Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, luck egalitarianism encounters several difficulties. (...) We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. (shrink)

To investigate whether Swedish physicians, contrary to Swedish health care policy, employ considerations of patient responsibility for illness when rationing expensive treatments.

Background The aim of this study was to investigate whether physicians who felt strongly for or against a treatment, in this case a moderately life prolonging non-curative cancer treatment, differed in their estimation of medical indication for this treatment as compared to physicians who had no such sentiment. A further aim was to investigate how the notion of medical indication was conceptualised. Methods A random sample of GPs, oncologists and pulmonologists comprised the study group. Respondents were randomised to receive either (...) version of a case presentation; in one version, the patient had smoked and in the other version she had never smoked. The physicians were labelled value-neutral and value-influenced on the basis of their attitude towards the treatment. Results In the ‘value-influenced’ group, there was a significant difference in the estimation of medical indication for treatment depending upon whether the patient had smoked or never smoked ). There was no such difference in the ‘value-neutral’ group. Conclusion This study shows that compared to value-neutral physicians, value-influenced physicians are more likely to base decisions of medical indication on medically irrelevant factors. Moreover, medical indication is used in an ambiguous manner. Hence, we recommend that the usage of ‘medical indication’ be disciplined. (shrink)

_Etter revisjonen av bioteknologiloven i mai 2020, ble eggdonasjon på norsk et faktum. I kjølvannet av «bioteknologiforliket» – en koalisjon mellom Ap, Frp og SV som sikret stortingsflertall for endringene i loven – skulle kompensasjonsstørrelsen fastsettes for kvinner som ønsker å donere bort egg. Det ble av den grunn holdt en høring om retningslinjene for donasjon av egg, herunder alternativer for hvor mye donor bør kompenseres økonomisk. I denne artikkelen har jeg analysert høringsutkastet, høringssvarene og de endelige retningslinjene for kompensasjon (...) av eggdonasjon. Hensikten med studien var å undersøke de ulike argumentene i den norske debatten om økonomisk kompensasjon for donasjon av egg. Tre gjennomgående temaer ble identifisert i høringsdokumentene: motivasjonens form og innhold, rettferdighet og donorbutikk. Et sentralt funn i høringen var en gjennomgående bekymring for økonomisk motivert donasjon. Samtidig var det bred enighet om at eggdonasjoner skulle være altruistiske. Altruisme ble forstått som et fravær av økonomisk motivasjon hos donoren, men uten at andre ikke-altruistiske motiver ble problematisert eller at forutsetningene for altruisme ble videre diskutert. Analysen viste også hvordan lignende argumenter ble vinklet ulikt for å kunne understøtte både en høyere og lavere kompensasjon. For eksempel endte en vektlegging av kvinners rettigheter i noen høringssvar opp som et forsvar for det høyeste forslaget til kompensasjon, mens i andre høringssvar ble den brukt som argument for et forbud mot enhver kompensasjon. Samlet sett gir denne studien innblikk i mangfoldet av argumenter som er blitt brukt i den norske debatten om økonomisk kompensasjon for eggdonasjon, og den viser viktigheten av å definere begrepene som brukes – som altruisme, frivillighet og økonomisk motivasjon – for å få bedre frem både enighetene og uenighetene mellom partene i debatten._ _Nøkkelord:_ altruisme, bioteknologi, eggcelledonasjon, godtgjørelse, motivasjon _English abstract_ After the revision of the Biotechnology Act in May 2020, egg donation in Norwegian became a fact. In the wake of the "biotechnology agreement" – a coalition between Ap, Frp and SV that secured a parliamentary majority for the changes in the law – the amount of compensation was to be determined for women who wish to donate eggs. A hearing was therefore held on the guidelines for egg donation, including options for how much the donor should be financially compensated. In this article, I have analyzed the consultation draft, the consultation responses and the final guidelines for compensation for egg donation. The purpose of the study was to examine the various arguments in the Norwegian debate about financial compensation for egg donation. Three consistent themes were identified in the consultation documents: the form and content of the motivation, justice and donor shop. A key finding in the consultation was a consistent concern about financially motivated donation. At the same time, there was broad agreement that egg donations should be altruistic. Altruism was understood as an absence of financial motivation on the part of the donor, but without other non-altruistic motives being problematized or the prerequisites for altruism being further discussed. The analysis also showed how similar arguments were angled differently in order to support both higher and lower compensation. For example, an emphasis on women's rights in some consultation responses ended up as a defense for the highest proposal for compensation, while in other consultation responses it was used as an argument for a ban on any compensation. Overall, this study provides an insight into the diversity of arguments that have been used in the Norwegian debate on financial compensation for egg donation, and it shows the importance of defining the terms used _–_ such as altruism, volunteering and financial motivation _–_ in order to better bring out both the agreements and the disagreements between the parties in the debate. _Keywords:_ altruism, biotechnology, egg cell donation, remuneration, motivation. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as well (...) as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

