The debate about justice and health care has occurred largely at a remove from the institutions it concerns; it has been about our most general moral principles, and about what things we value. This debate has foundered. But if the debate is turned in another direction, toward some moral principles that are widely accepted within those institutions, and toward principles that have to do with control over allocation decisions rather than with actually how to make those decisions, agreement may (...) be nearer at hand. (shrink)

The adversarial legal system is traditionally praised for its normative appeal: it protects individual rights; ensures an equal, impartial, and consistent application of the law; and, most importantly, its competitive structure facilitates the discovery of truth – both in terms of the facts, and in terms of the correct interpretation of the law. At the same time, legal representation is allocated as a commodity, bought and sold in the market: the more one pays, the better legal representation one gets. In (...) this article, I argue that the integration of a market in legal representation with the adversarial system undercuts the very normative justifications on which the system is based. Furthermore, I argue that there are two implicit conditions, which are currently unmet, but are required for the standard justifications to hold: that there is (equal opportunity for) equality of legal representation between parties, and that each party has (equal opportunity for) a sufficient level of legal representation. I, therefore, outline an ideal proposal for reform that would satisfy these conditions. (shrink)

For patients suffering from renal failure, cadaveric donor kidneys are a scarce and valuable good. In 1996, the Eurotransplant International Foundation implemented a new kidney allocation. system. The aim of this paper is to identify and discuss issues of distributive justice in kidney allocation, with an emphasis on the basic features of the new Eurotransplant system. Particular consideration is given to waiting time and medical success.

Alternative allocations of a fixed bundle of healthcare resources often involve significantly different indirect, non-health effects. The question arises whether these effects must figure in accounts of the conditions under which a distribution of healthcare resources is morally justifiable. In this article we defend a Scanlonian, affirmative answer to this question: healthcare resource managers should sometimes select an allocation which has worse direct, health-related effects but better indirect, nonhealth effects; they should do this when the interests served by such a (...) policy are more urgent than the healthcare interests better served by an alternative allocation. We note that there is a prima facie case for the claim that such benefits (and costs) are relevant—i.e. they are real benefits, and in other contexts our decisions can permissibly be guided by them. We then proceed to rebut three lines of argument that might be thought to defeat this prima facie case: they appeal to fairness, the Kantian Formula of Humanity as an End in Itself, and the equal moral worth of persons, respectively. (shrink)

This essay argues that considerations of justice that govern the morality of self-defense are also relevant in some cases in which organs are allocated for transplantation in conditions of scarcity. The essay's main substantive claim is that in general alcoholics are morally liable to be assigned a lower priority in the distribution of livers for transplantation because of their own responsibility for their need for a transplant. There are, however, practical obstacles to giving lower priority in the distribution of (...) medical resources generally to those who are responsible for their own illnesses, and it may seem unfair to single out alcoholics but not others for lower priority. (shrink)

Hugh V. Mclachlan Cet article est une réponse à la critique de Saunders de ma proposition de politique non conséquentialiste publiée précédemment concernant l’utilisation d’une loterie pour la distribution de vaccins rares par l’État face à une pandémie de grippe. J’y ai soutenu que, pour des raisons de justice, l’État devrait distribuer une partie du vaccin rare qu’il pourrait détenir à certains de ses employés de la santé et le reste aux citoyens de manière aléatoire et égale sur le (...) principe d’une loterie. Au coeur de la critique de Saunders se trouve l’affirmation selon laquelle j’ai omis à tort de prendre en compte les différences moralement pertinentes dans les besoins et la capacité de production entre les receveurs potentiels du vaccin. Le point central de ma réponse ici est que le fait que le besoin et la capacité de production soient ou non des facteurs moralement pertinents dépend de qui ou de quoi distribue le vaccin, à qui ils le distribuent et pourquoi ils le font. Par exemple, la discrimination entre les personnes dans la distribution de vaccins publics distribués à titre prophylactique sur la base de leur âge est injuste, qu’elle soit ou non moralement justifiable pour d’autres motifs. (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)

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine (...) and life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance. (shrink)

Volume 20, Issue 9, September 2020, Page 31-33.

