When do you have to sacrifice life and limb, time and money, to prevent harm to others? When must you save more people rather than fewer? These questions might arise in emergencies involving strangers drowning or trapped in burning buildings, but they also arise in our everyday lives, in which we confront opportunities to donate time or money to help distant strangers in need of food, shelter, or medical care. With the resources available, we can provide more help--or less. -/- (...) In The Rules of Rescue, Theron Pummer argues that we are often morally required to engage in effective altruism, directing altruistic efforts in ways that help the most. Even when the personal sacrifice involved makes it morally permissible not to help at all, he contends, it often remains wrong to provide less help rather than more. Using carefully crafted examples, he defends the view that helping distant strangers is more morally akin to rescuing nearby strangers than most of us realize. The ubiquity of opportunities to help distant strangers threatens to make morality extremely demanding, and Pummer argues that it is only thanks to adequate permissions grounded in considerations of cost and autonomy that we may pursue our own plans and projects. He ultimately concludes that many of us are required to provide no less help over our lives than we would have done if we were effective altruists. (shrink)

People often have a strong intuitive sense that we ought to rescue those in serious need, even in cases where we could produce better outcomes by acting in other ways. It has become common in such cases to refer to this as the Rule of Rescue. Within the medical field this rule has predominantly been discussed in relation to decisions about whether to fund particular treatments. Whilst in this setting the arguments in favour of the (...) class='Hi'>Rule of Rescue have generally been found to be unconvincing, there are some reasons for thinking that it may have more of a role to play at the clinical level. In this article we examine three lines that such reasoning might take. In each case we argue that the reasons given do not support the adoption of a Rule of Rescue in clinical practice. (shrink)

The dominant rule of economic evaluation within health care posits that resources are distributed in order to maximize health benefit. There are instances, however, where the public has demonstrated that they do not prefer such an allocation scheme, particularly in the context of life-saving interventions. Objectives Deviations from preferences of maximizing health benefit have important implications on both financial and distributive levels. This study sought to specify the circumstances in which respondent preferences are inconsistent with maximizing health benefit. Methods (...) Ninety respondents recruited from the London School of Economics and Political Science completed a questionnaire comprised of a series of paired profiles involving various combinations of life-saving or quality-of-life enhancing interventions. Results The results indicate that saving a life holds value beyond that captured by traditional health benefit measurement and that the value of saving a life is not consistent across ages. More specifically, the value of saving a life was age-dependent and markedly attenuated for older-age patients. Conclusions Many respondents were willing to overlook maximizing health benefit in order to rescue a life in immediate peril, and showed a diminished sense of moral imperative to rescue older-age patients. In light of difficulties related to the implementation of larger-scale policies incorporating Rule of Rescue concerns, the most realistic approaches will likely involve adopting smaller-scale policies that address issues such as do not resuscitate and living wills. Potential policy solutions such as age or monetary thresholds for life-saving interventions may be favoured in a research context; however, their overall social feasibility is questionable. (shrink)

The National Institute for Health and Care Excellence, the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies programme. It argues that although NICE in all likelihood does (...) not act because of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker. (shrink)

I consider various principles which might explain our intuitive obligation to rescue people from imminent death at great cost, even when the same resources could produce more benefit elsewhere. Our obligation to rescue is commonly explained in terms of the identifiability of the rescuee, but I reject this account. Instead, I offer two considerations which may come into play. Firstly, I explain the seeming importance of identifiability in terms of an intuitive obligation to prioritise life-extending interventions for people (...) who face a high risk of an early death, and I explain this in turn with a fair innings-style principle which prioritises life-extending interventions for people expected to die young. However, this account is incomplete. It does not explain why we would devote the same resources to rescuing miners stuck down a mine even if they are elderly. We are averse to letting people die suddenly, or separated from friends and family. And so, secondly, I give a new account that explains this in terms of narrative considerations. We value life stories that follow certain patterns, classic patterns which are reflected in many popular myths and stories. We are particularly averse to depriving people of the opportunity to follow some such pattern as they approach death. This means allowing them to sort out their affairs, say goodbyes to family and friends, review their life, or come to terms with death itself. Such activities carry a lot of meaning as ways of closing our life story in the right way. So, for someone who has not been given much notice of their death, an extra month is worth much more than for other patients. Finally, I review the UK National Health Service's end of life premium, which gives priority to patients with short life expectancy. I suggest it falls short in terms of such considerations. For example, the NHS defines its timings in terms of how long the patient can expect to live as at the time of the treatment decision, whereas the timings should be specified in terms of time from diagnosis. (shrink)

