This chapter contains sections titled: What Is “Greater Need” for Health Care? Longevity Should the Health‐care System Maximize QALYs? QALYs and Equality The Evidence Base for QALY‐informed Decisions Choosing Between Claimants Allocation and Liberation Moral Evaluation of Persons Natural Justice Utility to Society Numbers of Dependents Age and Life Expectancy Fairness and Quality of Life Conclusion References.

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

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Developing Health Care in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences of health care providers working in resource-poor settings, with stories written by those on the frontlines of global health. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of global health practitioners within the frameworks of sociology and (...) medical anthropology respectively.The burgeoning interest in global health among students, health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantial moral claims. People working in global health often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to quality health care services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among global health equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basic health services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducing health disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes of health inequity.We believe that global health must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of global health as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by global health leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of global health work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic and moral—involved in this work. The profound scarcity of resources available to health providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and other health care workers, who make difficult choices every day about what to do with the few resources they have. These are the ethical dilemmas of mortal dramas at their most dire. Global health work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of global health practitioners. They highlight the translation of the moral and programmatic challenges of health care delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-up care. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)

The leading ethical problem in medical practice for the coming decade is likely to be how to select patients for priority. Criteria for such decision-making in the case of cancer patients are discussed. Clinicians, ethicists and others need to agree guidelines on giving priority to one patient over another when resources are limited, and such criteria need to be approved by society at large. The public must accept that in a non-explicit rationing system, each individual competes with (...) every other. In the case of even more difficult ethical choices, a multidisciplinary national committee is required to advise on decision-making, and its views need to be debated by the general public. (shrink)

There is a common view, dating back at least to Hume, that property rights presuppose scarcity. This paper is a critical examination of that thesis. In addition to questioning the thesis, the paper highlights the need to divorce the debate over this thesis from the debate over Intellectual Property (IP) rights (the area where it is most frequently applied). I begin by laying out the thesis’ major line of defense. In brief, the argument is that (1) property rights are (...) legitimate only when necessary, (2) necessary only to avoid injury resulting from one party’s use or possession of a good over others’, and (3) that such injury is possible only where there is scarcity. While I accept (1) (at least for the sake of argument), I argue that each of three prominent theories of the justification of property rights cast doubt on (2) and (3). As it turns out, at the theoretical level, there are a number of different ways of dealing with this conflict. However, I argue, no matter which theoretical path one takes, it turns out that the practical implications of the relationship between property rights and scarcity have been woefully misconstrued. Finally, I recount an independent argument for the thesis under consideration and argue that, whether or not it is successful against IP, it does not extend as an argument against ownership of non-scarce goods in general. This serves to further highlight the need to distinguish arguments for the thesis under consideration from arguments against IP. (shrink)

Professional control in the selection of treatment options for patients is changing. In light of social and legal developments emphasising patient choice and autonomy, and restricting medical paternalism and judicial deference, this article examines how far patients and families can demand NHS treatment in England and Wales. It considers situations where the patient is an adult with capacity, an adult lacking capacity and a child. In all three cases, there is judicial support for professional autonomy, but there are (...) also inconsistencies that have potential to elevate the importance of patient and family preferences. In combination, they may be perceived by healthcare professionals as an obligation to follow patient preferences, even where doing so conflicts with other professional obligations. It is argued that a more nuanced approach to shared decision-making could help clarify the boundaries of decision-making responsibility. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

