This paper rebuts suggestions made by Littlejohns et al that NICE is not ageist by analysing the concept of ageism. It recognises the constraints that finite resources impose on decision making bodies such as NICE and then makes a number of positive suggestions as to how NICE might more effectively and more justly intervene in the allocation of scarce resources for health.

Originally published in 1980 this book argues that we are all responsible for the harm we could have prevented and explores the effect of this conclusion on a morality which makes fundamental the belief that we ought not to harm others if we can possibly avoid it. A theory of responsibility is developed and defended which has consequences for the way we live as well as for a number of problems in contemporary moral, political and social philosophy, and in jurisprudence. (...) In particular, the author attacks the view that there is a moral difference between killing and letting die and proposes a radical conception of violence. Among other controversial issues covered in the book are neutrality, the ethics of organ transplants and the allocation of scarce resources. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Catholic Social Teaching and the Allocation of Scarce ResourcesJohn Langan S.J. (bio)I shall approach the issue of justice in the allocation of scarce resources from the viewpoint of Catholic social teaching, as developed over the last century. This teaching is found primarily in the social encyclicals issued by popes from Leo XIII (1878–1903) to John Paul II (1978- ), but also in the (...) pastoral letters of the various bishops’ conferences, especially in the United States and in Latin America. These documents, which enjoy a high standing in Catholic teaching but which are not taken as binding in all their particulars, form part of a tradition of moral and social theorizing that a contemporary American would regard as “communitarian.” On social questions, this tradition also has shown itself to be historicist in that it is capable of modifying itself in significant ways in response to changing political and economic situations. It normally approaches issues from a universalist perspective, though it has shifted from a preoccupation with the concerns of the industrial societies of Europe to an advocacy of much of the reform agenda of the Third World.Rooted in classical and biblical sources and modified in the course of the last [End Page 401] century to include a principled acceptance of religious freedom, of human rights, and of democratic political institutions, the Catholic social tradition proposes a number of ideas that can serve as the basis for significant criticism of currently dominant liberal modes of organizing and interpreting advanced industrial societies. These ideas do not form a countertheory to liberalism so much as they indicate ways in which a religious organization that includes both hierarchical and egalitarian elements in its structure and that has both moral commitments and practical responsibilities with regard to health care can draw on its intellectual resources to develop alternative strategies for the reform of health care.I shall survey six ideas that figure prominently in Catholic social teaching and that are relevant to the allocation of scare resources in American health care. Space constraints require that I present them in a very condensed fashion, without tracing the complex development they have undergone in the internal Catholic debate or subjecting them to much criticism.First, Catholic social teaching, especially the great encyclical of John XXIII, Pacem In Terris (PT 1963), affirms the full range of human rights recognized in such modern documents as the Universal Declaration of Human Rights (1949). In addition to the civil and political rights enumerated in the Bill of Rights added to the original U.S. Constitution (1791), the Universal Declaration includes rights “to life, to bodily integrity, and to the means which are suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services” (PT 11). Catholic social teaching has not committed itself to one particular way of institutionalizing these rights, but it effectively endorses the comprehensive West European welfare states that the Christian Democratic political parties helped to construct in the period after 1945.Second, Catholic social teaching has accorded a central organizing role to the notion of the common good, the realization of which “is the whole reason for the existence of civil authorities” (PT 54). The common good, however, is not to be understood as identical with the interest or the power of the state; rather, it “embraces the sum total of those conditions of social living whereby men are enabled to achieve their own integral perfection more fully and more easily” (PT 58; quoting Mater et Magistra). John XXIII is particularly anxious to affirm that the common good cannot be construed so as to exclude some groups or to violate the rights of individuals and that it must include both physical and spiritual goods (PT 55–61). The notion of the common good has both an inherent attractiveness and a vagueness that cries out for specification and clarification. But in the contemporary situation it serves to remind us that “individual citizens and intermediate groups are obliged to make their specific contributions to the common welfare” (PT 53).Third, while an insistence on the primacy of the common good and on the [End Page 402... (shrink)

Vaccines, when available, will prove to be crucial in the fight against Covid-19. All societies will face acute dilemmas in allocating scarce lifesaving resources in the form of vaccines for Covid-19. The author proposes The Value of Lives Principle as a just and workable plan for equitable and efficient access. After describing what the principle entails, the author contrasts the advantage of this approach with other current proposals such as the Fair Priority Model.