Thirty years of debate have passed since the term “Rule of Rescue” has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical (...) fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one’s fellow creatures. The present article argues against both objections. It suggests that the debate’s focus on consequences should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice. (shrink)

The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are (...) likely to remain severely disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation. (shrink)

The central issue that I consider in this paper is the use of the so‐called ‘Rule of Rescue’ in the context of resource allocation. This ‘Rule’ has played an important role in resource allocation decisions in various parts of the world. It was invoked in Ontario to overturn a decision not to fund treatment for Gaucher's Disease and it has also been used to justify resource decisions in Israel concerning the same condition. -/- In the paper I (...) consider the nature of the Rule of Rescue and its moral justification. The latter involves consideration of the distinction between agent‐relative and agent‐neutral obligations. If the Rule of Rescue is to be justified, it is plausible to think that it will be in the context of agent‐relative obligations. Two problems with this suggestion are considered: the role of identifiability in the Rule of Rescue and the extent to which policy makers in a health care system can be taken to have such obligations. It is argued that in both cases these problems can be overcome and hence that there is a prima facie obligation to follow the Rule of Rescue. (shrink)

The rule of rescue holds that special weight should be given to protecting the lives of assignable individuals in need, implying that less weight is given to considerations of cost-effectiveness. This is sometimes invoked as an argument for funding or reimbursing life-saving treatment in public healthcare even if the costs of such treatment are extreme. At first sight one might assume that an individualist approach to ethics—such as Scanlon’s contractualism—would offer a promising route to justification of the (...) class='Hi'>rule of rescue. In this chapter I argue that contractualism cannot endorse the rule of rescue, whereas a collectivist approach that appeals to group solidarity would offer support for rescue cases. The argument, however, has its limitations, and though solidarity is of central concern in shaping public healthcare, there are good reasons for not endorsing the rule of rescue as a moral basis for allocating scarce resources in clinical care. (shrink)

In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the “Rule of Rescue”). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the (...) Rule of Rescue in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others. (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)

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style reasoning (...) are commonly combined in an ethically acceptable fashion. (shrink)

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale (...) allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic. (shrink)

Universal access to health care is still a dream rather than a reality in the United States. This is partly because a rule of rescue, by impelling us to help people in need, urges us to ignore the limits of our health care policies wherever those limits would adversely affect a given individual. As the rule of rescue undermines whatever limits we set on health care entitlements, it can thwart the cost containment so essential to expanding (...) access. Rather than accept unlimited expense, we have thus far declined to universalize health care. The situation is exacerbated by an economic insulation shielding patients and physicians from the costs of care, prompting both to regard health care as free, an unlimited right. To reverse this costly entitlement mentality and place reasonable limits on rescue, patients must exercise greater personal responsibility for the costs of their care by directly experiencing some of the economic consequences of their health care decisions. Several mechanisms are available to accomplish this goal without posing economic barriers to needed care or penalizing people for becoming ill. Keywords: Clinton health plan, rationing, rule of rescue CiteULike Connotea Del.icio.us What's this? (shrink)

abstract The central issue that I consider in this paper is the use of the so‐called ‘Rule of Rescue’ in the context of resource allocation. This ‘Rule’ has played an important role in resource allocation decisions in various parts of the world. It was invoked in Ontario to overturn a decision not to fund treatment for Gaucher's Disease and it has also been used to justify resource decisions in Israel concerning the same condition. In the paper I (...) consider the nature of the Rule of Rescue and its moral justification. The latter involves consideration of the distinction between agent‐relative and agent‐neutral obligations. If the Rule of Rescue is to be justified, it is plausible to think that it will be in the context of agent‐relative obligations. Two problems with this suggestion are considered: the role of identifiability in the Rule of Rescue and the extent to which policy makers in a health care system can be taken to have such obligations. It is argued that in both cases these problems can be overcome and hence that there is a prima facie obligation to follow the Rule of Rescue. (shrink)

