Rationale, aims and objectives Given the increasing prevalence of cataract and demand for cataract extraction surgery, patients must often wait to undergo this procedure. We validated a previously developed priority scoring system in terms of clinical variables, pre-intervention health status, appropriateness of surgery and gain in visual acuity (VA) and health-related quality of life (HRQoL).Methods Explicit prioritization criteria for cataract extraction created by a variation of the Research and Development (RAND) and University of California Los Angeles appropriateness methodology (...) were retrospectively applied to a prospective cohort of 5257 patients on waiting lists to undergo cataract by phacoemulsification at 17 hospitals in Spain. Demographic data, clinical data and data related to surgical technique were collected by trained ophthalmologists. Patients were evaluated by their ophthalmologist before the intervention and 6 weeks afterward. They also completed, by mail, the Visual Function Index (VF-14) before the intervention and 3 months afterward.Results High-priority patients experienced greater improvement in VA and HRQoL than those classified as intermediate or low-priority (P < 0.0001), even after adjusting by VA and the VF-14 score at baseline. The time to intervention was the same for high-priority patients as it was for intermediate and low-priority patients.Conclusions The priority score we developed identified patients most likely to experience the greatest improvements from cataract extraction. Use of this tool could provide a fairer and more rational way to prioritize patients for cataract extraction. (shrink)

Medical criteria rooted in evidence-based medicine are often seen as a value-neutral ‘trump card’ which puts paid to any further debate about setting priorities for treatment. On this argument, doctors should stop providing treatment at the point when it becomes medically futile, and that is also the threshold at which the health purchaser should stop purchasing. This paper offers three kinds of ethical criteria as a counterweight to analysis based solely on medical criteria. The first set of (...) arguments concerns futility, probability and utility; the second, justice and fairness; the third, consent and competence. The argument is illustrated by two recent case studies about futility and priority-setting: the US example of ‘Baby Ryan’ and the UK case of ‘Child B’. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s (...) severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

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

Published accounts of specific priority-setting projects in healthcare are relatively few. This article chronicles the collaborative efforts of a professional practice lead and a bioethicist to strengthen the priority-setting process for a specific home care service. The project included two features not often reported in other priority-setting projects: the entire “frontline team” was involved for the project’s duration, and a group of parents was canvassed for their views. Informed by both Daniels’s “accountability for reasonableness” approach and challenges (...) levied against it, the article explains the evolution of an assessment procedure, eligibility and priority criteria, and guiding substantive principles and concludes with the “lessons learned” by the project leads. (shrink)

National Priority Regions (NPRs) are one of Israel’s most robust tools for redistribution: a resource allocation governmental plan that favors some regions over others, mostly according to their socioeconomic status and peripherality. Drawing on archival research, this article is the first to focus on this topic and provide a detailed description and analysis of this measure. It provides historical and theoretical accounts of NPRs, tracing their history, starting in the 1970s, over three periods and showing how they have been (...) used and abused. This allows for some important observations about the stakes of using a "color-blind" place-based distributive mechanism, and about the complex relationship between redistribution, development, and settlement. At the national level, this article shows how NPRs changed over the years from a discriminatory tool that excluded almost all Palestinian-Arab localities into a more inclusionary mechanism, but one that also works to support and incentivize Jewish settlement in the Occupied West Bank. At the theoretical level, this article lends itself to and supports a ‘region-skeptic’ approach that sees the regional scale, much like other seemingly “race-neutral” criteria, mostly as an elusive exercise of power that often deepens inequality. However, drawing on Israel’s experience with NPRs, this article provides some more specific cautionary tales that can, I suggest, work to improve the regional scale rather than eliminate it altogether. (shrink)

