: The move from a notion that community values ought to play a role in health care decision making to the creation of health care policies that in some way reflect such values is a challenging one. No single method will adequately measure community values in a way appropriate for setting health care priorities. Consequently, multiple methods to measure community values should be employed, thereby allowing the strengths and weaknesses of the various methods to complement each other. A preliminary research (...) agenda to bring together empirical research on community values with more traditional research on health care ethics is outlined, with the goal of identifying and measuring acceptable community values that are relatively consistent across measurement methods and, ultimately, developing ways to incorporate these values into health care priority decision making. (shrink)

Norman Daniels’ theory of justice and health faces a serious practical problem: his theory can ground the special moral importance of health and allows distinguishing just from unjust health inequalities, but it provides little practical guidance for allocating resources when they are especially scarce. Daniels’ solution to this problem is a fair process that he specifies as "accountability for reasonableness". Daniels claims that accountability for reasonableness makes limit-setting decisions in healthcare not only legitimate, but also fair. This paper assesses the (...) latter claim. Does accountability for reasonableness result in fair limit-setting decisions? It is argued that the answer to this question is not a clear yes. Daniels is remarkably unclear about the criterion of fairness that accountability for reasonableness satisfies. The paper discusses different options for resolving this lack of clarity and examines how they apply to Daniels’ accountability for reasonableness framework. It is concluded, first, that accountability for reasonableness is not a paradigm case of any of the classic notions of procedural justice; second, that what might be called "constrained pure procedural justice" best reflects how accountability for reasonableness results in fair limit-setting decisions; and third, that the procedural conditions of accountability for reasonableness must be further specified and amended to better achieve a fair process, and hence fair limit-setting decisions. (shrink)

This paper considers the problem that arises when the number of patients who need a resource exceeds the supply. An initial decision-making model is proposed that uses two essential criteria, medical prognosis and the priority of life-threatening situations. The model is then subjected to the criticism that it is grotesque to ignore questions relating to the value of, for example, a productive mother over against an aged recluse, and to treat them as having equal rights to access. It is argued (...) that this criticism need not be an expression of prejudice but may reflect a defendable view in which utilitarian considerations enter into the selection process provided that certain fundamental, or 'deontological' rights are observed for all. In the light of the discussion the model is modified in order to contain both a non-utilitarian feature that stresses the intrinsic importance of all persons, and a utilitarian feature that can allow one, in certain circumstances, to take consequences into account, especially those that follow from the 'irreplaceability' of some people. (shrink)

This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.

This paper is a critique of Norman Daniels' and James Sabin's ‘Accountability for Reasonableness’ framework for making priority-setting decisions in health care in the face of widespread disagreement about values. Accountability for Reasonableness has been rapidly gaining worldwide acceptance, arguably to the point of becoming the dominant paradigm in the field of health policy. The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even (...) those who would be adversely affected will have reason to abide by them. I argue that the framework's four conditions are inadequate to this task. While we certainly require a fair and legitimate procedure for making priority setting decisions in health care despite a lack of consensus on relevant ethical and political issues, we must significantly revise the four conditions, and we cannot avoid facing our substantive disagreements head on if we hope to arrive at decisions that would (and should) be acceptable to everyone. I offer two suggestions. First, there is need for greater public involvement in all stages of deliberation. Second, we should give up on the idea that we can simplify the task of democratic deliberation by disallowing particular kinds or reasons and types of reasoning. Reasons of all kinds should be on the table, but then should be judged on their merits, such as consistency, plausibility and explanatory power, without any regard for their alleged sources of authority. (shrink)

In this much-anticipated book, Jonathan Dancy offers the only available full-scale treatment of particularism in ethics, a view with which he has been associated for twenty years. Dancy now presents particularism as the view that the possibility of moral thought and judgement does not in any way depend on an adequate supply of principles. He grounds this claim on a form of reasons-holism, holding that what is a reason in one case need not be any reason in another, and maintaining (...) that moral reasons are no different in this respect from others. Ethics Without Principles offers detailed treatment and criticism of opposing positions of all sorts, with useful summaries. It also contains three chapters on the nature of what Dancy calls 'contributory' reasons, which, though the topic of much interest at the moment, are not often discussed in anything like the detail given here. And it offers a distinctive form of value-holism to go with the holism of reasons. As Dancy's definitive statement on particularism, the book will be required reading for all those working on moral philosophy and ethical theory. (shrink)

Commodities and Capabilities presents a set of inter-related theses concerning the foundations of welfare economics, and in particular about the assessment of personal well-being and advantage. The argument presented focuses on the capability to function, i.e. what a person can do or can be, questioning in the process the more standard emphasis on opulence or on utility. In fact, a person's motivation behind choice is treated here as a parametric variable which may or may not coincide with the pursuit of (...) self-interest. Given the large number of practical problems arising from the roles and limitations of different concepts of interest and the judgement of advantage and well-being, this scholarly investigation is both of theoretical interest and practical import. (shrink)

In bioethics, discussions of justice have tended to focus on questions of fairness in access to health care: is there a right to medical treatment, and how should priorities be set when medical resources are scarce. But health care is only one of many factors that determine the extent to which people live healthy lives, and fairness is not the only consideration in determining whether a health policy is just. In this pathbreaking book, senior bioethicists Powers and Faden confront foundational (...) issues about health and justice. How much inequality in health can a just society tolerate. The audience for the book is scholars and students of bioethics and moral and political philosophy, as well as anyone interested in public health and health policy. (shrink)

This book describes a new method of consulting the public that has been tried successfully around the world. The book combines the theory of democracy with actual practice. Fishkin lays out a theory of "deliberative democracy" and shows with practical examples, how it can be realized.

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

All health care systems face problems of justice and efficiency related to setting priorities for allocating a limited pool of resources to a population. Because many of the central issues are the same in all systems, the United States and other countries can learn from the successes and failures of countries that have explicitly addressed the question of health care priorities. We review explicit priority setting efforts in Norway, Sweden, Israel, the Netherlands, Denmark, New Zealand, the United Kingdom and the (...) state of Oregon in the US. The approaches used can be divided into those centered on outlining principles versus those that define practices. In order to establish the main lessons from their experiences we consider the process each country used, criteria to judge the success of these efforts, which approaches seem to have met these criteria, and using their successes and failures as a guide, how to proceed in setting priorities. We demonstrate that there is little evidence that establishment of a values framework for priority setting has had any effect on health policy, nor is there evidence that priority setting exercises have led to the envisaged ideal of an open and participatory public involvement in decision making. (shrink)