Clinicians and health researchers frequently encounter opportunities to rescue people. Rescue cases can generate a moral duty to aid those in peril. As such, bioethicists have leveraged a duty to rescue for a variety of purposes. Yet, despite its broad application, the duty to rescue is under-analyzed. In this paper, we assess the state of theorizing about the duty to rescue. There are large gaps in bioethicists’ understanding of the force, scope, and justification of the (...) two most cited duties to rescue—the individual duty of easy rescue and the institutional rule of rescue. We argue that the duty of easy rescue faces unresolved challenges regarding its force and scope, and the rule of rescue is indefensible. If the duty to rescue is to help solve ethical problems, these theoretical gaps must be addressed. We identify two further conceptions of the duty to rescue that have received less attention—an institutional duty of easy rescue and the professional duty to rescue. Both provide guidance in addressing force and scope concerns and, thereby, traction in answering the outstanding problems with the duty to rescue. We conclude by proposing and propose research priorities for developing accounts of duties to rescue in bioethics. (shrink)

There is substantial published evidence showing that countless people enroll each year in ethically deficient clinical trials. Many of the trials are problematic because the quality of the science used to justify their launch may not be sufficiently vetted while many other trials may lack requisite social value. This poses the question: why do people volunteer for them? The answer resides in large part in the fact that informed consent practices have historically masked, rather than disclosed, the information that would (...) alert research candidates to the ethically problematic nature of the trials. The “reasonable person” and “key information” provisions in the revised US Common Rule create the opportunity to correct this historical shortcoming. Two sources are employed to shed light on what the “key information” is that should be disclosed to a “reasonable person”: the original disclosure aims of the Nuremberg Code, as well as an extensive body of meta-research evidence. Those sources jointly support a range of new disclosures in the informed consent process that would unmask the heretofore undisclosed information. The resulting proposed new disclosures pertain to the overall success prospects of clinical trials, the quality of the prior research that both forms the basis of clinical trials and informs assessment of their risks and benefits, the potential social value of clinical trials, and the commercial purposes of clinical trials. (shrink)

In this stimulating work of political philosophy, acclaimed philosopher G. A. Cohen sets out to rescue the egalitarian thesis that in a society in which distributive justice prevails, peopleâes material prospects are roughly equal. Arguing against the Rawlsian version of a just society, Cohen demonstrates that distributive justice does not tolerate deep inequality. In the course of providing a deep and sophisticated critique of Rawlsâes theory of justice, Cohen demonstrates that questions of distributive justice arise not only for the (...) state but also for people in their daily lives. The right rules for the macro scale of public institutions and policies also apply, with suitable adjustments, to the micro level of individual decision-making. Cohen also charges Rawlsâes constructivism with systematically conflating the concept of justice with other concepts. Within the Rawlsian architectonic, justice is not distinguished either from other values or from optimal rules of social regulation. The elimination of those conflations brings justice closer to equality. (shrink)

The information explosion and digital modes of learning often combine to inform the quest for the best ways of transforming information in digital form for pedagogical purposes. This quest has become more urgent and pervasive with the ‘turn’ to online learning in the context of COVID-19. This can result in linear, asynchronous, transmission-based modes of teaching and learning which commodify, package and deliver knowledge for individual ‘customers’. The primary concerns in such models are often technical and economic – technology as (...) a cost-effective ‘solution’ to educational challenges. In this paper I argue for the importance of dialogic learning space in teaching and learning by means of Information and Communication Technologies, whether in the form of fully online learning, blended learning or face-to-face encounters using ICT affordances. Although the 20th Century theorists Mikhail Bakhtin (1895–1975) and Hans-Georg Gadamer (1900–2002) produced their seminal works before the advent of ICTs, they were both concerned with the quality and authenticity of human engagement with texts and with other persons and contexts. Besides a shared interest in dialogue as an ontological feature of human life and being, they both used spatiotemporal concepts for understanding and interpreting texts. The article draws on Gadamer’s notions of dialogue and horizon, and Bakhtin’s notions of dialogue and chronotope, to conceptualize dialogic possibilities for online education. Its purpose is to provide a framework, grounded in Bakhtin’s and Gadamer’s ideas, for a dialogic approach to online teaching and learning in higher education. (shrink)

Clinicians and researchers can often rescue patients or research participants from serious harms. Indeed, they often have a duty to do so—a duty to rescue. Duties to rescue are frequently discussed in the medical ethics literature, but according to Tina Rulli and Joseph Millum they are under-theorised and more problematic than is normally acknowledged. Rulli and Millum outline two widely discussed conceptions of rescue duties: a so-called duty of easy rescue, applying to all moral agents (...) (including healthcare professionals), and the rule of rescue, applying specifically to institutions. They raise concerns about both. (shrink)