Individuals each have their own unique conceptions of what is good. Nevertheless, because human beings have common needs, there is a significant overlap in their appreciation of what counts as good...

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

Around the world, the population is ageing in ways that pose new challenges for healthcare providers. To date these have mostly been formulated in terms of challenges created by increasing costs, and the focus has been squarely on life-prolonging treatments. However, this focus ignores the ways in which many older people require life-enhancing treatments to counteract the effects of physical and mental decline. This paper argues that in doing so it misses important aspects of what justice requires when it (...) comes to older people. (shrink)

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

How should UNOS deal with the presence of scientific controversies on the risk factors for organ rejection when designing its allocation policies? The answer I defend in this paper is that the more undesirable the consequences of making a mistake in accepting a scientific hypothesis, the higher the degree of confirmation required for its acceptance. I argue that the application of this principle should lead to the rejection of the hypothesis that ‘less than perfect’ Human Leucocyte Antigen (HLA) matches are (...) an important determinant of kidney graft survival. The scientific community has been divided all along on the significance of partial antigen matches. Yet reliance on partial matches has emerged as one of the primary factors leading blacks to spend a much longer time than whites on the waiting list for kidneys, thereby potentially impacting the justice of the kidney allocation policy. My case study illustrates one of the legitimate roles non-epistemic values can play in science and calls into question the ideal of a value-free science. (shrink)

:Robert Nozick allegedly introduced his liberal theory of private ownership as an objection to theories of end-state justice. Nevertheless, we show that, in a stylized framework for the allocation of goods in joint ventures, both approaches can be seen as complementary. More precisely, in such a context, self-ownership followed by voluntary transfer can lead to end-state fairness. Furthermore, under a certain solidarity condition, the only way to achieve end-state fairness, following Nozick’s procedure, is to endorse an egalitarian rule for (...) the initial assignment of rights. (shrink)

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review (...) alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change. (shrink)

Regulation is often applied to business behavior to ensure that the social costs of doing business are included in the cost and pricing structures of the firm. Because the consumer benefits from the transaction that generated the social costs, asking the consumer to bear the burden imposed by the transaction is fair. However, there may be a lack of Justice m the internal and external distribution of the social costs of doing business if consumers are the only party bearing (...) that burden, or if the costs are being shifted to employees or taxpayers when a closer stakeholder is also benefiting from the transaction – the stockowner. A social justice perspective requires that those benefiting from a transaction share in the burdens of it. We propose that a Tobin-like tax on stock transactions might be a just means of achieving greater justice in the distribution of the social cost burden. (shrink)

The literature on the ethics of machine learning in healthcare contains a great deal of work on algorithmic fairness. But a focus on fairness has not been matched with sufficient attention to the relationship between machine learning and distributive justice in healthcare. A significant number of clinical prediction models have been developed which could be used to inform the allocation of scarce healthcare resources. As such, philosophical theories of distributive justice are relevant when considering the ethics of their (...) design and implementation. This paper considers the relationship between machine learning in healthcare and distributive justice with a focus on four aspects of algorithmic design and deployment: the choice of target variable, the model's socio-technical context, the choice of input variables, and the membership of the datasets that models are trained and validated on. Procedural recommendations for how these considerations should be accounted for in the design and implementation of such models follow. (shrink)

According to the sufficiency theory of justice in health, justice requires that people have equal access to adequate health. In this article, I lay out the structure of this view and I assess its distributive implications for setting priority (i) between health needs across persons and (ii) between health care spending and other societal goods. I argue, first, that according to the sufficiency theory, deficiency in health cannot be completely offset by providing other societal goods. And, second, that (...) it can prevent the medicalization of societies by stressing that improvements beyond the level of adequate health have relatively little weight, if any, from the standpoint of justice. (shrink)

Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice—the capacity to benefit, personal responsibility, and need—to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those (...) older women who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice. (shrink)

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

This contribution discusses three important issues that should be addressed by those concerned with global justice. Theorizing should be better informed by a range of important bodies of knowledge, such as scholarly, activist, policy, legal, and practitioner-based. There is also a need for more inclusive normative frameworks for allocating specific responsibilities to particular agents. I explain the need for both by discussing an especially important neglected topic, namely that of corruption, which so badly undermines prospects for global justice.

