abstract The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, (...) each of which focuses on separate intuitions. Although this account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting‐point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs‐based priority setting to social welfare maximisation. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept (...) of health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out (...) and discuss a number of queries which seem to arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

Assessments of health care needs are embedded in contracts for health services. Such contracts are the formal link between the identification of health care needs and the purchasing of services to satisfy those needs. They are a central part of the procedural relationship between the British health service (NHS) and the satisfaction of human needs. To evaluate contracts it is necessary to investigate this relationship. A number of headings under which it may be possible (...) to begin to evaluate contracts are described, and the potential of a ‘universalist’ approach to interrogate contract-based decision-making is briefly discussed. (shrink)

The debate about rationing health care often assumes that we can measure the health-care needs of groups and individuals. As this book makes clear, we are only just starting to develop a framework within which to measure health needs, predict the outcomes of treatments and define the conflicting priorities that influence resource allocation.

IntroductionThere is a significant disparity in the United States between the health care received by children with special health care needs versus physically healthy children.ObjectiveThe objective of the paper is to show that children with special needs receive less than adequate health care overall. This disparity affects the quality of life for these children and influences their ability to live their lives to their full potential.MethodsResearch was conducted by examining multiple studies with a focus (...) on six major factors that play a role in creating this disparity.ResultsThe findings show an alarming trend in the access and delivery of health care to children with special health care needs.ConclusionsSolutions to correcting the disparities are possible, but it will take a full understanding of the issues, perseverance, dedication, and hard work on the part of families, physicians, legislators, and others genuinely interested in creating an equal health care system for all children. (shrink)

Although the obesity epidemic appears to have affected all segments of the U.S. population, its impact on children with special health care needs has received little attention. “Children with special health care needs” is a term used in the U.S. to describe children who come to the attention of health care providers and policy makers because they need different services and supports than other children. Government, at both the federal and state levels, has (...) long felt a particular responsibility for safeguarding the health of children with special needs. The definition “children with special health care needs,” in fact, was developed by a work group established by the U.S. Maternal and Child Health Bureau to assist states in their efforts to develop community systems of services for children with complex medical and behavioral conditions. (shrink)

This commentary explores Medicaid's role for children with special health care needs today and considers how changes to Medicaid's federal financing structure under a per capita cap or block grant could affect coverage for these children.

This paper aims to provide an argument for saying that a publicly funded health care system, available to all free at the point of delivery, is morally superior to a market system, and to provide a framework for deciding questions about which forms of health care should be included in such a public system. The argument presents health care as a ‘head’, in the sense of something to which human beings are morally entitled as (...) a necessary condition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Daniels and Buchanan, are critically examined and rejected. (shrink)

A couple and their five‐year‐old daughter are in a car accident. The parents are not expected to survive. The child is transported to a children's hospital, and urgent treatment decisions must be made. Whom should the attending physician approach to make decisions for the child? When such cases arise in, for example, the hospitals where we work, the social worker or chaplain is instructed to use the Illinois Health Care Surrogacy Act as a guidepost to identify a decision‐maker. (...) But in our state and the country overall, the limitations of such statutes leave hospital workers to make a judgment call among friends, family, and clergy who may come forward. While surrogate decision‐making statutes comprehensively address surrogate decision‐makers for adults, a patchwork of laws—permanency statutes, kinship provider statutes, standby guardianship statutes, and, in some cases, surrogate decision‐making statutes—provide variable decision‐making pathways for children. (shrink)

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does (...) not mean that everyone will have whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of (...) needs must answer two distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

In one of the televised debates among Republican primary candidates for the 2012 U.S. presidential election, moderator Wolf Blitzer presented this hypothetical case to candidate Ron Paul:A healthy 30 year old young man has a good job, makes a good living, but decides — you know what — ‘I’m not going to spend 200 or 300 dollars a month for health insurance because I’m healthy, I don’t need it.’ But something terrible happens, all of a sudden he needs (...) it. Who’s going to pay if he goes into a coma?Paul, known for his libertarian views, initially responded that the patient “should assume responsibility for himself,” and that he should have purchased a major medical policy before he became ill. (shrink)

