In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the “Rule of Rescue”). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue (...) in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others. (shrink)

The National Institute for Health and Care Excellence, the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies programme. It argues that although NICE in all likelihood does not act because (...) of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker. (shrink)

This essay considers whether permitting the cost-effectiveness of healthcare to govern its allocation is ethically objectionable on the grounds that it fails to give sufficient weight to the severity of people’s health states. After documenting the popular sentiment that appears to support this criticism, the essay considers how to implement prioritising severity, focusing on Erik Nord’s work. The remainder of the essay scrutinises the ethical arguments supporting policies prioritising severity and challenges those who would prioritise severity to define a notion (...) of severity whose prioritisation they can defend. (shrink)

Thirty years of debate have passed since the term “Rule of Rescue” has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It (...) has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one’s fellow creatures. The present article argues against both objections. It suggests that the debate’s focus on consequences should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being (...) worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity). (shrink)

After surveying and criticizing some earlier definitions of "disease", we propose that a general term--malady--be used to represent what all diseases, illnesses, injuries, etc., have in common. We define a malady as the suffering, or increased risk of suffering an evil in the absence of a distinct sustaining cause. We discuss the key terms in the definition: evil, distinct sustaining cause, and increased risk. We show that the role of abnormality is to clarify these terms rather than to be used (...) directly in the definition of malady. (shrink)