This book focuses on resource allocation in military and humanitarian medicine during times of scarcity and austerity. It is in these times that health systems bend, break, and even collapse and where resource allocation becomes a paramount concern and directly impacts clinical decision-making. Such times are challenging and this book covers this very important, yet, scarcely researched topic within the field of bioethics. This work brings together experts and practitioners in the fields of military health care, philosophy, (...) ethics, and other disciplines to provide analysis on a variety of related topics ranging from case studies and first-hand experiences to policy and philosophical analysis. It is of great interest to to academics, practitioners, policy makers and students who are looking for analyses and guidance regarding the fair provision of medical care and the use of medical rules of eligibility under adverse conditions. (shrink)

Humanitarian social enterprises (HSEs) are facing mounting pressure to incorporate social innovation into their practice. This study thus identifies how HSEs leverage organizational capabilities toward developing social innovation. Specifically, it considers how resource scarcity and operating circumstances affect the capabilities used by HSEs for developing social innovation, using a longitudinal case study approach with qualitative data from 12 hunger-relief HSEs operating in the United States. Based on 59 interviews with 31 managers and directors and related documents, several propositions (...) are posited. The findings suggest that resource availability (i.e., scarcity vs. abundance) leads some HSEs to focus on developing social innovation using their collaborative capabilities, while others leverage their absorptive capacity. Further, HSEs adjust their approach to developing social innovation based on whether they are operating in ordinary circumstances (i.e., before the COVID pandemic) or extraordinary ones (i.e., during the COVID pandemic). Interestingly, the findings suggest that the organizational capabilities used by HSEs are adjusted as these enterprises become more familiar with extraordinary operating circumstances. For example, at the onset of the COVID-19 pandemic, resource-scarce HSEs focused on parallel bricolage to develop social innovation. Subsequently, they focused on selective bricolage. The findings offer novel insights by relating the social innovation of social enterprises to crisis management. (shrink)

Although natural resource scarcity is a pressing issue for many organizations, it has received little attention in management research. Drawing on resource dependence theory, this article theorizes how organizations manage uncertainty from their dependence on scarce natural resources. For this end, it explains how socio-ecological processes involving anthropogenic impacts on ecosystem services cause this form of uncertainty. It then proposes that organizations develop wide-ranging responses to such uncertainty, depending on their predominant institutional logics, from protecting and restoring (...) ecosystems that provision critical natural resources to further developing those ecosystems for optimal resource yields at the risk of degrading them. The article adds to the limited existing research on the unique challenges of managing natural resource scarcity and extends resource dependence theory by accounting for socio-ecological dynamics that create uncertainty regarding natural resources. (shrink)

This essay historicizes cultural and psychic economies in the postwar United States under the sign of material scarcity. It situates the proliferation of plastic flowers in domestic space within a context of bureaucratic anxieties surrounding natural resource scarcity, and trends toward ‘outdoor living’ that were an offshoot of the ideology of economic growth. Interrogating repeated, if relatively unexamined, invocations of ‘anxious’ suburban subjects in descriptions of postwar society, the essay suggests that plastic flowers shored up a sense (...) of stability and permanence at a time when nuclear annihilation, Cold War paranoia, and population growth combined to render life uncertain and potentially unsustainable. The essay concludes by reflecting on how legacies of that epoch – and the fiction of permanence offered by plastic flowers – endure in contemporary fantasies of limitless progress. (shrink)

Park and Davies have laid out an illuminating map of major arguments bearing on whether vaccination status should affect access to scarce healthcare resources during a pandemic. Notably, they sugge...

Scarcity sharpens the conflict between short term gains and long term sustainability. Psychological research documents that decision makers focus on immediate needs under scarcity and use available resources more effectively. However, decision makers also borrow too much from future resources and overall performance decreases as a consequence. Using an online experiment, we study how scarcity affects borrowing decisions in groups. We first document that scarcity affects groups in a similar way as individuals. Then, we go on (...) to show that the negative effect of scarcity is weaker for groups than for individuals. Even in a minimal design that excludes direct interaction or communication, the fact that participants know that their own behavior affects and can be partly observed by another participant disciplines their use of scarce resources. Our results thus highlight the benefit of groups as units of human organization. (shrink)