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I (...) argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as (...) well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (shrink)

This article considers the possible relation between the idea of parity and some past work on the allocation of scarce resources. Parity of value is first connected with the idea of some goods being irrelevant in interpersonal comparisons. The notion of moral parity is introduced to describe the recognition that people who are moral equals (even when they are not on a par in terms of value) as not substitutable. The relation between a Separability Test and nonsubstitutability (...) of persons is considered. These ideas are then used to discuss various cases in which one must choose to whom to provide medical assistance, including whether and when to distinguish morally between a disabled and a nondisabled person. (shrink)

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that (...) all are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

The COVID‐19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub‐Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high‐income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID‐19 pandemic in low‐income countries suffering from chronic shortages in (...) health care resources, and chronic high morbidity and mortality from non‐COVID‐19 causes. A parallel is drawn between the distribution of severity of COVID‐19 disease and the classic “Fortune at the bottom of the pyramid” model that is relevant in SSA. Focusing allocation of resources during COVID‐19 on the ‘thick’ part of the pyramid in Low‐to‐Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post‐COVID‐19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID‐19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non‐pandemic times. (shrink)

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I (...) argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of prioritisation of (...) the resources available for healthcare or of rationing such resources must be governed by this principle. -/- This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational ‘reasons based consequentialism’ is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended. (shrink)

This chapter contains sections titled: What Is “Greater Need” for Health Care? Longevity Should the Health‐care System Maximize QALYs? QALYs and Equality The Evidence Base for QALY‐informed Decisions Choosing Between Claimants Allocation and Liberation Moral Evaluation of Persons Natural Justice Utility to Society Numbers of Dependents Age and Life Expectancy Fairness and Quality of Life Conclusion References.

COVID‐19 caused an imbalance between medical resources and the number of patients in Türkiye like in many countries. There was not pandemic‐triage system, and this situation led to decision making based on experience, intuition, and judgment of allocation of scarce resources. The research explains the guiding criteria that healthcare professionals used to prioritize the distribution of scarce medical resources during the COVID‐19 pandemic. The criteria preferred by 928 healthcare professionals were evaluated when preventive measures (...) for COVID‐19 were reduced and so the number of cases increased rapidly. The results indicate that Turkish healthcare professionals largely support the utilitarian approach, which focuses on medical benefit in pandemic. The main problem was that some criteria not approved in COVID‐19 triage guidelines were considered important by healthcare professionals. These criteria, which cause discrimination by preventing the provision of fair and equal medical care to patients, are a prominent issue in the study. (shrink)

In a much cited phrase in the famous English ‘Child B’ case, Mr Justice Laws intimated that in life and death cases of scarce resources it is not sufficient for health care decision-makers to ‘toll the bell of tight resources’: they must also explain the system of priorities they are using. Although overturned in the Court of Appeal, the important question remains of the extent to which health-care decision-makers have a duty to give reasons for their decisions. (...) In this paper, I examine the philosophical foundations of the legal obligation to give reasons in English law. Why are judges sometimes supportive of the imposition of a duty to give reasons and sometimes not? What is it about the context of life and death health care allocation problems that makes it unsuitable in their view for such a duty; and is this stance justified? What is it to give a reason for a decision? I examine Frederick Schauer’s account of reason-giving in terms of generalisation and commitment and I suggest that it provides an overstated account of what giving a reason commits one to. I go on to examine an idea of judicial creation: that where value judgements are “inexpressible” there is a strong reason not to impose a duty to give reasons on to public bodies. The strongest case for a duty to give reasons is in terms of the value of respect for citizens. I argue that there is nothing in the very nature of reason-giving that ought to preclude the imposition of such a duty in this context, but concede that there is a serious danger of legalism that could result in a hamstringing of health care decision-making. It is up to judges and lawyers to seek to avoid this danger. (shrink)

The prelims comprise: Micro‐v. Macro‐Allocation, and a Quandary for Clinical Practice Allocation and Theories of Justice Cost‐Utility Analysis as a Framework for Allocation Accounting for Specific Factors Other than Health‐Related Utility Further Questions and a Concluding Note References Further Reading.

Four ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.

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 response to a commentary on “Allocation of scarce resources, disability, and parity” considers whether a difference that would be morally relevant when choosing which of two people to save retains its relevance if this would affect other people’s chances of being saved.

