Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls'A Theory of Justicein 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls'A Theory of Justicehas been remodeled for healthcare philosophy (...) by Norman Daniels. Nozick's libertarian manifestoAnarchy, State, and Utopiahas been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare. (shrink)

A continuing need for care for elderly, combined with looser family structures prompt the question what filial obligations are. Do adult children of elderly have a duty to care? Several theories of filial obligation are reviewed. The reciprocity argument is not sensitive to the parent–child relationship after childhood. A theory of friendship does not offer a correct parallel for the relationship between adult child and elderly parent. Arguments based on need or vulnerability run the risk of being unjust to those (...) on whom a needs-based claim is laid. To compare filial obligations with promises makes too much of parents’ expectations, however reasonable they may be. The good of being in an unchosen relationship seems the best basis for filial obligations, with an according duty to maintain the relationship when possible. We suggest this relationship should be maintained even if one of the parties is no longer capable of consciously contributing to it. We argue that this entails a duty to care about one’s parents, not for one’s parents. This implies that care for the elderly is not in the first place a task for adult children. (shrink)

As individuals grow older, they usually require assistance with the daily tasks of self-care. This type of assistance, ancillary care, is essential to maintaining the health of those who need these services. In his prudential lifespan account, Norman Daniels includes access to such services making his account an attractive proposal given the current demographic shift. In this paper, I examine the prudential lifespan account through the lens of old age and I focus on the two concepts on which the lifespan (...) account relies. I show that these two concepts, normal species functioning and opportunity cannot buttress Daniels’s lifespan account; at least it cannot do so for older persons. The tensions that I identify in the prudential lifespan account in relation to aging are instructive for the more recent proposals to include aging in a theory of health and health justice. In addition, my analysis allows me to demonstrate that Daniels’s view of opportunity is irreconcilable to capabilities, the latter being more adaptable to the realities of aging. If capabilities appear more promising, it is nonetheless imperative that the specificities of extended care, such as the need for unpaid caregiving, be taken into consideration. (shrink)

This paper argues that we can see our lives as a snapshot happening now or as a moving picture extending across time. These dual ways of seeing our lives inform how we conceive of the problem of age group justice. A snapshot view sees age group justice as an interpersonal problem between distinct age groups. A moving picture view sees age group justice as a first-person problem of prudential choice. This paper explores these different ways of thinking about age group (...) justice and illustrates them using a principle of respect for human dignity, understood in terms of reasonable support for floor level central human capabilities at each stage of life. I argue that different frames are suitable for different kinds of decisions, and each provides a true, but partial, picture of aging and age group justice. (shrink)

Daniel Callahan has argued that economic and social benefits would result from a policy of withholding medical treatments which prolong life in persons over a certain age. He claims 'the real goal of medicine' is to conquer death and prolong life with the use of technology, regardless of the age and quality of life of the patient, and this has been responsible for the escalation of health care expenditure. Callahan's proposal is based on economic rationalism but there is little evidence (...) to suggest that substantial economic savings could be achieved. Moreover, his argument raises serious moral objections. A policy of withholding treatments from members of a social group involves elements of compulsion and discrimination, both of which would intrude on the doctor-patient relationship, undermine the autonomy of elderly patients, and invoke the slippery slope towards involuntary forms of euthanasia. Life-death decisions should be based on more than the one criterion of age, and take account of more relevant factors such as the patient's usual state of well-being, her/his expressed wishes, informed consent and the type of illness. Any move to the implementation and enforcement of the policy Callahan recommends would be rejected by health professionals and the public. (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)

This paper considers the place of children within liberal-democratic society and its related political morality. The genesis of the paper is two considerations which are in tension with one another. First, that there must be some point at which children are divided from adults, with children denied the rights which go along with full membership of the liberal community. The justification for the difference in the statue between these two groups must be rooted in some notion of capacities, since these (...) are the only relevant differences between adults and children. Second, that linking an individual's capacities to her status undermines the central liberal commitment of political equality. This dilemma explains what I term the threshold view, which holds that children become adult citizens upon reaching an age of competence and that above this level differences in abilities cease to matter to an individual's status. While this view has attractions, this paper argues that this view must eventually be rejected because of its inability to deal with the actual process of human development. In its place, the paper proposes a modification to this view which sees the threshold constrained by moral demands and applied indirectly to age groups rather than individuals. These constraints preserve the commitment to equality in a way consistent with a plausible view of children's place in society. (shrink)

This paper explores the debate between perfectionists and anti-perfectionists in the context of children. It suggests that the most influential and compelling arguments in favour of anti-perfectionism are adult-centric. It does this by considering four leading reasons given in favour of anti-perfectionism and shows that none apply in the case of children. In so doing, the paper defends a perfectionist account of upbringing from the attacks made against perfectionism more generally. Furthermore, because the refutation of the various anti-perfectionist arguments are (...) made exclusively dealing with children, the paper suggests that the perfectionist view of upbringing is compatible with anti-perfectionist restrictions on dealing with adults. This dual view combining perfectionism for children and anti-perfectionism for adults is referred to as restricted perfectionism. (shrink)

Children are among the few social groups that are systematically and universally disenfranchised. Although children are citizens worthy of equal moral treatment and rights, their right to vote is restricted in almost all states, and this is seen as legitimate by most democratic theories. What is particular about childhood that justifies the restriction of their right to vote? How can democratic systems legitimise the exclusion of a section of their citizenry? This article provides a critical analysis of the principles that (...) ground child disenfranchisement, and of the allocative mechanisms proposed for restricting the right to vote. It shows that most arguments in favour of child disenfranchisement are unsatisfactory, as they are inconsistently used to target the child population (but not other groups) or are incompatible with a commitment to equality. Among the principles for child disenfranchisement, only those that appeal to political incompetence may be valid for excluding children. Regarding the allocative method of exclusion, this article shows that age thresholds cannot be justified to restrict franchise, and that, while competence tests fare better in theory, there may be issues of implementation. The article contributes by providing a clear and systematic analysis of the core arguments in favour of child disenfranchisement, and the conditions that must be met to justify such a practice. (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)

This article brings together two debates in contemporary political philosophy: on the one hand, the dispute between the distributive and relational approaches to equality and, on the other hand, the field of intergenerational equality. I offer an original contribution to the second domain and by doing so, I inform the first. The aim of this article is thus twofold: shedding some light on an under-researched and yet crucial question – ‘which inequalities between generations matter?’ and contributing to a far-reaching debate (...) that touches upon the nature of egalitarianism. After showing that there are two key problems that fall within the scope of intergenerational equality – questions of justice between age groups and questions of equality between birth cohorts – I argue that, contrary to what the default distributive view states, some inequalities between age groups matter independently of their diachronic impact, and so partly for relational reasons. I argue that, even if we are distributive egalitarians, we must endorse the relational egalitarian conception to successfully make sense of some inequalities between age groups. I infer from this both that the putative view that the ‘relational’ conception of equality can be redescribed as distributive must be rejected and that the distributive view requires supplementation by the relational view. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)