What are the criteria for reasonable clinical judgements? The reasonableness of macro-level decision-making has been much discussed, but little attention has been paid to the reasonableness of applying guidelines generated at a macro-level to individual cases. This paper considers a framework for reasonable clinical decision-making that will capture cases where relevant guidelines cannot reasonably be followed. There are three main sections. (1) Individual claims on healthcare from the point of view of concerns about equity are analysed. (2) The demands (...) of responsibility and equity on professional clinical performance are discussed, and how the combination of these demands emerges into seven requirements that constitute the framework is explored. Since this framework is developed to assist in reasonable clinical decision-making, practical implications of all these requirements are also suggested. (3) Challenges concerning the framework are discussed. First, a crucial presumption that the framework relies upon is considered—namely, clinicians’ willingness to justify their decisions as requested. Then how public deliberation may influence clinical decision-making is discussed. Next is a consideration of how clinicians’ need to have confidence in their own judgements in order to perform in a manner worthy of trust would be compatible with adherence to the framework supported by public deliberation. It is concluded that fair distribution in the interplay between macro- and micro-level considerations can be secured by legitimising procedures on each level, by ensuring well-organised and continuing public debate and by basing individual clinical judgements upon well-justified and principled normative bases. (shrink)

Next SectionBackground International and national agencies play a major role in setting HIV care-and-treatment priorities in low-income-countries. Little is known about priority setting at lower health-system levels. The objective of this article is to explore experiences of HIV priority decisions, at what levels these decisions are made and how they might influence the distribution of health benefits in a high-endemic region in Tanzania. Methods This is a qualitative study using observations, key documents and semistructured focus-group and individual interviews (...) (43) with health workers, patients and administrators at one regional and one district hospital. The analysis was based on an editing analysis style. Results Health workers did not perceive themselves as bedside rationing agents and they reported following national recommendations and felt they have little impact on important priority decisions. Health benefit distributions were largely determined by priority decisions made at a national level. External factors, such as eligibility criteria, inadequate funding and barriers to access seemed to play a major role in the actual distribution of health services and benefits in the region. Patient groups who were actually given high priority were the sickest patients, those living near a facility and those who could afford long journeys and frequent visits. Low-priority groups were those experiencing other co-morbidities or treatment failure, children, asymptomatic patients and the poorest. Conclusions/significance The interaction of priority setting across health-system levels and their impact on distribution of health outcomes in the population has been underestimated. The distributional pattern of health outcomes calls for further normative assessment. (shrink)

The Scandinavian welfare states have public health care systems which have universal coverage and traditionally low influence of private insurance and private provision. Due to raises in costs, elaborate public control of health care, and a significant technological development in health care, priority setting came on the public agenda comparatively early in the Scandinavian countries. The development of health care priority setting has been partly homogeneous and appears to follow certain phases. This can be of broader interest as (...) it may shed light on alternative models and strategies in health care priority setting. Some general trends have been identified: from principles to procedures, from closed to open processes, and from experts to participation. Five general approaches have been recognized: The moral principles and values based approach, the moral principles and economic assessment approach, the procedural approach, the expert based practice defining approach, and the participatory practice defining approach. There are pros and cons with all of these approaches. For the time being the fifth approach appears attractive, but its lack of true participation and the lack of clear success criteria may pose significant challenges in the future. (shrink)

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and to purchase medication; and, primary care is free. However, (...) during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing. (shrink)

Adapting a terminology introduced by Brian Barry, I make a distinction between want-regarding and ideal-regarding principles and apply it to the norms and criteria put forward in environmental ethics. I argue that priority should be given to want-regarding principles over ideal-regarding ones because the former are universalizable while the latter are not, universalizable being understood in the sense ofappealing to value premises for which universal assent can be secured. This sense is different both from R. M. Hare's metaethical (...) concept of universalizability and J. L. Mackie’s “three stages of universalisation.”. (shrink)

Adapting a terminology introduced by Brian Barry, I make a distinction between want-regarding and ideal-regarding principles and apply it to the norms and criteria put forward in environmental ethics. I argue that priority should be given to want-regarding principles over ideal-regarding ones because the former are universalizable while the latter are not, universalizable being understood in the sense of appealing to value premises for which universal assent can be secured. This sense is different both from R. M. Hare’s (...) metaethical concept of universalizability and J. L. Mackie’s “three stages of universalisation.”. (shrink)