Intuitively we feel that we ought to (attempt) to save the lives, or ameliorate the suffering, of identifiableIdentifiable individuals where we can (Rulli and Millum, 2016, p. 261). But this comes at a price. It means that there may not be any resources to save the lives of others in similar situations in the future. Or worse, there may not be enough resources left to prevent others from ending up in similar situations in the future. This chapter asks (...) whether this is justifiable or whether we would be better served focusing on public health in the form of preventative medicine. It looks briefly at the supposed difference between benefiting individuals and benefiting populations by considering the difference between interventions aimed at ‘rescue’ and those which are preventative. It then considers the rule of rescueRule of rescue in the health care setting, and looks at some of the reasons stemming from this that we might have for allocating resources to rescue interventions. If these reasons do not provide adequate justification for preferring these types of interventions, then the implication is that our current mode of resource allocation may need to be revised in favour of a more public health-oriented model. (shrink)

This paper introduces a new, expanded range of relevant cognitive psychological research on collaborative recall and social memory to the philosophical debate on extended and distributed cognition. We start by examining the case for extended cognition based on the complementarity of inner and outer resources, by which neural, bodily, social, and environmental resources with disparate but complementary properties are integrated into hybrid cognitive systems, transforming or augmenting the nature of remembering or decision-making. Adams and Aizawa, noting this distinctive (...) complementarity argument, say that they agree with it completely: but they describe it as “a non-revolutionary approach” which leaves “the cognitive psychology of memory as the study of processes that take place, essentially without exception, within nervous systems.” In response, we carve out, on distinct conceptual and empirical grounds, a rich middle ground between internalist forms of cognitivism and radical anti-cognitivism. Drawing both on extended cognition literature and on Sterelny’s account of the “scaffolded mind” (this issue), we develop a multidimensional framework for understanding varying relations between agents and external resources, both technological and social. On this basis we argue that, independent of any more “revolutionary” metaphysical claims about the partial constitution of cognitive processes by external resources, a thesis of scaffolded or distributed cognition can substantially influence or transform explanatory practice in cognitive science. Critics also cite various empirical results as evidence against the idea that remembering can extend beyond skull and skin. We respond with a more principled, representative survey of the scientific psychology of memory, focussing in particular on robust recent empirical traditions for the study of collaborative recall and transactive social memory. We describe our own empirical research on socially distributed remembering, aimed at identifying conditions for mnemonic emergence in collaborative groups. Philosophical debates about extended, embedded, and distributed cognition can thus make richer, mutually beneficial contact with independently motivated research programs in the cognitive psychology of memory. (shrink)

Ruth Macklin argued that dignity is nothing more than respect for persons or their autonomy. During the COVID-19 pandemic, difficult decisions are being made about the allocation of scarce resources. Respect for autonomy cannot justify rationing decisions. Justice can be invoked to justify rationing. However, this leaves an uncomfortable tension between the principles. Dignity is not a useless concept because it is able to account for why we respect autonomy and for why it can be legitimate to (...) override autonomy in times of critical care resource shortages. Dignity affirms the worth of the human individual as a meaning-making embodied subject, who is always in relationship to others, the world, time, and transcendence, and who realizes their dignity through their moral behaviour. Such an understanding means people should be helped to make morally right decisions about their own treatment, which may include forgoing potentially beneficial treatment for the good of others. Respect for dignity does not require fulfilling the morally wrong choices of one who insists on treatment at the expense of others. Dignity also protects the discretion of clinicians to make decisions appropriate to their competence by prohibiting the application of broad-based criteria such as age. (shrink)

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

This book addresses the problem of how to make democratically-legitimate public policy on issues of contentious bioethical debate. It focuses on ethical contests about research and their legitimate resolution, while addressing questions of political legitimacy. How should states make public policy on issues where there is ethical disagreement, not only about appropriate outcomes, but even what values are at stake? What constitutes justified, democratic policy in such conflicted domains? Case studies from Canada and Australia demonstrate that two countries sharing historical (...) and institutional characteristics can reach different policy responses. This book is of interest to policymakers, bioethicists, and philosophers, and will deepen our understanding of the interactions between large-scale socio-political forces and detailed policy problems in bioethics. (shrink)

Escalating demands for limited food supplies at America’s food banks and pantries during the COVID-19 pandemic have raised ethical concerns underlying “first-come, first-served” distributions strategies. A series of model ethical principles are designed to guide ethical allocations of these resources to assure greater access among persons facing food insecurity.

