I consider various principles which might explain our intuitive obligation to rescue people from imminent death at great cost, even when the same resources could produce more benefit elsewhere. Our obligation to rescue is commonly explained in terms of the identifiability of the rescuee, but I reject this account. Instead, I offer two considerations which may come into play. Firstly, I explain the seeming importance of identifiability in terms of an intuitive obligation to prioritise life-extending interventions for people who face (...) a high risk of an early death, and I explain this in turn with a fair innings-style principle which prioritises life-extending interventions for people expected to die young. However, this account is incomplete. It does not explain why we would devote the same resources to rescuing miners stuck down a mine even if they are elderly. We are averse to letting people die suddenly, or separated from friends and family. And so, secondly, I give a new account that explains this in terms of narrative considerations. We value life stories that follow certain patterns, classic patterns which are reflected in many popular myths and stories. We are particularly averse to depriving people of the opportunity to follow some such pattern as they approach death. This means allowing them to sort out their affairs, say goodbyes to family and friends, review their life, or come to terms with death itself. Such activities carry a lot of meaning as ways of closing our life story in the right way. So, for someone who has not been given much notice of their death, an extra month is worth much more than for other patients. Finally, I review the UK National Health Service's end of life premium, which gives priority to patients with short life expectancy. I suggest it falls short in terms of such considerations. For example, the NHS defines its timings in terms of how long the patient can expect to live as at the time of the treatment decision, whereas the timings should be specified in terms of time from diagnosis. (shrink)

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

What justifies differences in the acceptance of paternalism towards competent minors and older people? I propose two arguments. The first argument draws on the widely accepted view that paternalism is easier to justify the more good it promotes for the paternalizee. It argues that paternalism targeting young people generally promotes more good for the people interfered with than similar paternalism targeting older people. While promoting people's interests or well-being is essential to the justification of paternalism, the first argument has certain (...) unfair implications in that it disfavours paternalism towards the worse off. The second argument caters to such fairness concerns. It argues that priority or inequality aversion supports age-differentiated paternalism because young people, who act imprudently and thereby risk their interests or well-being, are worse off than older people who act in similar ways. I suggest that both arguments are pertinent in evaluating specific paternalistic acts and policies. (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...

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources be distributed If not all demands can be met?

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)

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, where theorizing about just (...) principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives. (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.

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (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)

This article argues that, as commonly understood, indirect discrimination is not necessarily unjust: 1) indirect discrimination involves the disadvantaging in relation to a particular benefit and such disadvantages are not unjust if the overall distribution of benefits and burdens is just; 2) indirect discrimination focuses on groups and group averages and ignores the distribution of harms and benefits within groups subjected to discrimination, but distributive justice is concerned with individuals; and 3) if indirect discrimination as such is unjust, strict egalitarianism (...) has to be the correct account of distributive justice, but such egalitarianism appears vulnerable to the leveling down objection (whether decisively or not), and many theorists explicitly reject strict egalitarianism anyway. The last point threatens the position of liberals who oppose indirect discrimination but think significant inequalities can be just. (shrink)