This dissertation is an investigation of ontological priority. The Introduction argues that although philosophers have often been concerned with the things that are ontologically prior, they have seldom addressed the question of what ontological priority is. ;Part One gives a detailed analysis of what ontological priority is. Chapter 1 notes that there are two competing theories available: according to the first, ontological priority is a dependence relation; according to the second, it is a degrees-of-being relation. Since (...) the two views are in themselves irreconcilable and since there are no good grounds for choosing between them, it is better to find a "higher" theory that encompasses both of them. Chapter 2 lays the groundwork for the development of this "higher" theory by examining the Scotistic notion of "essential order", a notion that includes the two relations that have been called 'ontological priority' as noted in Chapter 1. Chapter 3 adapts Scotus's understanding of essential order to formulate a definition of ontological priority. The definition does not define just one relation; rather, it gives membership criteria for an entire class of "ontological priority relations". ;Part Two examines some of the members of the class of ontological priority relations. Chapter 4 examines dependence and concludes three things: first, that the received understanding of dependence is incorrect; second, that dependence properly understood is an ontological priority relation; third, that the relation that is usually thought to be dependence is also an ontological priority relation. Chapter 5 examines degrees-of-being. Since the question of what degrees-of-being is is too complicated to deal with in the context of the dissertation, the chapter examines several theories and shows that degrees-of-being is an ontological priority relation according to any of the theories. ;The Conclusion shows some relations among the three ontological priority relations discussed in Part Two. It also shows briefly how the concept of ontological priority relations can be used to talk about the orderings of the universe. Finally, it points the way to further investigation. (shrink)

The philosophical literature understands ontological priority in two ways, in terms of dependence, and in terms of degrees-of-being. These views are not reconcilable in any straightforward manner. However, they can be reconciled indirectly, if both are seen as instances of higher-level concept that is a modification of John Duns Scotus' notion of essential order. The result is a theory of ontological priority that takes the form of a list of membership criteria for the class of "ontological (...) class='Hi'>priority relations", of which dependence and degrees-of-being are just two examples. (shrink)

Dr Gray leaves us with a question at the conclusion of his article--how should we choose priorities? He says that the debate so far has been mainly on what we should choose, but perhaps we should consider how to choose even more. Under the various subheadings of Criteria, Principles and Persons Dr Gray sets out the pros and cons of the arguments in the priority debates and tries to offer some more specific guidelines to offset the criticism that (...) the government's priority discussions have been too generalised. Yet this is a difficult task when everyone's priorities are so different. (shrink)

BackgroundNusinersen is one of an increasing number of new, expensive orphan drugs to receive authorization. These drugs strain public healthcare budgets and challenge principles for resource allocation. Nusinersen was introduced in the Norwegian public healthcare system in 2018. A national expert group consisting of physicians was formed to oversee the introduction and continuation of treatment in light of specific start and stop criteria.MethodsWe have studied experiences within the expert group with a special emphasis on their application of the start (...) and stop criteria, rationing of treatment, and experienced moral dilemmas. A research interview with six members of the national expert group was performed, then analysed with manifest content analysis. The analysis was supplemented with publically available sources on priority setting and the process leading up to the introduction of nusinersen and the establishment of the expert group.ResultsSixty-six patients have received treatment within the first 25 months since the national expert group’s establishment. Treatment has not been discontinued for any patient. No patients under 18 years of age have been denied treatment, as those who were referred at this age were all deemed to fulfill the start criteria. The expert group has, however, increased geographical treatment equity and facilitated important cooperation at the national level. Furthermore, it has enhanced open and critical discussions of both medical issues and new ethical dilemmas.ConclusionAlthough facilitating equal access to treatment for SMA patients, the national expert group has not discontinued treatment for any patient. It is suggested that in order for clinicians to be able to ration care for individual patients, they require both adequate support and sufficient formal authority. Start and stop criteria need to be re-evaluated as more knowledge and experience are gained regarding the treatment. (shrink)

Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), (...) which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework’s four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors. (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?