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the (...) major ethical challenges encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

The COVID-19 pandemic has placed an enormous burden on health systems, and guidelines have been developed to help healthcare practitioners when resource shortage imposes the choice on who to treat. However, little is known on the public perception of these guidelines and the underlying moral principles. Here, we assess on a sample of 1033 American citizens’ moral views and agreement with proposed guidelines. We find substantial heterogeneity in citizens’ moral principles, often not in line with the guidelines recommendations. As the (...) guidelines are likely to directly affect a considerable number of citizens, our results call for policy interventions to inform people on the ethical rationale behind physicians or triage committees decisions to avoid resentment and feelings of unfairness. (shrink)

Intuitively we feel that we ought (to attempt) to save the lives, or ameliorate the suffering, of identifiable individuals where we can. But this comes at a price. It means that there may not be any resources to save the lives of others in similar situations in the future. Or worse, there may not be enough resources left to prevent others from ending up in similar situations in the future. This chapter asks whether this is justifiable or whether (...) we would be better served focusing on public health in the form of preventative medicine. It looks briefly at the supposed difference between benefiting individuals and benefiting populations by considering the difference between interventions aimed at ‘rescue’ and those which are preventative. It then considers the rule of rescue in the health care setting, and looks at some of the reasons stemming from this that we might have for allocating resources to rescue interventions. If these reasons do not provide adequate justification for preferring these types of interventions, then the implication is that our current mode of resource allocation may need to be revised in favour of a more public health-oriented model. (shrink)

This paper discusses the attempt in this issue of the journal by Peter Singer, John McKie, Helga Kuhse and Jeff Richardson, to defend QALYs against the argument from double jeopardy which I first outlined in 1987. In showing how the QALY and other similar measures which combine life expectancy and quality of life and use these to justify particular allocations of health care resource, remain vulnerable to the charge of double jeopardy I am able to clarify some of the (...) central issues concerning the value of life. In particular, the idea that the value of a life varies with its life expectancy and with its quality, understood in terms of its richness, variety, success etc, is subjected to special examination. It is shown how defenders of QALYs are committed to the view that so far from all lives being of equal value, all lives are necessarily of subtly different value. The paper then analyses the use to which the notorious 'veil of ignorance' has been put both by Singer et al and by others and shows how this device of John Rawls's cannot do the work so often assigned to it. The paper then considers the issue of hypothetical consent and the role that it can play in justifying disposing of the lives of people who have not in fact consented to their lives being disposed of in particular ways. Finally, the paper makes some points about the comprehensive nature of the data collection and storage which would be required by QALY advocates and points out the independent problems attaching to licensing such comprehensive collection and use of personal data. (shrink)

BackgroundECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a (...) small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations.MethodsAn online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic.ResultsWhen initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%).ConclusionsWe found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic. (shrink)

Many ecological and environmental economists take a microeconomic approach to envi­ronmental valuation and view the macroeconomy as an amalgam of firms whose primary task is to efficiently allocate scarce resources. In this framework, replacing freely provided ecosystem services with costly human-provided substitutes is by definition inefficient. Although destroying and replacing the free gifts of nature can sometimes be an economic benefit, in the case of apple-tree pollination in Maoxian County, China, the positive economic benefits do not justify eliminating (...) the natural processes. To the contrary, the Maoxian case illustrates the danger of allowing the logic of the market and its apologetic models to drive conservation policy. The conflict between the market economy and the natural world must be recognized and addressed in a more substantial way. The bees of Maoxian County are a parable for the relationship between humans and the natural world and show clearly the danger of leaving the fate of nature to the whims of the markets even if prices are “corrected.”. (shrink)

This paper stems from the current global worsening of the scarcity of resources for healthcare, which will deepen even more in future public emergencies. This justifies strengthening the reflection on the allocation of resources which, in addition to considering technical issues, should also involve ethical concerns. The two plans in which the allocation of resources develops—macro and micro—are then systematized, both requiring the identification of ethical criteria for the respective complex decision-making. Then, we describe how (...) the complexity at the macro level focuses on the joint consideration of the rectitude of the principles, the goodness of the ends, and the integrity—respectively the deontological, teleological, and procedural perspectives; and at the micro level, it focuses in prioritizing people, which can result in the exclusion of some, as happened with the elderly during peaks of COVID-19. The main objective of this article is to show that, in public health emergency situations, in which the daily criteria for prioritizing access to health care are not efficient, it is possible not only to ration the available means but also to rationalize them. We argue that rationing and rationalization are different concepts, entail different consequences, have different ethical foundations, and draw different guidelines for patient care. We apply them to the distribution of intensive care and vaccines to the elderly thus demonstrating the ethically legitimate domain of implementation of each of these two prioritization criteria. We conclude that rationalization respects more strictly the core ethical principles of our common morality. (shrink)