BackgroundLittle is known about the ethical situations which physiotherapists encounter internationally. This lack of knowledge impedes the ability of the profession to prepare and support physiotherapists in all world regions in their ethical practice. The purpose of the study was to answer the following research questions: What types of ethical issues are experienced by physiotherapists internationally? How frequently are ethical issues experienced by physiotherapists internationally? Can the frequency and type of ethical issue experienced by physiotherapists be predicted by sociodemographic, educational (...) or vocational variables?MethodsAn observational study was conducted in English using an online survey from October 2018 to May 2019. Participants were 1212 physiotherapists and physiotherapy students located internationally which represented less than 1% of estimated number of physiotherapists worldwide at that time. The survey questionnaire contained 13 items requesting demographic detail and knowledge of ethical codes and decision-making, and 46 items asking what frequency participants experienced specific ethical issues in four categories: Physiotherapist and patient interaction, Physiotherapist and other health professionals including other physiotherapists, Physiotherapists and the system and Professional and economic ethical situations.ResultsThe two most frequently experienced ethical issues were ‘Scarce resources and time affecting quality of physiotherapy treatment’ and ‘Physiotherapy not accessible to all people in society who need it’. These items were experienced, on average, more often than monthly. Interprofessional practice also presented frequent ethical issues for participants. Ethical issues related to the context of ‘Physiotherapists and the system’ were most frequently experienced for all world regions. Working longer years in physiotherapy and learning about ethics in basic physiotherapy education was associated with participants reporting lower frequencies of ethical issues across all contexts.ConclusionThis study provides the first global profile of ethical issues experienced by physiotherapists. Societal and cultural systems are key influences on physiotherapists’ ethical practice. Physiotherapists globally need support from their work organisations, academic institutions and professional associations, and robust ethical training, to assist them to be active moral agents in their practice. (shrink)

The scarcity of resources during the COVID‐19 pandemic caused ethical dilemmas in prioritizing patients for treatment. Medical and ethical guidance only emphasizes clinical procedures but does not consider the sociocultural aspect. This study explored the perception of former COVID‐19 patients and their families on the decision‐making process of the patient's selection at a time of scarcity of resources. The result will inform the development of an ethical guide for allocating scarce resources that aligns with Indonesian culture. We conducted (...) qualitative research with in‐depth interviews between May ‐ December 2022 involving sixteen participants from various cities in Indonesia. We transcribed the interviews and analyzed the results using thematic analysis. This study found that doctor's decisions often differed from patient's expectations in allocating scarce resources, and therefore, it should be communicated appropriately. Medical decisions were not sufficiently made ethically, but must also be made communicatively. In Indonesia's strong communal culture, community involvement was essential to distributing limited resources. A better approach to ethical education, including adequate communication skills, is necessary to prepare health professionals for facing unpredictable future pandemics. (shrink)

Occasionally, doctors and health providers have to choose whom they save from death and this is an extremely hard decision to take. Here, I work on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on medical (...) doctors, nurses and other people who are at the front of the war against COVID-19. During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often have been), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, bring other good results to society? This discussion is of course important, but it leaves aside something more fundamental: the fact that resources are not simply scarce, they have been made scarce in the last years by a series of public policies nourished by an economic view that sacrificed social welfare on behalf of neoliberal beliefs. (shrink)

This research aims to examine access to medical treatment during the COVID-19 pandemic for people living with disabilities. During the COVID-19 pandemic, the practical and ethical problems of allocating limited medical resources such as intensive care unit beds and ventilators became critical. Although different countries have proposed different guidelines to manage this emergency, these proposed criteria do not sufficiently consider people living with disabilities. People living with disabilities are therefore at a higher risk of exclusion from medical treatments as physicians (...) tend to assume they have poor quality of life, whereas access to medical treatment should be based on several parameters, including clinical data and prognosis. However, the COVID-19 pandemic shifts the medical paradigm from person-centred medicine to community-centred medicine, challenging the main ethical theories. We reviewed the main guidelines and recommendations for resources allocation and examined their position toward persons with disabilities. Based on our findings, we propose criteria for not discriminating against people with disabilities in allocating resources. The shift from person-centred to community-centred medicine offers opportunities but also risks sacrificing the most vulnerable people. The principle of reasonable accommodation must always be considered to guarantee the rights of persons with disabilities. (shrink)