This article provides a systematic analysis of the proposal to use Covid‐19 vaccination status as a criterion for admission of patients with Covid‐19 to intensive care units (ICUs) under conditions of resource scarcity. The general consensus is that it is inappropriate to use vaccination status as a criterion because doing so would be unjust; many health systems, including the UK National Health Service, are based on the principle of equality of access to care. However, the analysis reveals that (...) there are several unique features of Covid vaccination status in the context of a pandemic that make this issue disanalogous to cases (such as lung cancer caused by smoking) discussed previously. First, there is equality in access to care at the point of vaccination; the unvaccinated refuse the offer of preventive care when they decline vaccination, weakening their claim to ongoing care if they become ill (this is qualitatively different from ‘poor lifestyle choices’ such as smoking). Second, the decision of one person to refuse vaccination substantially increases the risk that they will become seriously ill and need ICU care; the person who chooses not to get vaccinated thus potentially increases the pressure on intensive care bed provision, as well as increasing the risk that he or she will infect others who in turn might end up needing ICU care. Third, justice cuts both ways, and giving unvaccinated patients equal priority may itself be unjust when other patients have reduced their risk of ending up on the ICU by getting vaccinated. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:You Can't Say "No" to That!(A "Difficult Patient" Story)Ingrid BergAs a sequela of COVID-19, my rural Wisconsin hospital has been jam-packed for months with patients for whom we routinely provide care and many for whom we do not. An exodus of health care workers and other constraints have made the transfer of critically ill patients very difficult. In this disquieting "new-normal" of our work life, we routinely (...) must call bigger cities throughout our state to find beds for complex patients.So, it was not surprising when a young patient, an IV drug user in sepsis from a heart infection, was admitted to me in the middle of the night. In less disheartening times, before the pandemic, this patient would have been transferred promptly to the big-city hospital. Now, though, the possibility of finding an open bed is next to impossible. Resigned, I placed admission orders, continued antibiotics and fluids, and crossed my fingers. Then the unexpected happened: a bed opened up, and we could send her at once!The patient had a harsh heart murmur. It was likely that a "vegetation" was clinging to the valve, between the right upper and lower chambers of her heart. A vegetation is a clump of debris, such as platelets, clotting proteins, and bacteria that is a menace to the body. Her chest imaging looked like her infection had already spread to her lungs.A definitive diagnosis for endocarditis requires a special ultrasound with a probe that goes down through the esophagus, a procedure performed by cardiologists. It's a serious infection, one that requires weeks of IV antibiotics and is best monitored by infectious disease specialists. Sometimes, cardiothoracic surgeons are called upon to strip away the infection at the site, depending on how badly the valve has been slayed or the size of the vegetation. My only recommendation for a young, otherwise healthy patient in this scenario, is transfer.All of these reasons for transfer were lolling around in my tired head when the night-time [End Page 14] nursing supervisor approached me and said, "We have a problem." When the patient was updated about the transfer, she balked: "She says she is tired and refusing to go," the supervisor began. "She doesn't feel like getting into an ambulance in the middle of the night and she doesn't care if her condition is life-threatening. She knows we can't force her to go and she will only talk about it again in the morning."The cartoon version of myself at that moment had bugged-out eyes, a dropped jaw, fists tight and clenched at my sides, and steam coming out of my head. I can look past a patient's self-neglect, poor medication adherence, abysmal communication, alcohol and drug addiction, and other crimes. But saying no to a bed at a tertiary care facility? Unacceptable!I marched down the quiet hallway and into her room. She was lying on her side, facing the door, one IV in a thin arm. I was confident I could reason with her once I explained the scarcity of beds and the medical necessity of transfer. But she was having none of it. I was calm until I could no longer maintain my cool: "You can't give up this bed!""Maybe in the morning," she insisted, yawning. "But not now. I am tired and want to rest!""But there might not be a bed in the morning," I countered. "And your infection can be life-threatening." (This is true, but we both knew she wasn't dying at this very moment.)"I am not going anywhere!" She raised her voice and then closed her eyes.And she was right. I had no choice but to keep her. I could not kick her out of the hospital because she was making a poor choice, and I was frustrated for having to manage the fallout of that decision. Giving her antibiotics and fluid boluses to bolster her blood pressure was certainly within my scope of practice. And fretting. Fretting is always within my scope of practice; not that my scope of practice matters when all the big... (shrink)

With healthcare systems under pressure from scarcity of resources and ever‐increasing demand for services, difficult priority setting choices need to be made. At the same time, increased attention to patient involvement in a wide range of settings has given rise to the idea that those who are eventually affected by priority setting decisions should have a say in those decisions. In this paper, we investigate arguments for the inclusion of patient representatives in priority setting bodies at the policy (...) level. We find that the standard justifications for patient representation, such as to achieve patient‐relevant decisions, empowerment of patients, securing legitimacy of decisions, and the analogy with democracy, all fall short of supporting patient representation in this context. We conclude by briefly outlining an alternative proposal for patient participation that involves patient consultants. (shrink)