Ruth Tallman has recently offered a defense of the modified youngest first principle of scarce resource allocation [1]. According to Tallman, this principle calls for prioritizing adolescents and young adults between 15–40 years of age. In this article, I argue that Tallman’s defense of the modified youngest first principle is vulnerable to important objections, and that it is thus unsuitable as a basis for allocating resources. Moreover, Tallman makes claims about the badness of death for individuals at (...) different ages, but she lacks an account of the loss involved in dying to support her claims. To fill this gap in Tallman’s account, I propose a view on the badness of death that I call ‘Deprivationism’. I argue that this view explains why death is bad for those who die, and that it has some advantages over Tallman’s complete lives view in the context of scarce resource allocation. Finally, I consider some objections to the relevance of Deprivationism to resource allocation, and offer my responses. (shrink)

Reserve systems are a tool to allocate scarce resources when stakeholders do not have a single objective. This paper introduces some basic concepts about reserve systems for pandemic medical resource allocation. At the onset of the Covid-19 pandemic, we proposed that reserve systems can help practitioners arrive at compromises between competing stakeholders. More than a dozen states and local jurisdictions adopted reserve systems in initial phases of vaccine distribution. We highlight several design issues arising in some of (...) these implementations. We also offer suggestions about ways practitioners can take advantage of the flexibility offered by reserve systems. (shrink)

Resumen En este trabajo se exponen veintiuna tesis sobre la asignación de recursos escasos en tiempos de pandemia o crisis sanitaria. El autor parte de la base de que nunca se justifica tratar a una persona como un mero medio. A partir de este principio fundamental, y de otras exigencias de justicia, procura determinar cuáles son los límites a las consideraciones, por lo demás legítimas, de eficiencia o de utilidad. Esto le permite discernir qué criterios de distribución son moral mente (...) aceptables y cuáles no lo son. -/- This work presents twenty one theses on the allocation of scarce resources in times ofpandemic or health crisis. The author assumes that treating a person as a mere means is never justified. On the basis of this fundamental principle, and other requirements of justice, he seeks to determine what are the limits to considerations, otherwise legitímate, of efficiency or utility. This allows him to discern which distribution criteria are morally acceptable and which are not. (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)

In this essay it will be argued that if preferential treatment for individuals who have suffered from past discrimination is permissible in any context, it should be extended to the allocation of scarce medical resources. This contention will be based on two facts: one, that health care, in particular certain life-saving operations, constitutes a scarce social good similar to but more important than other social goods such as desirable jobs and positions in desirable professional schools; secondly, (...) that a claim can plausibly be made that the greater incidence of death due to heart disease among blacks is a result of the effect of past discrimination. In addition, an argument to the effect that preferential treatment is indeed permissible will be sketched that is based upon a critique of the decision in the Bakke case. (shrink)

Among industrialized nations the United States is relatively unique in relying on a mix of public and private financing and delivery of healthcare: federal and federal-state programs, such as Medicare and Medicaid; employment-based health insurance ; and state-subsidized insurance pools for high-risk individuals. In recent years, however, there have been efforts to apply the principles of private employment-based health insurance to the other forms of healthcare, and there is speculation that rising healthcare costs can only be addressed by further extending (...) capitated payment plans. This suggests that U.S. healthcare may increasingly be organized according to market principles. For some, this represents a historic departure from an emphasis on public responsibility for healthcare and a sacrifice of the value principles embodied in health relationships between patient and provider. But defenders of HMOs and a larger role for markets argue that managed care allows for a more rational allocation of scarce healthcare resources by minimizing inefficient low-benefit–high-cost care. More individuals receive essential care if inessential care is eliminated. HMOs are also said to encourage non-HMOs to provide lower priced healthcare. (shrink)

Hastings Center Report, Volume 51, Issue 5, Page 42-47, September‐October 2021.