Application of egalitarian and prioritarian accounts of health resource allocation in low‐income countries have both been criticized for implying distribution outcomes that allow decreasing/undermining health gains and for tolerating unacceptable standards of health care and health status that result from such allocation schemes. Insufficient health care and severe deprivation of health resources are difficult to accept even when justified by aggregative efficiency or legitimized by fair deliberative process in pursuing equality and priority oriented outcomes. I affirm the sufficientarian argument (...) that, given extreme scarcity of public health resources in low‐income countries, neither health status equality between populations nor priority for the worse off is normatively adequate. Nevertheless, the threshold norm alone need not be the sole consideration when a country's total health budget is extremely scarce. Threshold considerations are necessary in developing a theory of fair distribution of health resources that is sensitive to the lexically prior norm of sufficiency. Based on the intuition that shares must not be taken away from those who barely achieve a minimal level of health, I argue that assessments based on standards of minimal physical/mental health must be developed to evaluate the sufficiency of the total resources of health systems in low‐income countries prior to pursuing equality, priority, and efficiency based resource allocation. I also begin to examine how threshold sensitive health resource assessment could be used in the Philippines. (shrink)

Practical deliberation consists in thinking about what to do. Such deliberation is deemed rational when it conforms to certain normative requirements. What is often ignored is the role that an agent's context can play in so-called ‘failures’ of rationality. In this paper, I use recent cognitive science research investigating the effects of resource-scarcity on decision-making and cognitive function to argue that context plays an important role in determining which norms should structure an agent's deliberation. This evidence undermines the (...) view that the norms of ‘ideal’ rationality are necessary and universal requirements on deliberation. They are a solution to the problems faced by cognitively limited agents in a context of moderate scarcity. In a context of severe scarcity, the problems faced by cognitively limited agents are different and require deliberation structured by different norms. Agents reason rationally when they use the norms best suited to their context and cognitive capacities. (shrink)

William Ophuls has argued that the sources of and solutions for present scarcity conditions are to be found in Western political philosophy. I clarify various theoretical issues raised by Ophuls’ work and offer conceptual alternatives regarding some of the more basic issues. Specifically, I critique the Lockean and Hobbesian elements in Ophuls’ treatment of the role of liberal democracy, with special attention to abundance assumptions and Lockean individualism. I also argue that he fails to deal adequately with resource (...) distribution in his treatment of resource scarcity, that he improperly removes man from nature, that he misunderstands the relationship of technology and politics, and that he encounters other difficulties in terms of the public/private distinction and in integrating micro and macro issues. Ironically, Ophuls’ admirable attempt to shed light on the critical relationship between scarcity conditions and political philosophy may have created a new and disorienting set of shadows. (shrink)

In this article we investigate the value and utility of Machiavelli’s work for Community-Based Natural Resource Management. We made a selection of five topics derived from literature on NRM and CBNRM: Law and Policy, Justice, Participation, Transparency, and Leadership and management. We use Machiavelli’s work to analyze these topics and embed the results in a narrative intended to lead into the final conclusions, where the overarching theme of natural resource management for the common good is considered. Machiavelli’s focus (...) on practical realities produces new, sometimes unsettling, insights. We conclude that this focus helps to understand the development and performance of management regimes and their consequences and that institutional design should be seen as an ongoing process, which requires a constant adaptation of these institutions. (shrink)

Economists since the First Industrial Revolution have been interested in the links between economic growth and resources, often pointing to resource scarcities as a hindrance to growth. Offering a counter perspective, this volume highlights the positive role that scarcities can play in inducing technical progress and economic growth. It outlines a structural framework for the political economy of scarcity and rents, and offers a novel way of organizing the evidence concerning the role of resources in industrial growth. This (...) book proposes a major shift in the treatment of scarcity issues by focusing on bottlenecks and opportunities arising within the production system, and will appeal to economists and policy makers interested in the role of resources as triggers of structural change. (shrink)

This article attempts to answer two basic questions. First, can body parts be the subject of property rights? This requires us to start with a definition of property rights, and this is set out in the first section. In the second section, it will be argued that rights in relation to body parts can come within this definition of property rights. However, as explained in the third section, the fact that body parts can be the subject of property rights does (...) not mean that they should. To answer the question of whether body parts should be the subject of property rights we need to consider policy arguments. This article will develop an argument in favour of the recognition of property rights in body parts which focuses on the notion of scarcity of resources. (shrink)

I argue that, because of scarcity, the right to life cannot imply an obligation on others to save the life of the right-holder, and that collectivising resources for health care not only ensures that resources are used inefficiently and inappropriately but also removes from people the authority to make decisions for themselves about matters of health, life and death.