A small set of allocation principles is said to be behind several theories of distributive justice. However, disagreement about the appropriate relationship between these notions remains, so that compromises between principles may generate more agreement. Truncated utilitarianism is a prominent candidate. It demands maximising total wealth subject to a floor level of individual wealth for all people. Based on some well-known distributive notions, we developed a questionnaire setting and confronted student respondents with corresponding allocation problems, where an exogenously given (...) poverty line served as a floor. However, support for allocations resulting from this specific interpretation of truncated utilitarianism remained rather low. This is surprising because the respective solution was close to an equal split of resources, and aspects of efficiency and responsibility were explicitly introduced to promote more general acceptance. We argue that people may either wish to see higher floor levels or are more inequality averse than probably expected. Moreover, high support for an unconditional consideration of the poverty line can be witnessed, even though aspects of responsibility, but not efficiency arguments, display an influence. In general, attitudes with respect to the equality–efficiency trade-off are found to remain heterogeneous, although different equality concerns are prominent. Furthermore, trade-offs are moderated by the responsibility principle. (shrink)

The allocation of healthcare resources takes place at two distinct levels. At the macroeconomic level, policymakers decide on budgets, staffing, cost‐effectiveness thresholds, clinical guidelines and insurance payments; at the microeconomic level, healthcare professionals decide on whom to treat, what the appropriate treatment is, how much time and effort should each patient receive and how urgent the need for care is. At both levels, there is a constant social need for just allocation. Policymakers are mostly guided by abstract principles of (...) class='Hi'>justice, thinking in terms of groups of patients, epidemiological data, impersonal statistics and economic costs. On the other hand, healthcare professionals understand the need for justice at a more personal level, as they interact with patients and, in a sense, put theory into practice. Nurses hold a unique position in healthcare systems, as, traditionally, they are closer to patients than other health professionals. This means that they have a firsthand view of the effect that their decisions have on specific patients and, therefore, nurses tend to get more influenced by their personal feelings, values and beliefs at the microeconomic level. This presentation shall examine the gap between abstract macroeconomic and concrete microeconomic health resources allocation decisions, with a particular emphasis on the role of the nurse. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