There is no necessary connection between leadership in basic science and leadership in the applications of science, because scientific progress is a cooperative endeavour and not a competitive game; indeed, there may be a conflict between basic research and applied science. The notion of “a position of leadership”; in science raises questions of what leadership consists in and what its value is to the nation. The two main arguments for government support of science are cultural-social, and economic. The cultural-social argument (...) stresses scientific activity as a form of social consumption of wealth and raises the question of whether other uses of the resources employed would contribute more to the greatness of the society. The economic argument stresses basic scientific research as a form of investment for the future, and raises the questions of what the rate of return on such investment is and whether and to what extent government support is called for. Relevant economic research results bearing on this problem are scarce. Economic theory suggests that competition in the market will supply less than the optimal amount of basic research; but our society substantially supplements the market through private contributions to and government support of science, and the question is whether this supplementation is deficient or excessive. Here difficult problems arise, on which more economic research is needed; one of these concerns the relative merits of government and private support of science. The rule-of-thumb procedures generally recommended for determining the volume and allocation of government support to basic scientific research generally ignore these problems, and amount to endorsing the present level of government support or recommending that it be increased. Allocation of federal support of science should take account of the possibility of stimulating the economic development of poor regions of the country by locating scientific research facilities in them. (shrink)

ABSTRACT For a distribution of health care resources to be fair, it should consider the consequences for the whole lives of the affected persons and not just how badly off they are at the present moment. Since, other things being equal, a person is worse off if he dies young than if he dies old, it is fair to give scarce vital health care resources to young rather than to old persons. In the paper this ageist view (...) is restated and defended against a number of objections raised by John Harris. According to Harris' so‐called anti‐ageist argument the only relevant consideration in the distribution of vital health care resources is people's desire to go on living. On reflection, this is highly counterintuitive. Instead, it is argued that both present desires to go on living and possible future happiness should weigh together with considerations of fairness. Both fairness and possible future happiness will in most cases speak in favour of saving the young before the old. A number of other problems for the ageist view are discussed, and solutions are suggested. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while (...) others disagree. We offer a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

ABSTRACT For a distribution of health care resources to be fair, it should consider the consequences for the whole lives of the affected persons and not just how badly off they are at the present moment. Since, other things being equal, a person is worse off if he dies young than if he dies old, it is fair to give scarce vital health care resources to young rather than to old persons. In the paper this ageist view (...) is restated and defended against a number of objections raised by John Harris. According to Harris' so‐called anti‐ageist argument the only relevant consideration in the distribution of vital health care resources is people's desire to go on living. On reflection, this is highly counterintuitive. Instead, it is argued that both present desires to go on living and possible future happiness should weigh together with considerations of fairness. Both fairness and possible future happiness will in most cases speak in favour of saving the young before the old. A number of other problems for the ageist view are discussed, and solutions are suggested. (shrink)

During the first wave of the COVID-19 pandemic in Italy, practitioners had to make tragic decisions regarding the allocation of scarce resources in the ICU. The Italian debate has paid a lot of attention to identifying the specific regulatory criteria for the allocation of resources in the ICU; in this paper, however, we argue that deciding such criteria is not enough for the implementation of fair and transparent allocative decisions. In this respect, we discuss three (...) ethical issues: (a) in the Italian context, the treating physician, rather than a separate committee, was generally the one responsible for the allocation decision; (b) although many allocative guidelines have supported moral equivalence between withholding and withdrawing treatments, some health professionals have continued to consider it a morally problematic aspect; and (c) the health workers who have had to make the aforementioned decisions or even only worked in ICU during the pandemic often experienced moral distress. We conclude by arguing that, even if these problems are not directly related to the above-mentioned issues of distributive justice, they can nevertheless directly affect the quality and ethics of the implementation of allocative criteria, regardless of those chosen. (shrink)

Patients with insufficient financial resources place physicians in a conflict of interest between the patients' needs and the financial interests of the physician, other patients, and society. Not only must physicians act ethically, but they must avoid liability for violating their legal duties to their patients. The traditional rules of contract and malpractice law that govern the patient-physician relationship do not provide satisfactory guidelines. Better answers are found in the rules of fiduciary law, but only with regard to direct (...) conflicts between patients and physicians and only at the risk of reducing patient access to care. Certain types of legislative action can resolve these conflicts by altering the traditional legal rules, but care must be taken to preserve patient-physician trust, which the legal rules were designed to enhance. (shrink)

Resource allocation is a central part of the decision-making process in any health care system. Resources have always been finite, thus the ethical issues raised are not new. The debate is now more open, and there is greater public awareness of the issues. It is increasingly recognised that it is the technology which determines resources. The ethical issues involved are often conflicting and relate to issues of individual rights and community benefits. One central feature of resource (...) class='Hi'>allocation is the basing of decisions on the outcomes of health care and on their subsequent economic evaluation. The knowledge base is therefore of great importance as is the audit of results of clinical treatment. Public involvement is seen as an integral part of this process. For all parts of the process, better methodologies are required. (shrink)