Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is (...) a clear and much-needed introduction to this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

This volume explains why, and in what ways, health care is being rationed in the late-1990s health service. It examines the ethical questions which arise from this rationing and includes personal case studies, from surgeons to geriatric advisors.

The purpose of this article is to re-visit how rationing is defined for a health-care context, Two reasons justify returning to this topic. First, the variability as to how rationing has been defined in the legal, medical, and philosophical literature justifies a careful examination to identify its critical features. Second, I believe that if the definitions typically employed in the literature, several of which are discussed below, are compared to those that would be offered by the American (...) public, ethically weighty dissimilarities would be apparent. Disparate characterizations are worrisome because serious “disconnections” between policymakers’ understandings, rhetoric, and priorities and those of the general public are more likely. (shrink)

The purpose of this article is to re-visit how rationing is defined for a health-care context, Two reasons justify returning to this topic. First, the variability as to how rationing has been defined in the legal, medical, and philosophical literature justifies a careful examination to identify its critical features. Second, I believe that if the definitions typically employed in the literature, several of which are discussed below, are compared to those that would be offered by the American (...) public, ethically weighty dissimilarities would be apparent. Disparate characterizations are worrisome because serious “disconnections” between policymakers’ understandings, rhetoric, and priorities and those of the general public are more likely. (shrink)

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at (...) present, but it is mostly hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

Americans' appetite for life-prolonging therapies has led to unsustainable growth in health care costs. It is tempting to target older people for health care rationing based on their disproportionate use of health care resources and lifespan already lived, but aged-based rationing is unacceptable to many. Systems reforms can improve the efficiency of health care and may lessen pressure to ration services, but difficult choices still must be made to limit expensive, marginally beneficial interventions. In (...) the absence of agreement on principles to govern health care resource allocation, a fair, open priority-setting process should be created to allow for reasonable disagreement on principles while being seen as legitimate by all stakeholders. At the patient-care level, careful discussions about the benefits and burdens of medical intervention and support for slow medicine — a gentle, family-centered care approach for frail elders — can do much to avoid harming these patients with aggressive yet unwanted medical care while reducing wasteful spending. (shrink)

Mr. M. was a 77-year-old decisionally incapacitated long-term nursing home resident with chronic schizophrenia who was admitted to the hospital with a bacterial pneumonia. His past medical history was notable for deteriorating functional status over the past 2-3 years, urinary retention requiring chronic indwelling bladder catheterization, and two recent hospitalizations for urinary tract infections leading to sepsis. He developed respiratory failure soon after admission and was intubated and placed on mechanical ventilation. Follow-up studies suggested worsening pneumonia and acute respiratory distress (...) syndrome, as well as worsening kidney function. (shrink)

Background:In the face of scarcity, nurses may inevitably delay or omit some nursing interventions and give priority to others. This increases the risk of adverse patient outcomes and threatens safety, quality, and dignity in care. However, it is not clear if there is an ethical element in nursing care rationing and how nurses experience the phenomenon in its ethical perspective.Objectives:The purpose was to synthesize studies that relate care rationing with the ethical perspectives of nursing, and (...) find the deeper, moral meaning of this phenomenon.Research design:A systematic review and thematic synthesis of qualitative studies was used. Searching was based on guidelines suggested by Joana Brigs Institute, while the synthesis has drawn from the methodology described. Primary studies were sought from nine electronic databases and manual searches. The explicitness of reporting was assed using consolidated criteria for reporting qualitative research. Nine studies involving 167 nurse participants were included. Synthesis resulted in 35 preliminary themes, 14 descriptive themes, and four analytical themes. Discussion of relationships between themes revealed a new thematic framework.Ethical consideration:Every effort has been taken, for the thoroughness in searching and retrieving the primary studies of this synthesis, and in order for them to be treated accurately, fairly and honestly and without intentional misinterpretations of their findings.Discussion:Within limitations of scarcity, nurses face moral challenges and their decisions may jeopardize professional values, leading to role conflict, feelings of guilt, distress and difficulty in fulfilling a morally acceptable role. However, more research is needed to support certain relationships.Conclusions:Related literature is limited. The few studies found highlighted the essence of justice, equality in care and in values when prioritizing care—with little support to the ethical effects of rationing on nurses. Further research on ethical dimension of care rationing may illuminate other important aspects of this phenomenon. (shrink)

