (...) fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications. (shrink)

Ruth Tallman has recently offered a defense of the modified youngest first principle of scarce resource allocation [1]. According to Tallman, this principle calls for prioritizing adolescents and young adults between 15–40 years of age. In this article, I argue that Tallman’s defense of the modified youngest first principle is vulnerable to important objections, and that it is thus unsuitable as a basis for allocating resources. Moreover, Tallman makes claims about the badness of death for individuals at different ages, but (...) she lacks an account of the loss involved in dying to support her claims. To fill this gap in Tallman’s account, I propose a view on the badness of death that I call ‘Deprivationism’. I argue that this view explains why death is bad for those who die, and that it has some advantages over Tallman’s complete lives view in the context of scarce resource allocation. Finally, I consider some objections to the relevance of Deprivationism to resource allocation, and offer my responses. (shrink)

In this stimulating work of political philosophy, acclaimed philosopher G. A. Cohen sets out to rescue the egalitarian thesis that in a society in which distributive justice prevails, peopleâes material prospects are roughly equal. Arguing against the Rawlsian version of a just society, Cohen demonstrates that distributive justice does not tolerate deep inequality. In the course of providing a deep and sophisticated critique of Rawlsâes theory of justice, Cohen demonstrates that questions of distributive justice arise not only for the state (...) but also for people in their daily lives. The right rules for the macro scale of public institutions and policies also apply, with suitable adjustments, to the micro level of individual decision-making. Cohen also charges Rawlsâes constructivism with systematically conflating the concept of justice with other concepts. Within the Rawlsian architectonic, justice is not distinguished either from other values or from optimal rules of social regulation. The elimination of those conflations brings justice closer to equality. (shrink)

Bioethicists often present ‘saving lives’ as a goal distinct from, and competing with, that of extending lives by as much as possible. I argue that this usage of the term is misleading, and provides unwarranted rhetorical support for neglecting the magnitudes of the harms and benefits at stake in medical allocation decisions, often to the detriment of the young. Equal concern for all persons requires weighting equal interests equally, but not all individuals have an equal interest in ‘life-saving’ treatment.

Rational justification of claims with empirical content calls for empirical and not only normative philosophical investigation. Empirical approaches to bioethics are epistemically valuable, i.e., such methods may be necessary in providing and verifying basic knowledge about cultural values and norms. Our assumptions in moral reasoning can be verified or corrected using these methods. Moral arguments can be initiated or adjudicated by data drawn from empirical investigation. One may argue that individualistic informed consent, for example, is not compatible with the Asian (...) communitarian orientation. But this normative claim uses an empirical assumption that may be contrary to the fact that some Asians do value and argue for informed consent. Is it necessary and factual to neatly characterize some cultures as individualistic and some as communitarian? Empirical investigation can provide a reasonable way to inform such generalizations. In a multi‐cultural context, such as in the Philippines, there is a need to investigate the nature of the local ethos before making any appeal to authenticity. Otherwise we may succumb to the same ethical imperialism we are trying hard to resist. Normative claims that involve empirical premises cannot be reasonably verified or evaluated without utilizing empirical methods along with philosophical reflection. The integration of empirical methods to the standard normative approach to moral reasoning should be reasonably guided by the epistemic demands of claims arising from cross‐cultural discourse in bioethics. (shrink)

In Intricate Ethics, Kamm questions the moral importance of some non-consequentialist distinctions and then introduces and argues for the moral importance of ...

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 study used fMRI to investigate the neural substrates of moral cognition in health resource allocation decision problems. In particular, it investigated the cognitive and emotional processes that underpin utilitarian approaches to health care rationing such as Quality Adjusted Life Years. Participants viewed hypothetical medical and nonmedical resource allocation scenarios which described equal or unequal allocation of resources to different groups. In addition, participants were assigned to 1 of 2 treatments in which they either did or did not receive advanced (...) instructions about the principles of utilitarianism. In all cases, participants were asked to judged the proposed allocations as “fair” or “unfair.” More brain activity was observed within the superior parietal lobe, angular gyrus, middle temporal gyrus, and bilateral caudate nucleus when participants viewed scenarios depicting equal divisions of resources. Conversely, unequal resource divisions were associated with more activity in the inferior frontal gyrus and insula cortex. Furthermore, instructions about the principles of utilitarianism led to significant activation differences within the inferior frontal gyrus and the middle frontal gyrus. Significant differences in activity were also found within the inferior frontal cortex and anterior insula between medical and nonmedical scenarios. The implications for cognitive control mechanisms and the cognitive and neural bases of utilitarian ethical judgment are discussed. (shrink)