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural (...) areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children’s care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations. (shrink)

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held (...) informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient’s problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors. (shrink)

The migratory flows of recent decades that have exercised Europe as a socio-political and economic entity have produced extensive responses and interventions from European gender scholars. One relatively recent phenomenon in this context is the question of reparative surgical interventions, specifically clitoral reconstruction, in cases where women who have migrated to Europe have experienced female genital cutting. Clitoral reconstruction, which this article begins to explore, is recent in part because the related surgery was only established in the 1990s and is (...) to date only practised in a few European countries, and in part because the research with women who ask for and have undergone such surgery has also only recently begun. This article is therefore an initial attempt to map some of the related terrain and to suggest further work that needs to be done in this increasingly important area. (shrink)

The rhetoric of 'needs' has been used to legitimate all major turns in UK health policy since 1936. This study identifies the ethical, policy and technical issues arising from the concept of needs. In the first part a theory of needs is developed, which takes into account both the philosophical traditions and the practical problems arising in daily health care. In a second part, health systems throughout the world are described and compared, addressing ethical as well (...) as economical questions. Its interdisciplinary approach will make The Need for Healthcare important reading not only for those interested in or employed in the health care sector but also for students of philosophy. (shrink)

Digital health includes applications for smartphones and smart speakers as well as more traditional ways to access health information electronically, such as through your health care provider's online web‐based patient portal. As the number of digital health offerings—such as smartphone health trackers and web‐based patient portals—grows, what benefit do ethics, or bioethics, perspectives bring to digital health product development? For starters, the field of bioethics is concerned about issues of social justice, including equitable (...) benefit and minimization and fair distribution of the burden of harms. Researchers who employ user‐centered design methods should consider what digital health applications and products would look like if issues like equity and accessibility were foregrounded throughout design and development. One group whose needs are often neglected in the design of digital health products is older adults. Many people anticipate that the digital divide among older adults will close as the current generation of tech‐savvy consumers ages up. But since technology is constantly evolving, this divide may be constantly recreated. As bioethics moves ever further into the technology era, I want it to be mindful of the creation of digital health care disparities. (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)

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

The argument for children's rights in health care has been long in the making. The success of this position is reflected in the 1995 American Academy of Pediatrics recommendations for the role of children in health care decisionmaking, which suggest that children be given greater voice as they mature. But there are good moral and practical reasons for exercising caution in these health care situations, especially when the child and parents disagree. Parents need (...) the moral and legal space within which to make decisions that will facilitate their child's long‐term autonomy, not only her present‐day autonomy. Moreover, third‐party intrusion, by physicians or the state, should be resisted unless negligent and abusive decisions are in the making. (shrink)

The great majority of the Chinese population depended on religious ritual, which often incorporated materia medica, for its health care. Of the therapeutic rituals available, those of popular religion—popular in the sense of participation by all social strata—were most accessible. Its priests were usually neighbors, farmers or craftsmen who performed their liturgical duties as they were needed, often qualified by their ability to be possessed by spirits. Here too the government shaped popular religion, partly by registering temples whose (...) deities its functionaries judged morally orthodox and effective, and in part by periodically persecuting those it did not register. People at every level of society believed that the gods were a bureaucracy, which supervised the operations of sky and earth. Laymen measured the efficacy of individual deities by their ability to meet people’s needs, the curing of ailments prominent among them. The gods enforced conventional morality, rewarding what the community valued and preventing or punishing what it feared. This chapter studies popular ritual therapies, examines their role in curing medical disorders, and explains why and how many medical authors adapted them. (shrink)

This article investigates what notions of “just health care” are found at three Swedish hospitals among health care personnel and whether these notions are relevant to what priorities are actually made. Fieldwork at all three hospitals and 114 in-depth interviews were conducted. Data have been subject to conceptual and ethical analysis and categorisation. According to our findings, justice is an important idea to health care personnel at the studied hospitals. Two main notions of just (...) health care were found. The main idea was the notion of “equal treatment according to need”, the basic idea being that differences in treatment should be justified by differences in needs. The competing idea that merit should affect the treatment received is occasionally encountered, the idea here being that patients, by acting irresponsibly, may no longer deserve to be treated strictly according to needs. In practice, priorities are made on grounds that only partly comply with the basic idea of justice in health care, as it is understood by staff at the studied hospitals. Exceptions are made due to regional differences, considerations of cost-effectiveness, economic incentives, tradition, the daily patient flow, research, private alternatives, patient influence and favouritism of health care personnel. (shrink)