Jesus of Nazareth, like Socrates, left nothing behind written by himself. Yet, the records of his teaching indicate a rich interest in dialogic pedagogy, reflected in his use of the parable, primarily an oral genre, as a dialogic provocation. Working at the interface of pedagogy, theology and philosophy, this article explores the parable of the Good Samaritan from the perspective of dialogic pedagogy. It employs an analytical approach termed diacognition, developed from the notions of dialogue, position and cognition, to analyse (...) the moves within the parable and the teaching situation in which it is located. The article explores how Jesus engages the dialogue of and around the parable to position and reposition his interlocutor, provoking a re-cognition of what it means to love one’s neighbour. It concludes by reflecting on the implications of this analysis for the relation of meaning to knowing and doing. (shrink)

Dialogue is a seminal concept within the work of the Brazilian adult education theorist, Paulo Freire, and the Russian literary critic and philosopher, Mikhail Bakhtin. While there are commonalities in their understanding of dialogue, they differ in their treatment of dialectic. This paper addresses commonalities and dissonances within a Bakhtin-Freire dialogue on the notions of dialogue and dialectic. It then teases out some of the implications for education theory and practice in relation to two South African contexts of learning that (...) facilitate the access to education of disadvantaged groups, one in higher education and the other in early childhood education. (shrink)

This article examines the relationship between online dispute resolution (ODR) and trust. We discuss what trust is, why trust is important, and how trust develops. Our claim is that efforts to implement online dispute resolution on a site or service in a manner that promotes trust need to consider ODR as just one tool in a broader toolbox of trust-building tools and techniques. These techniques are amongst others marketing, education, trust seals, and transparency. By evaluating ODR in its proper context (...) as one component of a larger trust strategy, we can more accurately set expectations for its results and position our projects for success. (shrink)

The article presents proofs of the context freeness of a family of typelogical grammars, namely all grammars that are based on a uni- ormultimodal logic of pure residuation, possibly enriched with thestructural rules of Permutation and Expansion for binary modes.

Antimicrobial resistance (AMR) describes the evolution of treatment‐resistant pathogens, with potentially catastrophic consequences for human medicine. AMR is driven by the over‐prescription of antibiotics, and could be reduced through consideration of the ethical dimensions of the dilemma faced by doctors. This dilemma involves balancing apparently opposed interests of current and future patients, and unique contextual factors in different countries, which may modify the core dilemma. We describe three example countries with different economic backgrounds and cultures—South Africa, Sri Lanka and the (...) United Kingdom. Then we discuss how country‐specific factors impact on the prominence of various ethical dimensions of the dilemma (visibility and moral equality of future generations; Rule of Rescue; prescribing autonomy and conflicts of interest; consensus on collective action). We conclude that a nuanced understanding of national prescribing dilemmas is critical to inform the design of effective stewardship approaches. (shrink)

Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and (...) on substituted interest judgments. Patients’ known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR. (shrink)

Is there a rational and ethical basis for efforts to rescue individuals in dire straits? When does rescue have ethical support, and when does it reflect an irrational impulse? This paper defines a Rule of Rescue and shows its intuitive appeal. It then proceeds to argue that this rule lacks support from standard principles of justice and from ethical principles more broadly, and should be rejected in many situations. I distinguish between agent-relative and agent-neutral reasons, (...) and argue that the Rule of Rescue qualifies only in a narrow range of cases where agent-relative considerations apply. I conclude that it would be wise to set aside the Rule of Rescue in many cases, especially those involving public policies, where it has only weak normative justification. The broader implications of this analysis are noted. (shrink)

Many philosophers believe that agents are self-ruled only when ruled by their (authentic) selves. Though this view is rarely argued for explicitly, one tempting line of thought suggests that self-rule is just obviously equivalent to rule by the self . However, the plausibility of this thought evaporates upon close examination of the logic of ‘self-rule’ and similar reflexives. Moreover, attempts to rescue the account by recasting it in negative terms are unpromising. In light of these problems, (...) this paper instead proposes that agents are self-ruled only when not ruled by others. One reason for favouring this negative social view is its ability to yield plausible conclusions concerning various manipulation cases that are notoriously problematic for nonsocial accounts of self-rule. A second reason is that the account conforms with ordinary usage. It is concluded that self-rule may be best thought of as an essentially social concept. (shrink)