Objectives: The aim of this study was to examine priority setting for coronary artery bypass surgery, and to provide an overview of decisions and rationales used in clinical practice.Method: Questionnaires were sent to all permanently employed cardiologists, cardiothoracic surgeons, and anaesthesiologists at nine Swedish hospitals performing adult cardiothoracic surgery.Results: A total of 208 physicians responded . There was considerable agreement concerning the criteria that should be used to set priorities for coronary artery bypass interventions . However, there was (...) a lack of accord regarding the use of national guidelines for priority setting and risk indexes.Conclusions: Basic training and the strong support of ethical principles in priority setting are lacking. The respondents indicated a need for clearer guidelines and an open dialogue or discussion. The lack of generally acknowledged plans and guidelines for priority setting may result in unequal, conditional, and unfair treatment. (shrink)

Recent health legislation in Norway significantly increases access to specialist care within a legally binding time frame. The paper describes the contents of the new legislation and introduces some of the challenges with proliferations of rights to health care. The paper describes some of the challenges associated with the proliferation of legal rights to health care. It explains the benefits of assessing the new law in the light of a rights framework. It then analyses the problematic aspects of establishing additional (...) priority rules as solutions to rights conflicts. It then defends adequacy criteria for acceptable priority rules when such rules are unavoidable. It finally defends our proposed method and explores concrete applications. (shrink)

Explicit forms of rationing have already been implemented in some countries, and many of these prioritization systems resort to Norman Daniels’ “accountability for reasonableness” methodology. However, a question still remains: is “accountability for reasonableness” not only legitimate but also fair? The objective of this paper is to try to adjust “accountability for reasonableness” to the World Health Organization’s holistic view of health and propose an evolutionary perspective in relation to the “normal” functioning standard proposed by Norman Daniels. To accomplish this (...) purpose the authors depart from the “normal” functioning standard to a model that promotes effective opportunity for everyone in health care access, because even within the “normal” functioning criteria some treatments and medical interventions should have priority upon others. Equal opportunity function is a mathematical function that helps to hierarchize moral relevant necessities in health care according to this point of view. It is concluded, first, that accountability for reasonableness is an extremely valuable tool to address the issue of setting limits in health care; second, that what is called in this paper “equal opportunity function” might reflect how accountability for reasonableness results in fair limit-setting decisions; and third, that this methodology must be further specified to best achieve fair limit-setting decisions. Indeed, when resources are especially scarce the methodology suggested in this paper might allow not only prioritizing in an “all or nothing” basis but can contribute to a hierarchy system of priorities in health care. (shrink)

Most public and non-profit organisations that fund health research provide the majority of their funding in the form of grants. The calls for grant applications are often untargeted, such that a wide variety of applications may compete for the same funding. The grant review process therefore plays a critical role in determining how limited research resources are allocated. Despite this, little attention has been paid to whether grant review criteria align with widely endorsed ethical criteria for allocating health (...) research resources. Here, we analyse the criteria and processes that ten of the largest public and non-profit research funders use to choose between competing grant applications. Our data suggest that research funders rarely instruct reviewers to consider disease burden or to prioritise research for sicker or more disadvantaged populations, and typically only include scientists in the review processes. This is liable to undermine efforts to link research funding to health needs. (shrink)

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary (...) considerations, considerations that are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries. (shrink)

Background In the context of limited health care budgets in countries where Neglected Tropical Diseases are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost-effectiveness analyses may lead to biased and insufficiently justified priorities. Objectives The objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi- (...) class='Hi'>criteria decision-making matrix, and 3) discuss the conditions under which this decision-making procedure should be carried out in a real-world decision-making context. Methods This paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi-criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases. Discussion Our in vitro multi-criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil-transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision-making process and we stress the limitations of this study exercise. Conclusion By exploring how several criteria relevant to the multi-facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised. (shrink)

BackgroundIn the context of limited health care budgets in countries where Neglected Tropical Diseases (NTDs) are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost‐effectiveness analyses may lead to biased and insufficiently justified priorities.ObjectivesThe objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi‐criteria decision‐making (...) matrix, and 3) discuss the conditions under which this decision‐making procedure should be carried out in a real‐world decision‐making context.MethodsThis paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi‐criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases.DiscussionOur in vitro multi‐criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil‐transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision‐making process and we stress the limitations of this study exercise.ConclusionBy exploring how several criteria relevant to the multi‐facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised. (shrink)

Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event. Frailty is most frequently assessed in the old using the Clinical Frailty Scale (CSF) which ranks frailty from 1 to 9. This assessment typically takes less than one minute and is not validated in patients with learning difficulties or those under 65 years old. The National Institute for Health and Care Excellence (NICE) developed guidelines that use “frailty” as one of the priority-setting (...) class='Hi'>criteria for how scarce, but potentially lifesaving, health care resources should be allocated during the COVID-19 pandemic. Similar guidelines have been developed elsewhere. This paper discusses the ethical implications of such rationing and argues that this is an unproven and ethically problematic form of health care rationing. It specifically discusses: (1) how the frailty ascription becomes a self-fulfilling prophecy, (2) the problematic use of “frailty” in COVID-19 “triage,” (3) the circularity of the link between age and frailty, (4) indirect discrimination because of the use of a seemingly neutral criterion in health care rationing, and (5) the difficult link between comorbidities and frailty. It is found that there was no research into the use of global frailty scores as a criterion for access to acute treatment before January 2020 and so it is concerning how readily frailty scoring has been adopted to ration access to potentially lifesaving treatments. Existing gerontological frailty scoring systems have not been developed for this purpose, and repurposing them creates significant ethical issues. (shrink)

Background The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario’s protocols were presented to the public in a democratic deliberation during the summer of 2022. Objectives (1) To explore the perspectives of Quebec and (...) Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. Methods This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. Results A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value – a less acceptable tiebreaker. Conclusion Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria. (shrink)

The syntactic priority thesis (henceforth SP) asserts that the truth of appropriate sentential contexts containing what are, by syntactic criteria, singular terms, is sufficient to justify the attribution of objectual reference to such terms (Wright, 1983, 24). One consequence that the neo-Fregean draws from SP is that it is through an analysis of the syntactic structure of true statements that 'ontological questions are to be understood and settled' (Wright, 1983, 25). Despite the significant literature on SP, little consideration (...) has been given to this bold meta-ontological claim.1 My concern here is accordingly not with specific applications of SP to debates in the philosophy of mathematics, but rather with the .. (shrink)

Much research aimed at developing measures for normative criteria to guide the assessment of healthcare resource allocation decisions has focused on health maximization, equity concerns and more recently approaches based on health capabilities. However, a widely embraced idea is that health resources should be allocated to meet health needs. Little attention has been given to the principle of need which is often mentioned as an alternative independent criteria that could be used to guide healthcare evaluations. This paper develops (...) a model and indicator of need satisfaction that aggregates the health needs of a population in a particular time period into a single measure that weights individual health needs by the severity of their ill health. The paper provides a first step towards formalizing the principle of need as a measurable objective for healthcare policy and we discuss some challenges for future research, including incorporating the duration of time into need-based health evaluations. (shrink)

In Norway, priority for health interventions is assigned on the basis of three official criteria: health benefit, resources, and severity. Responses to the COVID-19 pandemic have mainly happened through intersectoral public health efforts such as lockdowns, quarantines, information campaigns, social distancing and, more recently, vaccine distribution. The aim of this article is to evaluate potential priority setting criteria for public health interventions. We argue in favour of the following three criteria for public health priority (...) setting: benefit, resources and improving the well-being of the worse off. We argue that benefits and priority to the worse off may reasonably be understood in terms of individual well-being, rather than only health, for public health priority setting. We argue that lessons from the COVID-19 pandemic support our conclusions. Keywords: COVID-19, Prioritarianism, Priority Setting, Public Health, Severity. (shrink)

In a school choice problem, each school has a priority ordering over the set of students. These orderings depend on criteria such as whether a student lives within walking distance or has a sibling at the school. A priority ordering provides a ranking of students but nothing more. I argue that this information is sufficient when priority is based on merit but not when priority is based on criteria such as walking distance. I propose (...) an extended formulation of the problem wherein a ‘priority matrix’, indicating which criteria are satisfied by each student-school pair, replaces the usual priority orderings. (shrink)