Physicians traditionally have been given role-specific obligations to promote the well-being of their individual patients, one patient at a time. They are not expected to be concerned with how health care is best allocated between patients, or with how health-care allocations compare to other social goods and services. The assumption seems to be that our society’s health-care allocation should be the cumulative result of individual clinical decisions made on behalf of individual patients. In this view, physicians are the gatekeepers of (...) health-care allocation, because they are responsible for making clinical decisions about prescriptions and admissions to health-care institutions and other services. But they should... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Just Share: Justice and Fairness in Resource Allocation*Pat Milmoe Mccarrick (bio) and Martina Darragh (bio)Each of us has some basic sense of what the words “fair” or “just” or “fairness” or “justice” mean. Each of us probably also has an idea of what is “fair” in health care. The attempt by the state of Oregon in the mid-1980s to quantify this notion made a previously private (...) exercise a public one. This transition has been chronicled in the bioethics literature that focuses on resource allocation. These works examine both theories of justice and concepts of “health”; the fair distribution of health resources has been of continuing interest since the beginning of bioethics in the 1960s. Early writing on justice includes authors Tom L. Beauchamp, Robert H. Blank, James F. Childress, H. Tristram Engelhardt, Paul T. Menzel, Paul Ramsey, and Robert M. Veatch (VII).During the 1980s, bioethicists such as Daniel Callahan and Norman Daniels proposed thinking of health care decisions not as moments of personal crisis but as choices that span a lifetime, possibly involving tradeoffs in other areas of one’s life, e.g., education. The Oregon experience added another dimension to the discussion. The initial rank-ordering of health services by cost produced a skewed list—for example, surgery for life-threatening conditions ranked below minor, elective procedures. For the project to make sense, the ranking algorithm could not be based on cost alone, but rather on a combination of costs and benefits both to individuals and to the community—“concatenations of individual and group goods” (I, Jecker and Jonsen 1995). Various metaphors have been used in the literature to facilitate discussion of this shift from individual to individual/community trade-offs: medical services as a “commons” (I, Asch 1995, Jecker and Jonsen 1995, Michels 1994); resource allocation as a “lifeboat” (I, Campbell 1995; III, Kaveny 1994); medical care as “shares” in a community health (III, Nelson 1992, Ford and Kissick 1995; II, Anderson 1993); and rationing as traveling through the desert with one jug of water for two people (a story from the Halachah literature) (I, Zoloth-Dorfman 1995). [End Page 81]Such metaphors do not promote any one “theory of justice” but rather draw from the work of a number of bioethicists as well as from theological, sociological, economic, and business literature. The five major conceptions of justice that are referenced most frequently are: “(1) a libertarian conception, which takes liberty to be the ultimate political ideal; (2) a socialist conception, which takes equality to be the ultimate political ideal; (3) a welfare liberal conception, which takes contractual fairness or maximal utility to be the ultimate political ideal; (4) a communitarian conception, which takes the common good to be the ultimate political ideal; and (5) a feminist conception, which takes a gender-free society to be the ultimate political ideal” (I, Sterba 1995).The use of new metaphors also draws on expanded concepts of “health.” “As health care is currently practiced, the most powerful symbols for public and professional alike are those that promise the defeat of time” (I, Campbell 1995). When medical care is perceived as an unrelated series of individual cures, the fact that health care resources are finite cannot be addressed.Reflections concerning the difficulties in limiting the use of health care resources have an ancient lineage and reveal a tight bond with the obsession to postpone death at all costs. Plato in Book 3 of the Republic recognizes the quandary of infinite expectations and finite resources that characterizes the challenge of health care choices. (I, Engelhardt 1996)The proliferation of expensive medical technologies and the loss of autonomy by health care professionals further complicates perceptions of the crucial issues at hand. Some have said that Americans place too much emphasis on individualism to address these issues. Daniels et al. believe that this is too pessimistic a view and that the American commitment to protecting equal opportunity for all provides a firm basis for developing a public consensus on what is fair in health care (III, Daniels, Light, and Caplan 1996). Finally, several authors suggest that the nature of all four principles of medical ethics, not justice alone, must be... (shrink)

This article draws attention to the limited amount of scholarship on what constitutes fairness and equity in resource allocation to health research by individual funders. It identifies three key decisions of ethical significance about resource allocation that research funders make regularly and calls for prioritizing scholarship on those topics – namely, how health resources should be fairly apportioned amongst public health and health care delivery versus health research, how health research resources should be fairly allocated between health problems experienced domestically (...) versus other health problems typically experienced by disadvantaged populations outside the funder's country, and how domestic and non-domestic health research funding should be further apportioned to different areas, e.g. types of research and recipients. These three topics should be priorities for bioethics research because their outcomes have a substantial bearing on the achievement of health justice. The proposed agenda aims to move discussion on the ethics of health research funding beyond its current focus on the mismatch between worldwide basic and clinical research investment and the global burden of disease. Individual funders’ decision-making on whether and to what extent to allocate resources to non-domestic health research, health systems research, research on the social determinants of health, capacity development, and recipients in certain countries should also be the focus of ethical scrutiny. (shrink)

The question of resource allocation is particularly pertinent to the realisation of socioeconomic rights. Perceptions of the place of resource allocation impact the adjudication of these rights. This article departs from the premise that with the adoption of the Optional Protocol to the International Covenant on Economic, Social and Cultural rights allowing individual communications and the establishment of the African Court on Human and Peoples’ Rights, there will be an increase in resource allocation questions for adjudication. The article interrogates the (...) experience of national courts and examines potential lessons that can be adopted at the international level to overcome the reluctance that supra-national tribunals may have when adjudicating on states obligations to fulfil. (shrink)