There are warning signs for impending scarcity of certain technology metals that play a critical role in high-tech products. The scarce elements are indispensable for the design of modern technologies with superior performance. Material scarcity can restrain future innovations and presents therefore a serious risk that must be counteracted. However, the risk is often underrated in the pursuit of technological progress. Many innovators seem to be inattentive to the limitations in availability of critical resources and the possible implications (...) thereof. The present shortages in industrial supply with technology metals may be interpreted as a wake-up call for technology developers to tackle the issue with due consideration. The article reviews the materials scarcity phenomenon from the viewpoint of sustainable development ethics. The following questions are discussed: ‘Should preventative actions be taken today in order to mitigate resource scarcity in future?’ and ‘Should technology developers feel responsible to do this?’ The discussion presents arguments for industrial designers and engineers to create a sense of responsibility for the proactive mitigation of material scarcity. Being protagonists of the innovation system, they have the opportunity to lead change towards resource-aware technology development. The paper concludes by outlining ideas on how they can pioneer sustainable management of critical materials. (shrink)

How are we disposed to the problem of natural resources scarcity that we face today and to the fact that certain natural sources remain unused, whereas the exploitation of others puts further strain on the already degraded biosphere? The scarcity of natural resources not only imposes a series of ecological issues on us; it also challenges democracy as organizational system and way of life, because it increases inequality, conflict, authoritarianism, and repression. One way to address this predicament would (...) be the re-appropriation of our relation with the biosphere by ceasing to see it as a limitless source of extraction and consumption. This essay suggests that a certain part of this.. (shrink)

In the street life of the Mission District in San Francisco, two opposite ways of understanding the female ownership of the body circulate among women who are drug-using sex workers: sexual slavery and women's liberation. This article analyzes how both models obfuscate the manner in which lack and scarcity govern the economy of needs and desires when drug abuse intersects with sex work. Lack and scarcity are shown to pervade not only economic resources but also drug-related gratification, bodily (...) well-being, sexual desire and body commitment during sexual practices. Even though both women and men are involved in this economy, there is an `artificial scarcity' of drug-related gratification for women. Controlling women's ability to close this circuit, men reinstate and reproduce the gender stereotypes that dominate in the street culture. (shrink)

This article makes a contribution to the on-going debates about universalism and cultural relativism from the perspective of sociology. We argue that bioethics has a universal range because it relates to three shared human characteristics,—human vulnerability, institutional precariousness and scarcity of resources. These three components of our argument provide support for a related notion of ‘weak foundationalism’ that emphasizes the universality and interrelatedness of human experience, rather than their cultural differences. After presenting a theoretical position on vulnerability and human (...) rights, we draw on recent criticism of this approach in order to paint a more nuanced picture. We conclude that the dichotomy between universalism and cultural relativism has some conceptual merit, but it also has obvious limitations when we consider the political economy of health and its impact on social inequality. (shrink)

Originally published as a French edition in 1991, and first translated into English for this Cambridge edition in 2004, in this exhaustive study Christian Bidard develops a theory of prices of production. This theory breaks down the symmetry between producers and consumers and gives more importance to reproduction rather than scarcity. In his analysis of multiple-product systems, Bidard focuses on the notion of an all-engaging system which elucidates the link with von Neumann's theory; examines the notions of sector and (...) vertical integration which make possible an elegant treatment of fixed capital; clarifies the status of the internal rate of return; proposes a general theory of rent. In the discussion of capital theory and marginal equalities or, more specifically, the treatment of exhaustible resources, Bidard compares different readings of Sraffa's work and revisits the question of relationships between classical theory and the general equilibrium theory. (shrink)

As we write, U.S. cities and states with extensive community transmission of Covid‐19 are in harm's way—not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just‐in‐time economic models resulted in storage of only those supplies needed then. (...) At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference. (shrink)

It is often claimed that our knowledge of the evolutionary process adds an extra dimension to the classical problem of natural evil and makes this problem worse. Especially the principle of natural selection is often portrayed as morally inappropriate or “unfitting” for a perfectly good God to use as a means for creating biological complexity. In this article, I argue that this common view is misconceived, and that natural selection is a wholly innocuous principle. The real source of evolutionary evils (...) is the fact that resources in nature are scarce – a fact that was known long before Darwin. The problem of natural and evolutionary evil, therefore, is best construed as a question about why God permits scarcity in nature. I argue that recent research about the interrelation between competition and cooperation in the evolutionary process provides resources for answering this perennial question in a more satisfactory way than could be done before the advent of evolutionary theory. (shrink)

Objective: A deep understanding of the relationship between a scarce drug's dose and clinical response is necessary to appropriately distribute a supply-constrained drug along these lines. Summary of key data: The vast majority of drug development and repurposing during the COVID-19 pandemic – an event that has made clear the ever-present scarcity in healthcare systems –has been ignorant of scarcity and dose optimisation's ability to help address it. Conclusions: Future pandemic clinical trials systems should obtain dose optimisation data, (...) as these appear necessary to enable appropriate scarce resource allocation according to societal values. (shrink)