Rawls's view that the right is prior to the good has been criticized by various scholars from divergent points of view. Some contend that Rawls's teleological/deontological distinction based on the priority of the right is misleading while others claim that no plausible ethical theory can determine what is right prior to the good. There is no consensus on how to interpret the priority of right to the good; nor is there an agreement on the criteria of teleological/deontological (...) distinction. In this article, I argue that the critics' interpretations of the principle of the priority of right to the good as well as their conceptions of the teleological/deontological distinction have serious shortcomings to the extent that they ignore rich theoretical resources we find in Kant's moral and political philosophy. Kant's conception of human dignity and his division of the doctrine of virtue and the doctrine of right supply powerful arguments to clarify and sustain the idea of the priority of right to the good and the teleological/deontological division. (shrink)

Rawls's view that the right is prior to the good has been criticized by various scholars from divergent points of view. Some contend that Rawls's teleological/deontological distinction based on the priority of the right is misleading while others claim that no plausible ethical theory can determine what is right prior to the good. There is no consensus on how to interpret the priority of right to the good; nor is there an agreement on the criteria of teleological/deontological (...) distinction. In this article, I argue that the critics' interpretations of the principle of the priority of right to the good as well as their conceptions of the teleological/deontological distinction have serious shortcomings to the extent that they ignore rich theoretical resources we find in Kant's moral and political philosophy. Kant's conception of human dignity and his division of the doctrine of virtue and the doctrine of right supply powerful arguments to clarify and sustain the idea of the priority of right to the good and the teleological/deontological division. (shrink)

Rawls's view that the right is prior to the good has been criticized by various scholars from divergent points of view. Some contend that Rawls's teleological/deontological distinction based on the priority of the right is misleading while others claim that no plausible ethical theory can determine what is right prior to the good. There is no consensus on how to interpret the priority of right to the good; nor is there an agreement on the criteria of teleological/deontological (...) distinction. In this article, I argue that the critics' interpretations of the principle of the priority of right to the good as well as their conceptions of the teleological/deontological distinction have serious shortcomings to the extent that they ignore rich theoretical resources we find in Kant's moral and political philosophy. Kant's conception of human dignity and his division of the doctrine of virtue and the doctrine of right supply powerful arguments to clarify and sustain the idea of the priority of right to the good and the teleological/deontological division. (shrink)

Kant states that necessity and strict universality are criteria of a priori knowledge. Interpreting this dictum standardly and straightforwardly in respect of necessity, it is inconsistent with there being necessary a posteriori truths or contingent a priori truths (cf Kripke). This straightforward interpretation may convict Kant of understandable error (at worst) in the case of necessity, but it is so uncharitable in the case of strict universality that we ought to seek an alternative. I offer a charitable interpretation of (...) the doctrine that necessity and strict universality are sufficient conditions of a priority, commenting briefly on comparable necessary conditions. (shrink)

Ethical reflection on Artificial Intelligence has become a priority. In this article, we propose a methodological model for a comprehensive ethical analysis of some uses of AI, notably as a replacement of human actors in specific activities. We emphasize the need for conceptual clarification of relevant key terms in order to undertake such reflection. Against that background, we distinguish two levels of ethical analysis, one practical and one theoretical. Focusing on the state of AI at present, we suggest that (...) regardless of the presence of intelligence, the lack of morally relevant features calls for caution when considering the role of AI in some specific human activities. (shrink)

In health care priority setting different criteria are used to reflect the relevant values that should guide decision-making. During recent years there has been a development of value frameworks implying the use of multiple criteria, a development that has not been accompanied by a structured conceptual and normative analysis of how different criteria relate to each other and to underlying normative considerations. Examples of such criteria are unmet need and severity. In this article these crucial (...) criteria are conceptually clarified and analyzed in relation to each other. We argue that disease-severity and condition-severity should be distinguished and we find the latter concept better reflects underlying normative values. We further argue that unmet need does not fulfil an independent and relevant role in relation to condition-severity except for in some limited situations when having to distinguish between conditions of equal severity. (shrink)

Expenditures on health in many developing countries are being disproportionately spent on health services that have a low overall health impact, and that disproportionately benefit the rich. Without explicit consideration of priority setting, this situation is likely to remain unchanged: resource allocation is too often dictated by historical patterns, and maintains vested interests. This paper explores how prioritization between different health interventions can be rationalised by the use of clearly defined criteria. A number of key efficiency and equity (...) criteria are examined, in particular analysing how potential tradeoffs could be incorporated into the decision making process. (shrink)