Action must be taken to combat climate change. Yet, how the costs of climate action should be allocated among states remains a question. One popular answer—the polluter-pays principle (PPP)—stipulates that those responsible for causing the problem should pay to address it. While intuitively plausible, the PPP has been subjected to withering criticism in recent years. It is timely, following the Paris Agreement, to develop a new version: one that does not focus on historical production-based emissions but rather allocates climate burdens (...) in proportion to each state’s annual consumption-based emissions. This change in carbon accounting results in a fairer and more environmentally effective principle for distributing climate duties. (shrink)

This paper investigates one of Anderson’s (2007) objections to individually-allocating principles of distributive justice: that they are incompatible with the free market. I argue that Anderson’s objection applies only to the specific principle she discusses, associated with luck egalitarianism, and not to individually-allocating principles generally. I then discuss different individually-allocating principles, the precepts of justice, broached by Rawls (1971,1999) but never developed by him. The precepts determine people’s distributive entitlements based on their contributions, efforts, and needs. I offer (...) an interpretation of each precept, explain why its distributive standard is compelling, show how the precepts avoid Anderson’s objection, and address Rawls’s rationale for not using the precepts in his account of distributive justice. I conclude by comparing the precepts to the kind of principle that Anderson prefers, range-constraining rules, arguing that the precepts meet the key standard associated with those rules. (shrink)

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one’s younger self for lifesaving treatments is prudent from an (...) individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age. (shrink)

Introduction: All countries face the issue of choice in healthcare. Allocation of healthcare resources is clearly associated with the concept of distributive justice and to the existence of a right to healthcare. Nevertheless, there is still the question of whether this right should include all types of healthcare services or if it should be limited to selected types. It follows that choices must be made, priorities must be set and that efficiency of healthcare services should be maximum.

Although a safe, effective, and licensed coronavirus vaccine does not yet exist, there is already controversy over how it ought to be allocated. Justice is clearly at stake, but it is unclear what justice requires in the international distribution of a scarce vaccine during a pandemic. Many are condemning ‘vaccine nationalism’ as an obstacle to equitable global distribution. We argue that limited national partiality in allocating vaccines will be a component of justice rather than an obstacle to (...) it. For there are role-based and community-embedded responsibilities to take care of one’s own, which constitute legitimate moral reasons for some identity-related prioritisation. Furthermore, a good form of vaccine nationalism prioritises one’s own without denying or ignoring duties derived from a principle of equal worth, according to which all persons, regardless of citizenship or identity, equally deserve vaccine-induced protection from COVID-19. Rather than dismissing nationalism as a tragic obstacle, it is necessary to acknowledge that a limited form of it is valuable and expresses moral commitments. Only then can one understand our world of competing obligations, a world where cosmopolitan duties of benevolence sometimes conflict with special obligations of community membership. Once these competing obligations are recognised as such, we can begin the work of designing sound ethical frameworks for achieving justice in the global distribution of a coronavirus vaccine and developing practical strategies for avoiding, mitigating or resolving conflicts of duty. (shrink)

As the federal government distributed remdesivir to some of the states COVID-19 hit hardest, policymakers scrambled to develop criteria to allocate the drug to their hospitals. Our state, Michigan, was among those states to receive an initial quantity of the drug from the U.S. government. The disparities in burden of disease in Michigan are striking. Detroit has a death rate more than three times the state average. Our recommendation to the state was that it should prioritize the communities that bear (...) a disproportionate burden of suffering in the allocation of the new potential treatment. This recommendation is justified not only for new drugs with uncertain effects, but also for drugs of certain benefit or vaccines. For states with significant health disparities, such as Michigan, this allocation priority may help to repair them. In fact, any other allocation strategy may make them worse. (shrink)

The consideration of the problem of healthcare allocation as a special case of distributive justice is especially alluring when we only consider consequentialist theories. I articulate here an alternative Rawlsian non-consequentialist theory which prioritizes the fairness of healthcare allocation procedures rather than directly setting distributive parameters. The theory in question stems from Rawlsian commitments that, it is argued, have a better Rawlsian pedigree than those considered as such by Tännsjö. The alternative framework is worthy of consideration on its own (...) merits, but it also casts light on two related difficulties with Tännsjö’s approach: (i) the limits of his supposedly ecumenical methodology, which is revealed to be dialectically suspect and (ii) issues with the type of abstraction and idealization from actual judgements and preferences which the approach requires. (shrink)

This chapter contains sections titled: The Conceptual Geography Some Teleological Approaches to Distributing Health Care Hypothetical Contractor Theory Libertarian Approaches: Autonomy by Default Conclusion.