The cost and quality of health care services can vary significantly, with high cost not necessarily indicating high quality. As consumers pay for a growing proportion of their care, they have an increased need for cost and quality information before they receive care, so they can plan and make informed decisions. Transparency tools can provide such information to consumers and others. This book examines information on cost and quality available to consumers from selected transparency tools; (...) characteristics of effective transparency tools; limitations, if any, in the effectiveness of CMS transparency tools; and CMS efforts to expand cost and quality information available through transparency tools. The book also examines how various factors affect the availability of health care price information for consumers; and the information selected public and private health care price transparency initiatives make available to consumers. (shrink)

The future will be controlled by those nations which most intelligently allocate their resources. Our nation's capital is the stored flexibility needed by our children to meet the future. How we allocate our nation's limited resources and capital will dictate the kind of lives our children will lead. We are not correctly or intelligently allocating our nation's health care resources. There are serious internal contradictions in a society that no longer produces the radios, televisions, or video recorders it (...) invented, yet pays for all patients receiving lung transplants and artificial hearts. While moving our basic value-producing industries - steel and automobiles - abroad, we continue to manufacture MX missiles and artificial hearts. We give heart transplants to smokers, but we close our steel mills. We spend freely on military and medicine, yet we refuse to spend enough to succeed in international trade. We overtreat sick people but undertreat our sick economy. Like the fading southern family in William Faulkner novels that "takes sick," as a nation we are treating our illnesses at the expense of our livelihoods. (shrink)

To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original (...) research articles while (12) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues. (shrink)

Little is known about health care professionals’ perceptions regarding what it means to treat patients and families with respect and dignity in the intensive care unit (ICU) setting. To address this gap, we conducted nine focus groups with different types of health care professionals (attending physicians, residents/fellows, nurses, social workers, pastoral care, etc.) working in either a medical or surgical ICU within the same academic health system. We identified three major thematic domains, namely, (...) intrapersonal (attitudes and beliefs), interpersonal (behaviors), and system (contextual) factors that influence treatment with respect and dignity. Participants suggested strategies for improving treatment of patients and families in the ICU with respect and dignity, as well as the related need for enhancing respect among the multidisciplinary team of clinicians. Implementing these strategies will require innovative educational interventions and leadership. Future research should focus on the design and evaluation of such interventions on the quality of care. (shrink)

Health Care Ethics examines the way ethical dilemmas are played out in everyday clinical practice and argues for an approach to ethical decision-making which focuses more on patient needs than competing professional interests. While advances in medical science and technology have improved the ability to save and prolong lives, they have also given rise to fundamental questions about what constitutes life and personhood, especially in the context of what are termed 'persistent vegetative state' and 'brain death'. Drawing on (...) the example of intensive care where such questions feature strongly in everyday practice, Kath M Melia examines how decisions are taken within the context of multiprofessional teamworking, including · whether to admit a patient and commence treatment · what the aim of treatment should be (i.e. palliation, care or cure) · when to limit, withhold or withdraw treatment · when to donate organs. As an area in which different professional groups work closely together, the author argues that there are lessons to be learnt from intensive care which can be applied to ethical decision making in all areas of health care for the greater good of patients. The book makes a significant contribution to the literature on ethics in health care and to the development of ethical decision making which prioritises the needs of patients. It is essential reading for ethicists, sociologists and health care professionals. (shrink)

This paper is essentially concerned with defending the idea of a universal right to adequate health care coverage. It will argue for the existence of a human right grounded in Catholic social thought. At the outset, a statement of clarification is needed. This paper does not pretend to offer the panacea for all ills relating to health care provision. Rather, it is an inquiry into the kinds of value that should inform decision making relating to (...) class='Hi'>health policy. A universal right to adequate health care cannot be established without questioning the underlying values that inform the debate and bring them firmly to the level of deliberative consciousness. It is these value concerns that structure the dynamic of health care provision and the general provision of wider resources in society. (shrink)

Background: Inclusion or not of a treatment strategy in the publicly financed health care is really a matter of prioritisation. In Sweden priority setting decisions are governed by law in which it is stated that decisions should be guided by firstly the principle of need and secondly the principle of cost-effectiveness.