Originally published in 1989 Social Philosophy and Ecological Scarcity presents a systematic study of the implications of ecological scarcity for social philosophy. The book argues for a new social philosophy based on a conception of the 'good society' and the 'good life' which makes fewer, rather than more demands on scarce ecological resources. The book shows that the two major competing social philosophies in modern philosophical thought - the bourgeois liberal and the state socialist - are both forms (...) of capitalism. Despite their obvious differences, they both pursue the logic of capitalism, of ever-increasing accumulation, growth and consumption. This pursuit is carried out by means of modern science and its technology, which assume that Nature's resources are inexhaustible and can be exploited to meet infinite human wants or needs, ignoring ecological scarcity. The recognition of ecological scarcity would lead to a social philosophy, based on a frugal mode of socialism which has more affinities with the social visions of Fourier and Morris than with that of Marx. Their theories, far from being too 'utopian', are shown as more 'realistic' and less 'fantastic' than either bourgeois capitalism or state capitalism based on the Marxist model. (shrink)

We propose that procedures of separation have two functions, namely first, to establish the integrity of individual parts, and second, to make previously joint entities discreet and therefore countable. This allows taking stock of available resources, including evaluating the use of individual objects, a process that is especially adaptive under conditions of threat of contagious disease and resource scarcity.

By trying to see how one can use African values to fight against fraud, the paper attempts to bring out the structural dimension of this moral cancer by showing how it is linked to the ethical and economic/business systems where it thrives. I start by making some theoretical remarks about how values are to be placed in each socio‐cultural setting. An analysis of how the free market economy as a system creates conditions where fraud becomes possible then follows. This is (...) contrasted with an analysis of the African worldview and economic system where the starting point is that material and human resources abound, provided they are shared. The paper ends by suggesting ways in which African ethical values can be merged with the dominant economic system. (shrink)

Professor Hall is to be congratulated on his thoughtful analysis of an issue that, as he rightly suggests, “is one of the most important issues that will confront health care tort law throughout the remainder of the century.”’ He argues that malpractice law currently can accommodate considerable latitude both for a conservative streamlining of medical practices in general and for a cost-sensitivity in individual treatment decisions. And he further argues that existing tort principles, such as the locality rule, can comfortably (...) be stretched to embrace still greater room for economics in the medical standard of care. I quite agree.Unfortunately, Hall's arguments do not go nearly far enough, for they are framed around a seriously oversimplified picture of the economic changes that are revolutionizing medicine in the United States. He envisions a fairly uniform, global set of resource constraints that generally pressure physicians to conserve on care—pressures that tort law can then encompass equally globally as it accepts more cost-efficient standards of care. However, neither the changing economics of medicine nor the resulting jurisprudential challenges are anywhere near this generalized. (shrink)

Abstract Normative criteria for evaluations of economic and social outcomes are often formulated in terms of social welfare functions which are essentially and importantly non-satiable. However, there are good reasons to consider certain normative criteria and many policy objectives to be capped, i.e. bounded, and thus satiable provided sufficient resources are made available for their satisfaction. Inspired by the Foster–Greer–Thorbecke class of indicators, this paper uses an interdisciplinary approach to develop a model for assessing outcomes in terms of capped objectives (...) based on an understanding of individual shortfalls from the objective, denoted needs. We present an indicator to measure need satisfaction in a population of individuals with heterogeneous needs and highlight an aggregation problem under scarcity. For such situations, we develop three ways in which the indicator can be weighted that reflect respectively concerns over the frequency, depth and severity of the need shortfalls and show that normative evaluations based on these weighting schemes can conflict, yielding mutually inconsistent outcome rankings. The indicator can be adapted to measure a wide variety of phenomena, e.g. health needs, education shortfalls, deprivation, etc., and it is suited for targeting exercises and other policy implementations. In particular, it allows for exogenous weighting schemes, i.e. weights that can incorporate non-shortfall characteristics relevant for the evaluation, e.g. age, gender, ethnicity, etc. The indicator thus enables new ways for researchers to promote and study satiable objectives in a wide variety of contexts relevant to economic and social policy, e.g. human development programs, poverty reduction, healthcare policies, etc. (shrink)