What does it mean to be a “just” and “caring” society in meeting the health care needs of the terminally ill when we have only limited resources to meet virtually unlimited health care needs? That question is the focus of this essay. Put another way: relative to all the other health care needs in our society, especially the need for lifesaving or life-prolonging health care, how high a priority ought the health care needs of persons (...) who are terminally ill have? On the one hand, we might see the terminally ill as being among the “medically least well off” and therefore deserving very high priority. On the other hand, we might see them as squandering vast medical resources for marginal medical benefits, thereby denying needed resources to others who would benefit much more. We begin the essay by making a number of morally relevant distinctions with regard to the category of “being terminally ill.” We note, given contemporary medicine, that individuals may be terminally ill several times in the course of a life. Not all such circumstances make equal just claims to needed health care. We also note that our conceptions of health care justice are ultimately incapable of making very fine-grained, morally justified rationing judgments in complex medical circumstances. We conclude that we must finally rely upon fair processes of rational democratic deliberation to articulate such judgments for our own future, possibly terminally ill selves, thereby undercutting the rhetoric of “death panels.”. (shrink)

In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. But there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted.Is health care rationing passé? I contend that debates about health care rationing have waned not because the need to (...) ration has dwindled nor because ethical debates about how or whether to ration have been resolved. They have declined because the word “rationing,” and unrelated concepts such as cost‐effectiveness analysis, have been replaced by terms—“parsimony,” “value,” and “CER”—that are not burdened by emotional and historical baggage.Sometimes the best way to promote healthy moral debate is to turn to new words that don't carry the burden of past debates. (shrink)

I agree with Professor ter Meulen that there is no need to make a forced choice between “justice” and “solidarity” when it comes to determining what should count as fair access to needed health care. But he also asserts that solidarity is more fundamental than justice. That claim needs critical assessment. Ter Meulen recognizes that the concept of solidarity has been criticized for being excessively vague. He addresses this criticism by introducing the more precise notion of “humanitarian solidarity.” However, (...) I argue that these notions are still not precise enough and are in need of behavioral translation, especially in relation to the problem of fair health care rationing. More specifically, I argue that translation ought to take the form of a well-ordered process of rational democratic deliberation, which I describe and defend in this essay. Such a process is what is required to construct a working model of just solidarity as opposed to a merely abstract idealization of just solidarity. (shrink)

What does it mean to be a “just” and “caring” society in meeting the health care needs of the terminally ill when we have only limited resources to meet virtually unlimited health care needs? This is the question that will be the focus of this essay. Another way of asking our question would be the following: Relative to all the other health care needs in our society, especially the need for lifesaving or life-prolonging health care, how (...) high a priority ought the health care needs of persons who are terminally ill have? Should any of the health care needs of the terminally ill be assigned very low priority? Or should all their health care needs be assigned the highest priority? If we reflect a bit, we will find ourselves greatly internally conflicted. On the one hand, the “caring” side of our moral self might see terminally ill individuals as being among the “medically least well off,” and therefore, deserving virtually any medical resources that will yield any degree of good for them. (shrink)

This paper compares and contrasts three different substantive principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of (...) class='Hi'>rationing principle. In conclusion, it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions. (shrink)

The concept of equality is subject to many different interpretations, and it is closely connected to similar concepts such as equity, justice, fairness, and human rights. As an ideal, equality entails many aspects that are untenable. For instance, genetic and social inequalities may never be extinct, but they can both be ameliorated by proper distribution of society's resources. Likewise, within the context of health care, equality can be promoted by proper rationing of health resources, amongst which nursing (...) class='Hi'>care stands out. In the field of nursing, the principle of equality presents itself in various forms of ethical and deontological mandates. However, beyond good intentions and abstract notions, there is a need to examine the ways in which nurses enforce this principle in practice, within the reality of modern health systems. Although there is scarcity of qualitative evidence in the nursing care rationing literature, existing studies suggest that fair treatment pertains to a largely intuitive sense of equality which involves subjective perceptions and judgements about rationing. Nurses’ initial predisposition is to view all patients as equal and treat them in an equal manner; yet, on an individual basis, each patient has a different starting point, different needs and different prospects that render rationing decisions complex and uncertain. Equality should be accepted with its unavoidable limitations in practice and be further examined within the context of nursing care rationing, in the hope that it can be advanced in a consistent way, despite the idealistic nature in many of its aspects. (shrink)