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

The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among (...) class='Hi'>patients and lack of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions. (shrink)

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

This article contributes to the discourse on global justice as it pertains to resources and the just distribution of resources. The focus is on the concept of scarcity. In examining different understandings of scarcity through the use of analogies and examples, a distinction is made between absolute scarcity and relative scarcity. I examine the conceptual understanding of scarcity of resources in the context of distributive justice. Conceptual clarity is necessary to ensure (...) that scarcity is properly referred to in the discourse so that scarcity is not erroneously used when justifications are sought for material deprivation and consequent human suffering. The field of distributive justice arguably requires a full comprehension of scarcity of resources, and this can only be achieved by properly examining the concept of scarcity. (shrink)

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

The Community FoodBank of NJ was a $100 million charitable organization that distributed over 44 million pounds of food each year through its partner organizations like food pantries, soup kitchens and the like. Its mission was to “fight hunger and poverty in New Jersey [USA] by assisting those in need and seeking long term solutions.” In a time of governmental cutbacks and shrinking private donations, the nonprofit sought new sources of revenue. One idea was to leverage perishable bakery donations and (...) an in-house commercial kitchen, by creating and marketing an up-scale bagel crisp. After product development and market testing, the resulting business plan won a “Break the Gala Addiction” cash prize from the Prudential Foundation to further the social entrepreneurship effort. Now the organization needs to decide if it should use its scarce resources to scale the business internally—to maximize job creation, leverage existing facilities and capture all the revenue, or if it should outsource production and distribution for a percentage of sales so that it can focus on other efforts more tightly aligned to its mission. Students are encouraged to use ethical frameworks to think through the nonprofit’s dilemma. (shrink)

BackgroundRadiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant (...) principles.MethodsSemi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles.ResultsParticipants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier.ConclusionsMultiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views. (shrink)

There has been much philosophical interest regarding the ‘hierarchy of evidence’ used to determine which study designs are of most value for reporting on questions of effectiveness, prognosis, and so on. There has been much less philosophical interest in the choice of outcome measures with which the results of, say, an RCT or a cohort study are presented. In this paper, we examine the FDA’s recently published guidelines for assessing the psychometric adequacy of patient-reported outcome measures. We focus on their (...) recommendations for demonstrating content validity and also for how researchers should weigh up the sum of psychometric evidence when choosing these measures. We argue that questions regarding judgment and understanding meaning of these measures should play a more central role in determining their adequacy. (shrink)

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

BackgroundRespecting patients’ confidentiality is an ethical and legal responsibility for health professionals and the cornerstone of care excellence. This study aims to assess health professionals’ knowledge, attitudes, and associated factors towards patients’ confidentiality in a resource-limited setting.MethodsInstitutional based cross-sectional study was conducted among 423 health professionals. Stratified sampling methods were used to select the participants, and a structured self-administer questionnaire was used for data collection. The data was entered using Epi-data version 4.6 and analyzed using SPSS, version 25. (...) Bi-variable and multivariable binary logistic regression analyses were used to measure the association between the dependent and independent variables. Odds ratio with 95% confidence intervals and P value was calculated to determine the strength of association and to evaluate statistical significance.ResultOut of 410 participants, about 59.8% with [95% CI (54.8–68.8%)] and 49.5% with [95% CI (44.5–54.5%)] had good knowledge and favorable attitude towards patents confidentiality respectively. Being male (AOR = 1.63, 95% CI [1.03–2.59]), taking training on medical ethics (AOR = 1.73, 95% CI = [1.11–2.70]), facing ethical dilemmas (AOR = 3.07, 95% CI [1.07–8.79]) were significantly associated factors for health professional knowledge towards patients’ confidentiality. Likewise, taking training on medical ethics (AOR = 2.30, 95% CI [1.42–3.72]), having direct contact with the patients (AOR = 3.06, 95% CI [1.12–8.34]), visiting more patient (AOR = 4.38, 95% CI [2.46–7.80]), and facing ethical dilemma (AOR = 3.56, 95% CI [1.23–10.26]) were significant factors associated with attitude of health professionals towards patient confidentiality.ConclusionThe findings of this study revealed that health professionals have a limited attitude towards patient confidentiality but have relatively good knowledge. Providing a continuing medical ethics training package for health workers before joining the hospital and in between the working time could be recommended to enhance health professionals’ knowledge and attitude towards patient confidentiality. (shrink)