Summary Background The principle of maximization, which roughly means that we should save more lives and more years of life, is usually taken for granted by the health community. This principle is even more forceful in crises like the COVID-19 pandemic, where we have scarce resources which can be allocated only to some patients. However, the standard consequentialist version of this principle can be challenging particularly when we have to reallocate a resource that has already been given to a (...) patient. -/- Methodology Engaging in thought experiments, conceptual analysis, providing counterexamples, and appealing to moral intuitions, we challenge the standard consequentialist version of the maximization principle and make a case for adopting an alternative deontological version. -/- Discussion In certain cases, the standard consequentialist version of the maximization principle is shown to yield intuitively immoral results. The deontological version of this principle is preferable because it can retain the merits of the standard consequentialist version without falling prey to its problems. -/- Conclusion Compared to the standard consequentialist version, the deontological version of the maximization principle can better guide the ethical decisions of the health community, even in cases where we face a scarcity of resources. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by (...) markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

The rule of rescue describes the moral impulse to save identifiable lives in immediate danger at any expense. Think of the extremes taken to rescue a small child who has fallen down a well, a woman pinned beneath the rubble of an earthquake, or a submarine crew trapped on the ocean floor. No effort is deemed too great. Yet should this same moral instinct to rescue, regardless of cost, be applied in the emergency room, the hospital, or the community clinic? (...) -/- In health care, the desire to save lives at any cost must be reconciled with the reality of resource scarcity. As one example, the estimated cost for prophylactic Factor VIII to treat one patient with hemophilia for one year is $300,000. Costs of this magnitude have been accepted by public and private insurers in the developed world, even though, in principle, these sums could provide greater overall health benefit if allocated to pay for the unmet health care needs of many other patients. Looking forward, however, broad application of the rule of rescue will be increasingly untenable. But the moral instinct will remain: the desire to help those weakest among us, especially when their small numbers allow us to see them as unique individuals. What, then, is the ethical framework that can guide coverage and reimbursement decisions for orphan drugs into the future? (shrink)

Debate about the epistemic prowess of historical science has focused on local underdetermination problems generated by a lack of historical data; the prevalence of information loss over geological time, and the capacities of scientists to mitigate it. Drawing on Leonelli’s recent distinction between ‘phenomena-time’ and ‘data-time’ I argue that factors like data generation, curation and management significantly complexifies and undermines this: underdetermination is a bad way of framing the challenges historical scientists face. In doing so, I identify circumstances of epistemic (...) scarcity where underdetermination problems are particularly salient, and discuss cases where legacy data—data generated using differing technologies and systems of practice—are drawn upon to overcome underdetermination. This suggests that one source of overcoming underdetermination is our knowledge of science’s past. Further, data-time makes agnostic positions about the epistemic fortunes of scientists working under epistemic scarcity more plausible. But agnosticism seems to leave philosophers without much normative grip. So, I sketch an alternative approach: focusing on the strategies scientists adopt to maximize their epistemic power in light of the resources available to them. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Moral Responsibility in a Context of Scarcity:the Journey of a Haitian PhysicianPaul PierreAlmost all Haitian physicians have been involved in some sort of "social movement" at one point in their professional life. In a country characterized by a natural inclination to question authority, fighting the status quo of the ineffective, corrupt and disorganized [End Page 89] Haitian health system often appears to be the right thing to do.In (...) 2002, I played an active role in a large protest movement for better working conditions at the largest health facility in Port-au-Prince: the General Hospital (GH). Port-au-Prince is the capital and economic center of Haiti. It is home to close to a third of Haiti's ten million people. At that time, the situation at the GH facility was dire. All of the 400 beds at the GH were dirty. The staff was underpaid and unhappy. Drug and medical supply stock-outs were routine. Medical equipment was rarely maintained and only one of the six operating theatres in the surgery block was working. Unsupervised physicians in training (like me) were the main health care providers. Attending physicians were busy running their own private clinics, and most of them would come to the hospital solely to "recruit" the less poor patients for their clinics. As physicians-in-training, we had the responsibility of caring for the poor, but we had no means. We grew frustrated and angry witnessing our powerless patients losing legs, arms and their lives for lack of care. On many occasions, I had the parents of my patients buy the gloves that I would use to examine their sick relatives. I've seen patients fighting for the inheritance of medications left by others who had just passed away. There was no way for this hospital to fulfill its mission, and no way for its staff to deliver anything other than mediocre care. We could not accept that situation at such an early stage in our medical development, and so we refused to continue to work. We went on a strike, which completely paralyzed the delivery of care at the hospital for nearly two months. After intense negotiation, the strike ended with a signed agreement with the Minister of Health that addressed, more or less, the reasons of our movement. However, the implementation of the agreement was permanently delayed by other competing "state emergencies" including a general insurrection.At the time of our movement, I thought we were making history. After witnessing 11 "social movements" that similarly paralyzed the GH in the following decade for reasons identical to ours, I am now convinced that we were not. We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince. The social movement that we started ended up hurting the very same people that we were trying to help.Extending access to heath care to poor people seemed to me at that time to be too complicated and too expensive for an unorganized state like Haiti. I realized that local protests could, at best, influence the allocation of local resources. But so-called local resources are so limited in "resource-limited" countries. Haiti spends only $40 U.S. dollars per capita for health care. This is not enough for good care. The options we were provided were not real ones—since all of them would end in more suffering. The case of providing health care to poor people needed to be approached differently.I was born in Port-au-Prince at the same general hospital in which I would later work. I am the third of four children, and the first male child in my family. My father made me understand very clearly that my first responsibility was for my siblings. My sisters made me understand equally clearly that I had no authority over any of them. I ended up with a lot of responsibility but with very little authority. The few of us who completed school, entered university, studied abroad and "emerged" were considered, to some extent, responsible for the others—the ones who couldn't go to school, university, or abroad, the ones who had "sunk... (shrink)