One of the most controversial issues in many health care systems is health care rationing. In essence, rationing refers to the denial of - or delay in - access to scarce goods and services in health care, despite the existence of medical need. Scarcity of financial and medical resources confronts society with painful questions. Who should decide which medicine or new treatment will be covered by social security and on which criteria such decisions must be (...) based? Can age, for example, be justified as a selection criterion? Should decision-making be left to health care policymakers, hospital administrators, or rather, to treating physicians? And finally: is there a role for individual patients? These are difficult questions that suggest the need for transparent and democratic decision-making. In reality, however, the rationing debate occurs in a sub rosa world, based on imperfect information, distorted interpretations of effectiveness, and hidden cost concerns. This book explores these and other questions from various perspectives. Each of the book's contributors analyzes the debate from a different angle, in search of fair and just rationing decisions. (shrink)

In health care systems where access to resources is limited, priorities must be set. The Canadian health care system relies on physicians as clinical or micro-level gatekeepers to health care access. Several studies have indicated that physicians do not tend to consider distributive justice concerns when making clinical-level resource allocation decisions. This is concerning, given that the normative literature on micro-level rationing has featured justice considerations as a necessary condition for fair decision-making. I will first discuss (...) the basics of bedside rationing and some studies which identify a possible justice “value deficit.” I will then analyze the relevant normative frameworks in the rationing literature to identify if and where decision-making may be falling short. Finally, I will use Beauchamp and Childress’ fifth and sixth editions of Principles of Biomedical Ethics to examine whether justice in micro-level rationing is best conceptualized as a principle or a virtue. (shrink)

Bioethicists are increasingly commenting on health care resource allocation, and sometimes suggest ways to solve various rationing dilemmas ethically. I argue that both because of the assumptions bioethicists make about social reality, and because of the methods of argument they use, they cannot possibly make a useful contribution to the debate. Bioethicists who want to make a practical difference should either approach health care resource allocation as if the matter hinged upon tribal competition (which is essentially what (...) it does), or they should do political philosophy in the traditional sense, and examine the health system from the outside. (shrink)

My assigned task in today’s colloquium is to review philosophers’ perspectives on the broad question of whether health care rationing ought to target the elderly. This is a revolutionary question, particularly in a society that is so sensitive to apparent discrimination, and the question must be approached carefully if it is to be successfully dealt with. Three subordinate questions attend this one and must be addressed in the course of answering it. The first such question has to do (...) with the issue of justice: how is it fair to target the elderly in achieving reductions in health care costs? Isn’t the proposal, or for that matter, isn’t targeting any age group, morally objectionable as a species of ageism, just as targeting members of a particular race or sex would be racist or sexist? The second subordinate question has to do with the issue of fittingness. Given that we can show in some way that targeting the elderly is not inherently unjust, why would limiting health care to them be a fitting thing for medicine to do? How would it fit, for example, with the traditional commitments of medicine, to sustain life, to relieve suffering, to heal and cure and restore function? And in particular, if medicine has the ability to save and relieve and restore the elderly, why should it replace that set of commitments with a different set for this particular population? The third subordinate question seems political, an arena reserved for one of my speaker colleagues today. There are, I believe, some underlying philosophical dimensions to its answer, and so I will say something about it. The philosophical/political questions is, Given that rationing health care to the elderly is not patently unjust, and given that a case can be made out that the ends of medicine are not violated by such limitation, shy should the elderly, as a group, assent to such a limitation? I want to address these subordinate questions, for I believe them to be the chief stumbling blocks for the possibility of an affirmative answer to our... (shrink)

: Bioethical discussion of justice in health care has been much enlivened in recent years by new developments in the theory of rationing and by the emergence of a strong communitarian voice. Unfortunately, these developments have not enjoyed much in the way of close engagement with feminist-inspired reflections on power, privilege, and justice. I hope here to promote interchange between "mainstream" treatments of justice in health care and feminist thought.