In this article I revisit earlier stages of the discussion of personal identity, before Neo-Lockean psychological continuity views became prevalent. In particular, I am interested in Bernard Williams’ initial proposal of bodily identity as a necessary, although not sufficient, criterion of personal identity. It was at this point that psychological continuity views came to the fore arguing that bodily identity was not necessary because brain transplants were logically possible, even if physically impossible. Further proposals by Shoemaker of causal relations between (...) mental states in our memory and Parfit’s discussion of branching causal chains created additional complications. My contention in this paper is that psychological continuity views deflected our attention from what should have remained in the spotlight all the time: the intersubjective character (or not) of criteria proposed to decide personal identity in our language game, and ultimately our form of life concerning ourselves as persons. B. Williams’ emphasis on the body was not just common sense. It was also recognition of the importance of giving priority to criteria that could be kept under intersubjective control. (shrink)

Despite the international interest in priority setting as an important tool for health policy, there has been comparatively little interest in the setting of research priorities. One of the few places where there has been such an interest is at the National Institutes of Health (NIH) in the United States. Under pressure from Congress to explain its priority setting process, the NIH has tried to explain the criteria and process it uses. The NIH procedure is described, and (...) the problems created by the criteria it uses are analyzed. Although it uses the language of priority setting, it is uncertain whether it does have a real method of setting priorities. Nonetheless, despite the lack of a method, the results of its work are lauded. In the long run, however, NIH will need a more rigorous method of setting priorities. (shrink)

Fair prioritization of healthcare resources has been on the agenda for decades, but resource allocation dilemmas in clinical practice remain challenging. Can clinical ethics committees be of help? The aim of the study was to explore whether and how CECs handle priority setting dilemmas and contribute to raising awareness of fairness concerns. Descriptions of activities involving priority setting in annual reports from Norwegian CECs were studied and categorized through qualitative content analysis. Three hundred thirty-nine reports from 38 CECs (...) were studied. We found 78 activities where resource use or priority setting were explicitly highlighted as main topics. Of these, 29 were seminars or other educational activities, 21 were deliberations on individual patient cases, whereas 28 were discussions of principled or general cases. Individual patient cases concerned various distributional dilemmas where values were at stake. Six main topics and seven roles for the CEC were identified. CECs handle issues concerning the introduction of new costly drugs, extraordinarily costly established treatment, the application of priority setting criteria, resource use for vulnerable groups, resource constraints compromising practice, and futility of care. The CEC can act as an analyst, advisor, moderator, disseminator, facilitator, watch dog, and guardian of values and laws. In order to fulfil their responsibilities in handling priority setting cases, CECs need knowledge of both the ethics and the institutionalized systems of priority setting. There is potential for developing this aspect of the CECs’ work further. The Norwegian CECs are involved in priority setting decisions where they can play multiple constructive roles. In particular, they advise and raise awareness of ethical aspects in resource allocations; bridge clinical practice with higher-level decisions; and promote fair resource allocation and stakeholder rights and interests. (shrink)

Background Fair prioritization of healthcare resources has been on the agenda for decades, but resource allocation dilemmas in clinical practice remain challenging. Can clinical ethics committees be of help? The aim of the study was to explore whether and how CECs handle priority setting dilemmas and contribute to raising awareness of fairness concerns. Method Descriptions of activities involving priority setting in annual reports from Norwegian CECs were studied and categorized through qualitative content analysis. Results Three hundred thirty-nine reports (...) from 38 CECs were studied. We found 78 activities where resource use or priority setting were explicitly highlighted as main topics. Of these, 29 were seminars or other educational activities, 21 were deliberations on individual patient cases, whereas 28 were discussions of principled or general cases. Individual patient cases concerned various distributional dilemmas where values were at stake. Six main topics and seven roles for the CEC were identified. CECs handle issues concerning the introduction of new costly drugs, extraordinarily costly established treatment, the application of priority setting criteria, resource use for vulnerable groups, resource constraints compromising practice, and futility of care. The CEC can act as an analyst, advisor, moderator, disseminator, facilitator, watch dog, and guardian of values and laws. Discussion In order to fulfil their responsibilities in handling priority setting cases, CECs need knowledge of both the ethics and the institutionalized systems of priority setting. There is potential for developing this aspect of the CECs’ work further. Conclusions The Norwegian CECs are involved in priority setting decisions where they can play multiple constructive roles. In particular, they advise and raise awareness of ethical aspects in resource allocations; bridge clinical practice with higher-level decisions; and promote fair resource allocation and stakeholder rights and interests. (shrink)