Three metaphors appear to guide contemporary thinking about organ transplantation. Although the gift is the sanctioned metaphor for donating organs, the underlying perspective from the side of the state, authorities and the medical establishment often seems to be that the body shall rather be understood as a resource . The acute scarcity of organs, which generates a desperate demand in relation to a group of potential suppliers who are desperate to an equal extent, leads easily to the gift’s (...) becoming, in reality, not only a resource, but also a commodity . In this paper, the claim is made that a successful explication of the gift metaphor in the case of organ transplantation and a complementary defence of the ethical primacy of the giving of organs need to be grounded in a philosophical anthropology which considers the implications of embodiment in a different and more substantial way than is generally the case in contemporary bioethics. I show that Heidegger’s phenomenology offers such an alternative, with the help of which we can understand why body parts could and, indeed, under certain circumstances, should be given to others in need, but yet are neither resources nor properties to be sold. The phenomenological exploration in question is tied to fundamental questions about what kind of relationship we have to our own bodies, as well as about what kind of relationship we have to each other as human beings sharing the same being-in-the-world as embodied creatures. (shrink)

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives (...) and nurses and semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period. (shrink)

The COVID-19 pandemic has strained healthcare resources the world over, requiring healthcare providers to make resource allocation decisions under extraordinary pressures. A year later, our understanding of COVID-19 has advanced, but our process for making ethical decisions surrounding resource allocation has not. During the first wave of the pandemic, our institution uniformly ramped-down clinical activity to accommodate the anticipated demands of COVID-19, resulting in resource waste and inefficiency. In preparation for the second wave, we sought to make (...) such ramp down decisions more prudently and ethically. We report the development of a tool that can be used to make fair and ethical decisions in times of resource scarcity. We formed an interprofessional team to develop and use this tool to ensure that a diverse range of stakeholder perspectives were represented in this development process. This team, called the clinical activity recovery team, established institutional objectives that were combined with well-established procedural values, substantive ethical principles and decision-making criteria by using a variation on the well-known accountability for reasonableness ethical framework. The result of this is a stepwise, semiquantitative, ethical decision tool that can be applied to resource allocation challenges in order to reach fair and ethically defensible decisions. This ethical decision tool can be applied in various contexts and may prove useful at both the institutional and the departmental level; indeed this is how it is applied at our centre. As the second wave of COVID-19 strains healthcare resources, this tool can help clinical leaders to make fair decisions. There are no data in this work. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by (...) markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

This study addresses the critical shortage of parallel corpora for the Kashmiri language, a significant barrier to advancing language processing technologies for under-resourced languages. Despite Kashmiri's rich cultural heritage, the development of language technology resources, especially parallel corpora, has been notably limited. Our research involves a detailed analysis of the only available parallel corpora for Kashmiri, utilizing these datasets to develop and evaluate Neural Machine Translation (NMT) models. Through this evaluation, we categorize errors and assess the corpora's adequacy in quality (...) and quantity for supporting effective language processing tasks. Additionally, we investigate the reasons behind the scarcity of high-quality resources and identify the challenges inherent in creating robust parallel corpora for Kashmiri. By proposing solutions to these challenges, our study aims to contribute to the revitalization and global recognition of the Kashmiri language, bridging a significant gap in the field of language technology and emphasizing the importance of parallel corpora in preserving linguistic diversity and facilitating technological advancement. (shrink)