Health reform must include health care rationing, both for reasons of fairness and efficiency. Few politicians are willing to accept this claim, including the Clinton Administration. Brown and others have argued that enormous waste and inefficiency must be wrung out of our health care system before morally problematic cost constraining options, such as rationing, can be justifiably adopted. However, I argue that most of the policies and practices that would diminish waste and inefficiency include implicit (and (...) therefore morally problematic) rationing. Critics of rationing see as its most morally and psychologically troubling feature that an identified individual is denied potentially beneficial care. That psychic anguish may not be eliminable, and perhaps ought not be eliminated. But if rationing protocols are fairly adopted through a process of free and informed rational democratic deliberation to which all have access, the moral objections are largely overcome. Such a process is possible only if implicit rationing is recognized and rejected. Keywords: Justice, health care rationing, health reform, democratic decision-making CiteULike Connotea Del.icio.us What's this? (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. (...) We identify the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

Pricing Life is an extremely timely and stimulating book. The debate about health care rationing has now been running for several decades but there are still people who publicly deny that rationing of health care has to take place, or that health care rationing could be ethically justifiable. In many countries we have also had politicians who have refused to allow the “R” word to pass their lips. In this well written, and very direct (...) book Peter Ubel decisively shows that rationing is an inevitable feature of modern medicine and that it is not something that health care administrators and economists force doctors to perform against …. (shrink)

BackgroundWhen rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in (...) class='Hi'>rationing situations of relative scarcity.MethodsFourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.ResultsParticipants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.ConclusionsWe conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity (...) to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

The purpose of this study was to investigate nurses’ decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses’ are able to provide (...) class='Hi'>care for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses’ role and responsibility when resources are limited. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity (...) to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

Rationing in healthcare remains very much a taboo topic. Before COVID-19, it rarely received public attention, even when it occurred in everyday practices, mainly in the form of implicit rationing, as it continues to do today. There are different definitions, types and levels of healthcare rationing, according to different perspectives. With the aim of contributing to a more coherent debate on such a highly emotional healthcare issue as rationing, here are provided a number of reflections from (...) a patient advocate perspective which are specifically focused on bedside rationing, the most troublesome level, both for patients and clinicians, particularly in regard to cancer care. Oncology, with its numerous expensive therapies and increasing number of patients, is undeniably one of the main areas contributing to the increase in healthcare costs. However, the fixed budgets of today's publicly financed health systems cannot allow unlimited access to the potentially beneficial treatments to all patients. Bedside rationing constitutes the last phase of many decision-making processes occurring at different interrelated levels (macro-levels), both inside and outside healthcare systems, which implicitly and inevitably result in a bottleneck determined by the upstream decisions themselves. Shifting from implicit to explicit bedside rationing essentially means moving from a paternalistic to a citizen-before-patient approach; this implies, first of all, a cultural change. Practical bedside rationing is an ethically complex topic, but one that needs to be urgently addressed in a transparent and open debate. In this scenario, the oncological community – patients, patient advocates and clinicians – can and should play an important role. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more (...) modest and limited topic of medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

Although “rationing” continues to be a dirty word for the public in health policy discourse, Nir Eyal and colleagues handle the concept exactly right in their article in this issue of the Hastings Center Report. They correctly characterize rationing as an ethical requirement, not a moral abomination. They identify the key health policy question as how rationing can best be done, not whether it should be done at all. They make a cogent defense of what they call (...) “rationing through inconvenience” as a justifiable allocational technique. And they wisely call for research on the effectiveness and fairness of this approach and other methods of rationing. I fully agree with their approach to rationing and with their argument that the process they provocatively label “rationing through inconvenience” should not be rejected out of hand. But I believe they have underestimated two ways in which the practical impacts of rationing through inconvenience limit its potential usefulness: the asymmetry of its effect on patients and physicians and the way in which it reduces the capacity of health systems to learn from experience. (shrink)

Several quantitative surveys have been conducted internationally to gather empirical information about physicians’ general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician–patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?