In this analysis we discuss the change in criteria for triage of patients during three different phases of a pandemic like COVID-19, seen from the critical care point of view. Availability of critical care beds has become a hot topic, and in many countries, we have seen a huge increase in the provision of temporary intensive care bed capacity. However, there is a limit where the hospitals may run out of resources to provide critical care, which is heavily dependent (...) on trained staff, just-in-time supply chains for clinical consumables and drugs and advanced equipment. In the first phase, we can still do clinical prioritisation and decision-making as usual, based on the need for intensive care and prognostication: what are the odds for a good result with regard to survival and quality of life. In the next, the resources are mostly available, but the system is stressed by many patients arriving over a short time period and auxiliary beds in different places in the hospital being used. We may have to abandon admittance of patients with doubtful prognosis. In the last phase, usual medical triage and priority setting may not be sufficient to decrease inflow and there may not be enough intensive care unit beds available. In this phase different criteria must be applied using a utilitarian approach for triage. We argue that this is an important transition where society, and not physicians, must provide guidance to support triage that is no longer based on medical priorities alone. (shrink)

The experience of Costa Rica highlights the potential for conflicts between the right to health and fair priority setting. For example, one study found that most favorable rulings by the Costa Rican constitutional court concerning claims for medications under the right to health were either for experimental treatments or for medicines that should have low priority based on health gain per unit of expenditure and severity of disease. In order to better align rulings with priority setting (...) class='Hi'>criteria, in 2014, the court initiated a reform in its assessment of claims for medicine. This paper assesses this reform’s impact on the fairness of resource allocation. It finds three effects. First, a reduction in successful claims for experimental medication, which is beneficial. Second, an increase in the success rate of medication lawsuits, which is detrimental because most claims are for extremely cost-ineffective medications. Third, a decline in the number of claims for medicine, which is beneficial because it forestalls such low-priority spending. This paper estimates that, taking all three effects into account, the reform has had a modest net positive impact on overall resource allocation. However, it also argues that there is a need for further reforms to lower the number of claims to low-priority medicines that are granted. (shrink)

With the limited initial availability of COVID-19 vaccines in the first months of 2021, decision-makers had to determine the order in which different groups were prioritized. Our aim was to find out what normative approaches to the allocation of scarce preventive resources were embedded in the national COVID-19 vaccination schedules. We systematically reviewed and compared prioritization regulations in 27 members of the European Union, the United Kingdom, and Israel. We differentiated between two types of priority categories: groups that have (...) increased infection fatality rate (IFR) compared to the average for the general population and groups chosen because their members experience increased risk of being infected (ROI). Our findings show a clear trend: all researched schedules prioritized criteria referring to IFR (being over 65 years old and coexisting health conditions) over the ROI criteria (eg occupation and housing conditions). This is surprising since, in the context of treatment, it is common and justifiable to adopt different allocation principles (eg introducing a saving more life-year approach or prioritizing younger patients). We discuss how utilitarian, prioritarian, and egalitarian principles can be applied to interpret normative differences between the allocation of curative and preventive interventions. (shrink)

Medical decision making often utilizes subjective observations to arrive at concrete judgments. The decisions frequently affect who receives scarce medical treatments and, thus, who lives or dies. In this paper, a model health status index is described. It is specific for the problem of choosing patients for hemodialysis or transplantation. Such a health status index may be designed for any medical decision involving such issues as drug treatment priorities, identification of salvageable patients, and selection of patients for scarce medical treatment. (...) This index (1) incorporates a physician''s own medical criteria and values, (2) can be modified as the data base improves, (3) assures consistency from decision to decision, and (4) can be developed and used without the help of a mathematician or computer. (shrink)