In all western countries health care budgets are under considerable constraint and therefore a reflection process has started on how to gain the most health benefit for the population within limited resource boundaries. The field of ethics of resource allocation has evolved only recently in order to bring some objectivity and rationality in the discussion. In this article it is argued that priority setting is the prerequisite of ethical resource allocation and that for purposes of operationalization, instruments such as need (...) assessment and health technology assessment (HTA) are essential worktools for making more rational decisions. Thresholds (deduced from the need assessment and HTA) are - within this context - guiding but not binding principles. -/- Discussion of theoretical concepts of not only priority setting, need assessment and HTA complemented by practical examples for showing the challenges and the need, but also the chances of a more explicit and transparent policy of resource allocation in health care. Results: Priority setting in health care is based on the values of equity, justice and solidarity. Health packages decisions are determined from medical need (the severity of the condition) and/or the appropriateness of medical interventions (their cost-effectiveness). With growing awareness that originally effective and cost-effective services and programmes are eventually provided inappropriately, the focus is shifting towards the organisational aspects of provision and application. Therefore, need assessment is based on the distinction of health care needs from demand, supply, or actual care. Additionally HTA provides the evidence on health care interventions in a way that it becomes obvious who benefits from an intervention and who definitely does not benefit, but eventually is harmed. -/- Health services research on effective and cost-effective interventions and research/monitoring of performance that the effective and cost-effective services are provided appropriately are of increasing importance for guiding the decision-making process on priority setting and need assessment. Effective healthcare for all is sustainable, if we start to put expenditures in perspective and focus health policies and research strategies on managing expectations through patient information and a more realistic notion of medical advancements and, on the other hand, on encouraging need-based and cost-effective innovations. (shrink)

This article examines the inherently ethical nature of resource allocation in policing. Decision-makers must make trade-offs between values such as efficiency vs. equity, individual vs. collective benefit, and adopt principles of distribution which allocate limited resources fairly. While resource allocation in healthcare has been the subject of extensive discussion in both practitioner and academic literature, ethical resource allocation in policing has received almost no attention. We first consider whether approaches used in healthcare settings would be suitable for policing. Whilst there (...) are some high-level similarities in the relevant ethical considerations and processes—such as aiming for efficient and equitable resource deployment—there are also fundamental differences between the two settings, which we argue necessitate a different approach. These differences include: (1) greater diversity and incommensurability of the benefits of policing, (2) more frequent non-linearity in returns on policing investment, (3) greater “ethical divisibility” (permissible scaling down) of programs in policing, (4) a requirement to assess “need” for policing resources at the collective (rather than individual) level, and (5) clearer primacy of equity considerations in policing. Having drawn out the implications of these differences, we sketch some tentative proposals for ethical resource allocation in policing. (shrink)

One central question of climate justice is how to fairly allocate the global emissions budget. Some commentators hold that the concept of fairness is hopelessly equivocal on this point. Others claim that we need a complete theory of distributive justice to answer the question. This paper argues to the contrary that, given only weak assumptions about fairness, we can show that fairness requires an allocation that is at least as prioritarian as the equal per capita view. Since even (...) the equal per capita view is more prioritarian than is politically feasible, fairness is univocal enough for all practical purposes. (shrink)

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

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

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

For much of 2021, allocating the scarce supply of Covid‐19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the (...) ACIP violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy‐five years of age as the only criterion to identify individuals at high risk of death from Covid‐19 during phase 1b, failing to recommend place‐based vaccine distribution, and implicitly endorsing first‐come, first‐served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade‐offs between principles may have prevented these mistakes and saved lives. (shrink)