This essay attempts to describe contemporary Catholic sponsored health care in the United States and to describe the purpose and structure of these particular Christian charitable organizations within the broader society. As health care has become more complex, critics claim that there is not a need for Catholic sponsored health care any longer. The author attempts to evaluate critically whether Catholic health care has a place in contemporary society. He reviews some (...) salient biblical, ecclesial, and justice teachings of the Church to demonstrate why religious institutional presence is still needed. The author reviews contemporary health care structures to show how this is accomplished. He also uncovers additional issues which need to be addressed in order for these charitable institutions to carry on the ministry of the Church, to shape social structures, and to proclaim the reign of God. (shrink)

An argument based on Kant for access to health-care for all is a most helpful addition to prior discussions. My paper argues that while such a point of view is helpful it fails to be persuasive. What is needed, in addition to a notion of the legislative will, is a viewpoint of community which sees justice as originating not merely from considerations of reason alone but from a notion of community and from a framework of common human experiences (...) and capabilities. (shrink)

This paper addresses three factors that have contributed to shifts in decision making in health care. First, the notion of patient autonomy, which has changed due to the rise of patient-centred approaches in contemporary health care and the re-conceptualization of the physician-patient relationship. Second, the understanding of patient autonomy has broadened to better engage patient participation. Third, the need to develop cross-cultural health care ethics. Our paper shows that the shift in the West (...) from the individual to the relational self indicates an important change in the understanding of autonomy through the lens of culture. Practices that recognize the notion of the relational self allow for a more balanced view of autonomy and a richer conception of moral agency. (shrink)

The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of (...) solidarity, which has been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups—that is, what people need at different stages of life. (shrink)

Obtaining a patient’s informed consent to treatment is an ethical, legal, and professional requirement based on the defense of human dignity. In some cases, however, a government may mandate treatment for patients without their consent if their failure to obtain treatment could endanger the common good. Such a need may arise, for example, in public emergencies, with cases of tuberculosis, and with patients who have mental health issues. May a Catholic health care professional or institution ethically (...) provide treatment to patients who resist or refuse it? The author replies with a qualified yes. Legally mandated treatment may be given without a patient’s consent so long as the treatment is necessary to protect the lives of others, it is limited strictly to what is necessary to protect others, and the principle of subsidiarity applies. National Catholic Bioethics Quarterly 13.3 (Autumn 2013): 483–498. (shrink)

America's patchwork quilt of health care coverage is coming apart at the seams. The system, such as it is, is built upon an inherently problematic base: employment. By definition, an employment-based approach, by itself, will not assure universal coverage of the entire population. If an employment-based approach is to be the centerpiece of a system that provides universal coverage, special attention must be paid to all the categories of individuals who are not employees – children, unemployed spouses or (...) singles, the unemployable ill and disabled, persons between jobs, students, retirees, the elderly. Moreover, in a purely voluntary employment-based arrangement, some employers will not provide insurance at all, and others will provide inadequate coverage, necessitating other special provisions for coverage. As a consequence, about one out of six people now has no health coverage whatsoever, and even more have inadequate coverage. All the while, the rapidly-increasing transaction costs of sustaining this grossly inadequate pluralistic system eat up sufficient funds to provide basic benefits to the entire population. The time for systematic reforms has come and gone; what is now needed is action to prevent disaster, followed by a complete rebuilding of this country's health coverage system. Although perhaps more likely to be tried than more radical, completely nationalized, ones, stepwise reforms may not go far enough to cure the significant ills of the current employment-based system. Passage of inadequate reforms, then, could well set the stage for nationalized health care in the not too distant future. (shrink)