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)

The Global Burden of Disease project quantifies the impact of different health conditions by combining information about morbidity and premature mortality within a single metric, the Disability Adjusted Life Year. One important goal for the GBD project has been to inform decisions about global health priorities. A number of recent studies have used GBD data to argue that global health funding fails to align with the GBD. We argue that these studies’ shared assumption that global health resources should ‘align’ with (...) the burden of disease is unfounded and has troubling implications. First, since the allocation of resources involves difficult trade-offs between different, potentially competing goals, any ‘misalignment’ of allocation and disease burdens need not necessarily indicate that the allocation of funds fails to meet recipient countries’ needs or interests. Second, using alignment as a baseline implicitly makes controversial assumptions about how harms of different magnitudes affecting different numbers of individuals should be aggregated. We discuss two alternative ways in which GBD data could help inform decisions about resource allocation, neither of which gives more than a limited role to GBD data. (shrink)

Many economic measures are structured to reflect ethical values. I describe three attitudes towards this: maximalism, according to which we should aim to build all relevant values into measures; minimalism, according to which we should aim to keep values out of measures; and an intermediate view. I argue the intermediate view is likely correct, but existing versions are inadequate. In particular, economists have strong reason to structure measures to reflect fixed, as opposed to user-assessable, values. This implies that, despite disagreement (...) about precisely how to do so, economists should standardly adjust QALYs and DALYs to reflect egalitarian values. (shrink)

Summary measures of health, such as the quality-adjusted life year and disability-adjusted life year, have long been known to incorporate a number of value choices. In this paper, though, I show that the value choices in the construction of such measures extend far beyond what is generally recognized. In showing this, I hope both to improve the understanding of those measures by epidemiologists, health economists and policy-makers, and also to contribute to the general debate about the extent to which such (...) measures should be adjusted to reflect ethical values. (shrink)

Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this analysis, the (...) paper arrives at the following three conclusions: that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case. (shrink)

In any normal population, health is unequally distributed across different age groups. Are such age-based health inequalities unjust? A divide has recently developed within egalitarian theories of...

Many ethical theorists believe that a given distribution of healthcare is morally justified only if (1) it is cost-effective and (2) it does not discriminate against older adults and disabled people. However, if (3) cost-effectiveness involves maximizing the number of quality-adjusted life-years (QALYs) added by a given unit of healthcare resource, or cost, it seems the pursuit of cost-effectiveness will inevitably discriminate against older adults and disabled patients. I show why this trilemma is harder to escape than some theorists think. (...) We cannot avoid it by using age- or disability-weighted QALY scores, for example. I then explain why there is no sense of “discrimination” on which discrimination isbothunjust, and thus something healthcare rationing must avoid,andsomething cost-effective healthcare rationing inevitably involves. I go on to argue that many of the reasons we have for not favoring rationing that maximizes QALYs outside the healthcare context apply in healthcare as well. Thus, claim (1) above is dubious. (shrink)

Accelerated COVID-19 vaccine development represents an important accomplishment and a milestone in the history of vaccine evolution. However, the vaccine’s scarcity made its equitable global allocation and distribution ambiguous. Despite the initial pledges from wealthy countries for fairness and inclusivity towards the poorer ones, the policies followed diverged significantly. Wealthy countries have vastly superior access to vaccines in a reality likened to an ethical disaster. This paper calls for the need for fair global vaccine allocation and distribution and examines the (...) barriers that were met along the way, originating from different points, such as the nationalistic approach on the matter that most wealthy countries have adopted or the inability of poor countries to purchase or manufacture vaccines. Further, a suggestion regarding the ethical principles and values that ought to guide global vaccine allocation and distribution is provided with a higher priority given to helping the worst-off, saving the most lives, protecting people in high risk, such as frontline healthcare professionals, and minimising social gaps, along with an ethical theoretical background for each prioritisation. It is not too late for wealthy countries to realise that vaccine inequity prolongs pandemics, so that they change their policies in favour of the global common good that will not only provide immediate universal benefits but will also serve as a guide for future pandemic crises. (shrink)

Recent research indicates that there is a gap in life expectancy between the rich and the poor. This raises the question: should we on egalitarian grounds use income-based equity weights when we assess benefits of alternative benevolent interventions, so that health benefits to the poor count for more? This article provides three egalitarian arguments for using income-based equity weights under certain circumstances. If income inequality correlates with inequality in health, we have reason to use income-based equity weights on the ground (...) that health inequality is bad. If income inequality correlates with inequality in opportunity for health, we have reason to use such weights on the ground that inequality in opportunity for health is bad. If income inequality correlates with inequality in well-being, income-based equity weights should be used to mitigate inequality in well-being. Three different ways in which to construe income-based equity weights are introduced and discussed. They can be based on relative income inequality, on income rankings and on capped absolute income. The article does not defend any of these types of weighting schemes, but argues that in order to settle which of these types of weighting scheme to choose, more empirical research is needed. (shrink)

It is a common view that benefits to the worse off should be given priority when health benefits are distributed. This paper addresses how to understand who is worse off in this context when individuals are differently well off at different times. The paper argues that the view that this judgment about who is worse off should be based solely on how well off individuals are when their complete lives are considered (i.e. 'the complete lives view') is implausible in this (...) context. Instead, it is argued that a pluralistic stance toward this issue should be accepted. This pluralistic stance recognizes that also the view that only focuses on how well off individuals are now and in the future (i.e. 'the forward-looking view') is relevant. The argument is based on appeals to intuitive judgments concerning who is worse off in different cases and reference to various underlying reasons why priority to benefits to the worse off is justified. (shrink)

Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being (...) equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. (shrink)

Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a (...) low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off. (shrink)

We review methods for economic evaluation recently developed in health economics by focusing on the epistemic and non-epistemic values they embody. The emphasis is on insights into valuing health,...

Ageism is the view that it is of greater moral value to allocate health care resources to younger people than to older people. In medical ethics, it is well-known that standard interpretations of distributive principles such as utilitarianism and egalitarianism imply some form of ageism. At times, ethicists argue as if practical complications are the only or main reason for not abiding to ageism. In this article, we argue that inferences to ageism from such distributive principles tend to commit what (...) we call the anticipation-blindness fallacy: A much too narrow focus on life quality benefits of health care treatments inclines us to overlook the importance of life quality benefits of health care safety, that is the mere trust in and expectation of being treated and cared for as one grows old. This is a key omission because health safety has value for a much larger population and for much longer time. Taking health safety into account therefore has important implications as for how ageist we ought to be. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)