BackgroundPatients not attending their appointments without giving notice burden healthcare services. To reduce non-attendance rates, patient non-attendance fees have been introduced in various settings. Although some argue in narrow economic terms that behavioural change as a result of financial incentives is a voluntary transaction, charging patients for non-attendance remains controversial. This paper aims to investigate the controversies of implementing patient non-attendance fees.ObjectiveThe aim was to map out the arguments in the Norwegian public debate concerning the introduction and use of patient (...) non-attendance fees at public outpatient clinics.MethodsPublic consultation documents (2009–2021) were thematically analysed (n=84). We used a preconceived conceptual framework based on the works of Grant to guide the analysis.ResultsA broad range of arguments for and against patient non-attendance fees were identified, here referring to the acceptability of the fees’ purpose, the voluntariness of the responses, the effects on the individual character and institutional norms and the perceived fairness and comparative effectiveness of patient non-attendance fees. Whereas the aim of motivating patients to keep their appointments to avoid poor utilisation of resources and increased waiting times was widely supported, principled and practical arguments against patient non-attendance fees were raised.ConclusionA narrow economic understanding of incentives cannot capture the breadth of arguments for and against patient non-attendance fees. Policy makers may draw on this insight when implementing similar incentive schemes. The study may also contribute to the general debate on ethics and incentives. (shrink)

In this paper, we start by comparing the two agents, Ann and Bob, who are involved in two car crashes. Whereas Ann crashes her car through no fault of her own, Bob crashes as a result of reckless driving. Unlike Ann, Bob is held criminally responsible, and the insurance company refuses to cover the car’s damages. Nonetheless, Ann and Bob both receive emergency hospital treatment that a third party covers, regardless of any assessment of personal responsibility. What warrants such apparent (...) exceptionalism with respect to personal responsibility in the healthcare context? We turn our attention to an understudied aspect of the debate on personal health responsibility, namely, the conceptualisation of the person in need of emergency hospital treatment. Drawing on the research of Joshua Knobe and Shaun Nichols, we propose that a context-dependent conceptualisation of the person may help explain a reluctance to ascribe responsibility to the individual for negative health outcomes. (shrink)

BackgroundSwedish healthcare providers are supposed to be value-neutral when making clinical decisions. Recent conducted studies among Swedish physicians have indicated that the proportion of those whose personal values influence decision-making vary depending on the framing and the nature of the issue.ObjectiveTo examine whether the proportions of value-influenced and value-neutral participants vary depending on the extent to which the intervention is considered controversial.MethodsTo discriminate between value-neutral and value-influenced healthcare providers, we have used the same methods in six vignette based studies including (...) 10 more or less controversial interventions. To be controversial was understood as being an intervention where conscientious objections in healthcare have been proposed or an intervention that is against law and regulations.ResultsEnd of life decisions and female reproduction issues are associated with conscientious objection and more or less against regu... (shrink)

Childhood obesity is an increasing health problem. Prior empirical research suggests that, although discussing lifestyle behaviours with parents could help prevent childhood obesity and its health-related consequences, physicians are reluctant to address parental responsibility in the clinical setting. Therefore, this paper questions whether parents might be responsible for their children’s obesity, and if so, whether parental responsibility ought to be addressed in the physician–patient/parent encounter. We illustrate how different ideal-typical models of the physician–patient/parent interaction emphasise different understandings of patient autonomy (...) and parental responsibility and argue that these models advocate different responses to an appeal for discussing parents’ role in childhood obesity. We suggest that responsibility should be attributed to parents because of their parental roles in providing for their children’s welfare. We also argue that whether, and how, this responsibility gives rise to a requirement to act depends on the parents’ capacities. A deliberative-oriented physician–patient/parent interaction best captures the current ideals of antipaternalism, patient autonomy, and shared and evidence-informed decision-making, and might facilitate parental role development. We conclude that, while not discussing parental responsibility for childhood obesity in the clinical setting can be warranted in particular cases, this cannot be justified as a general rule. (shrink)

Luck egalitarianism assigns a central role to personal responsibility in egalitarian justice. In the context of healthcare, luck egalitarianism is the view that the distribution of medical and healthcare resources—or common resources in general—should respond to the (im)prudence of individuals. Recently, Joar Björk, Gert Helgesson, and Niklas Juth have argued that it is impractical to use luck egalitarianism as a normative framework in healthcare because it has no reasonable way of dealing with the imprudent. In response to their (...) argument, this paper first suggests that the epistemic problems of applying luck egalitarianism to the healthcare context raised by Björk et al. can be circumvented by using the exemption system as a policy application of luck egalitarian healthcare justice. This paper then shows that an _ex ante_ policy, a tax system with refunds, can reasonably be adopted as a luck egalitarian institutional design of healthcare policy. We argue that the proposed conception of luck egalitarianism can deal with the problem of differential option luck. Finally, we show that the threshold problem for the definition of imprudence does not refute the proposed _ex ante_ policy. (shrink)