This is a book for reflective laypersons and health professionals who wish to better understand what the problem of healthcare rationing is all about. Ubel says clearly in the Introduction that it is unlikely that professional economists or philosophers are going to be very satisfied with this effort. For him it is more important (p. xix). This is a reasonable aim made achievable by Ubel's clear and engaging writing style. Probably the people who most need to be drawn into (...) these debates are physicians and medical students, this because one of Ubel's central claims is that the need for is both inescapable and sometimes morally permissible. What he wants to reject is the view of many physicians that bedside rationing by physicians is never morally permissible and that healthcare costs can be contained without having to resort to rationing of any kind. Before I explore this point any further, it is necessary to summarize the larger argument of this book. (shrink)

Caring is a complex attitude. At first look, it appears very complex: it seems to involve a wide range of emotional and other dispositions, all focused on the object cared about. What ties these dispositions together, so that they jointly comprise a single attitude? I offer a theory of caring, the Attentional Theory, that answers this question. According to the Attentional Theory, caring consists of just two, logically distinct dispositions: a disposition to attend to an object and hence to considerations (...) pertaining to it, and a disposition to respond to the real or apparent reasons those considerations provide. The emotional and other attitudes involved in caring are instantiations of these two, more general dispositions; and these apparently diverse emotional and other dispositions are connected because the real or apparent reasons to which they are dispositions to respond are connected, in structured “packages.” The fact that the reasons to which a caring agent responds are connected in this way provides the basis for an error theory, explaining why it appears as if the emotions involved in caring are governed by rational coherence requirements. (shrink)

Volume 20, Issue 7, July 2020, Page 167-169.

Death can be bad for an individual who has died, according to the “deprivation approach,” by depriving that individual of goods. One worry for this account of death’s badness is the Lucretian symmetry argument: since we do not regret having been born later than we could have been born, and since posthumous nonexistence is the mirror image of prenatal nonexistence, we should not regret dying earlier than we could have died. Anthony Brueckner and John Martin Fischer have developed a response (...) to the Lucretian challenge by arguing that it is rational to have asymmetric attitudes toward posthumous and prenatal nonexistence. Recently, Jens Johansson has criticized the Brueckner/Fischer position, claiming that it is irrelevant whether it is actually rational to care about future pleasures but not past pleasures. What matters, according to Johansson, is whether it would be rational for us to care about past pleasures had we come into existence earlier. In this paper, I add to the conversation between Johansson and Brueckner/Fischer by suggesting a way to defend the latter side’s position in a way that has not yet been suggested. I do this by considering a suggestion of Johansson’s for interpreting the Brueckner/Fischer position and by arguing that Johansson’s worry for the position I consider is actually incoherent. (shrink)

The age-rationing debate of fifteen years ago will inevitably reemerge as health care costs escalate. All age-rationing proposals should be judged in light of the current system of rationing health care by price in the U.S., and the resulting pattern of excess and deprivation. Age-rationing should be rejected as public policy, but recognized as a personal virtue of stewardship among the elderly.

Physicians are increasingly confronted with the consequences of allocation policies. In several countries, physicians have been assigned a gatekeeper role for secondary health care. Many ethicists oppose this assignment for several reasons, concentrating on the harm the intrusion of societal arguments would inflict on doctor-patient relations. It is argued that these arguments rest on a distinction of spheres of values and of rationality, without taking into account the mixing of values and rationalities that takes place in everyday medical practice. (...) If medical practice, then, does not follow a single, pure rationality, can it also incorporate the societal rationality of the gatekeeper role?Using a case from general practice, I try to show how physicians may integrate societal arguments into their practice in a morally acceptable way. A version of the model of reflective equilibrium and especially Beauchamp and Childress's safeguards, may be helpful both to analyse and teach such balancing of values and rationalities. (shrink)

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical (...) forms of rationality, has seen the word ‘unavoidable’ used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken‐for‐granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care. (shrink)