One of the most important motifs within (medical) ethics is scarcity: where essential (health) resources are scarce, urgent ethical questions arise. Over the last decade, at least 250 papers addressing the allocation of scarce health resources have been published in the Journal of Medical Ethics alone.1 In the typical set-up, the authors introduce a situation of scarcity and then review and adjudicate the available or recommended courses of action, sometimes through the lens of a pet normative ethical theory. (...) It is much less common for (medical) ethicists to focus their enquiries on the origins of scarcity. Why aren’t there sufficient health resources to go around? Who caused the scarcity, and how should they be held responsible? These questions are also firmly within the remit of the discipline. Discussions of scarcity tend to circumvent these difficult questions by focussing on exceptional cases in Global North settings, where scarcity is relatively rare, and is sometimes defensible or insoluble. For example: it would be wasteful for a hospital to overstock expensive, bulky, energetically intensive, specialist equipment whose supply would only be challenged under the most extreme and unforeseen circumstances (eg, a pandemic), and there may never be sufficient usable donor organs to meet the demand for transplants. Much less attention is given to under-resourced settings, generally in the Global South, where scarcity is common, and is often both indefensible and soluble. The literature appears to favour what is ‘unusual’ and ‘interesting’ in some contexts, rather than what is commonplace, and by that fact more worrying, in others. This division of attention entrenches the idea that scarcity is a fixed feature of certain places and lives. Why do medical ethicists so often fight shy of these meta-questions? They are, of course, harder and messier. More work and greater care are needed to contextualise …. (shrink)

The issue of the allocation of resources in health care is here to stay. The goal of this study was to explore the views of physicians on several topics that have arisen in the debate on the allocation of scarce resources and to compare these with the views of policy makers. We asked physicians and policy makers to participate in an interview about their practices and opinions concerning factors playing a role in decision making for patients in different age groups. (...) Both physicians and policy makers recognised allocation decisions as part of their reality. One of the strong general opinions of both physicians and policy makers was the rejection of age discrimination. Making allocation decisions as such seemed to be regarded as a foreign entity to the practice of medicine. In spite of the reluctance to make allocation decisions, physicians sometimes do. This would seem to be only acceptable if it is justified in terms of the best interests of the patient from whom treatment is withheld. (shrink)

Due to the rapid advance of the pandemic caused by COVID-19, several countries perceived that human and material resources would be insufficient to meet the demand of infected patients. The aim of this study is to analyze the knowledge of health professionals working in the pandemic about the application of ethical criteria in decision-making in situations of resource scarcity. This is a cross-sectional, descriptive, and quantitative survey study, conducted from June to December 2020, with health professionals working in (...) the COVID-19 pandemic in Brazil. We applied a questionnaire to assess the professionals’ knowledge about ethical criteria in decision-making in the allocation of scarce resources during the pandemic, containing 14 questions and possible score from 0 to 70, which was developed by researchers from documents and protocols validated by organizations from various countries, available in the first months of the pandemic, a sociodemographic characterization questionnaire and a self-assessment questionnaire regarding knowledge about bioethics. A total of 197 health professionals participated in the study, 37.6% of whom were nurses and 22.8% of whom were physicians, working in the Family Health Unit (28.4%) with a degree at the level of specialization (46.2%). Moreover, (9.5%) of nurses, (18.2%) of dental surgeons and (24.4%) of physicians reported that they have no prior knowledge about bioethics. Physicians and hospital workers scored higher on the knowledge assessment questionnaire. The mean score of the participants was 45.4 (SD = 7.2). Investments in training and professional education in the field of health focused on Bioethics are necessary, considering models and ethical theories that help professionals, managers and society to better position themselves in the face of pandemic contexts. (shrink)

In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity is absolute and ongoing; and argue (...) that Kerstein and Bognar are mistaken to base their allocation principles on differences in personhood. (shrink)

The ethical allocation of scarce medical resources has received significant attention, yet a key question remains unaddressed: how should scarce, divisible resources be allocated? We present a case from the COVID-19 pandemic in which scarce resources were divided among patients rather than allocated to some patients over others. We assess how widely accepted allocation principles could be applied to this case, and we show how these principles provide insufficient guidance. We then propose alternatives that may help guide decision-making in such (...) cases, and we evaluate the possibility of treating patients equally by dividing resources equally. Resource scarcity is not limited to pandemic situations, and many healthcare resources are divisible. This question—how to allocate these divisible resources—deserves greater attention from bioethics. (shrink)