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

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system–paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide ‘high-value, cost-conscious care’ (HVCCC), which proponents believe is the future of (...) sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors’ professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients–redefining the currency of value from monetary costs to a patient’s quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:"To make a difference...":Narrative Desire in Global MedicineByron J. Good and Mary-Jo DelVecchio GoodIf, as Arthur Frank (2002) writes, "moral life, for better and worse, takes place in storytelling," this collection of narratives written by physicians working in field settings in global medicine gives us a glimpse of some aspects of moral experience, practice, and dilemmas in settings of poverty and low health care resources. These essays are (...) written from the midst of practice, in diverse settings in Africa, South Asia, Latin America, the Caribbean, and the United States. The majority of the writers are practitioners of contemporary 'global medicine'—physicians from North America or Europe who spend part of their lives flying into settings of poverty or special need to practice medicine and work with on-going collaborative clinical and public health systems—while a smaller number are working in the societies in which they were born. Although a few work for classic humanitarian organizations or have developed their own local NGO's, the great majority are engaged in the 'hybrid life' described by Robert Riviello and noted by Renée Fox, moving between academic medical centers and distant health care systems that are supported by local governments, major international organizations and funding agencies, and international NGO's like Partners in Health. These diverse forms of practice have become a common model for contemporary clinicians engaged in what has emerged as a new discipline of global health or global medicine, and these narratives give us a glimpse of some of the enduring, as well as newly emerging, forms of moral practice and ethical dilemmas characteristic of today's global medicine.Many of these stories are filled with the tension and pathos that makes clinical narratives powerful to read. Physicians are forced to make unfathomable decisions about whether to resuscitate and keep a baby alive, using all means available, or to let the infant die, whether to carry out a procedure that will save an infant in birth but would put the mother at risk, about how to deal with a cancer found in a very advanced state. However, virtually all of the stories transcend these classical stories of the decisions physicians are forced to make by being placed in settings of great scarcity of resources, which stand in particular contrast to the academic medical settings in North America or Europe where many of these global medicine specialists have trained and many continue to practice. The unspeakable inequality of resources emerges throughout these narratives as a kind of master theme, as the underlying moral, as opposed to plot, which gives meaning and sense to the stories. For those who practice medicine in such settings, global inequalities and scarcity of medical resources are deeply felt. They produce the rage that Jeffrey Deal describes. ("I learned to despise American churches during that time, a time when my world encompassed a dying newborn in Sudan, as well as the air conditioned padded seats [End Page 121] of our affluent suburban church.") They produce the distinctive experiences of helplessness and pain felt by clinicians who cannot separate how they would be able to treat such a patient at home from how they have to practice in these settings. For those clinicians working in their own societies, scarcity of resources often produces deep anger at the corrupt governments that fail to support basic human services for the great majority of their population. ("We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince," writes Haitian physician Paul Pierre about his experience prior to joining Partners in Health.)But for those who regularly travel back and forth across the divide between rich and poor, whether across national boundaries or within their own society, the challenge to live a moral life is unendingly complicated. While becoming a part of a struggle for global justice with colleagues and advocates from both sides of the divide, few of the narrators can avoid personal feelings of ambivalence and guilt at being able to easily move from one side of that divide to the other back home. Many fantasize about giving up their lives in the north to devote themselves... (shrink)

The aim of the present article is to consider the shortcomings of the physicalist rainfall example set forth by Aristotle in Physics II.8. I first outline the ancient physicalist account of the coming-to-be of natural organisms and the accompanying rejection of the teleological character of such processes. Then I examine the rainfall example itself. The fundamental difficulty is that rainfall does not appear to have a proper nature. Hence it is not natural in the strict sense and cannot be used (...) in arguments either for or against natural teleology. Rainfall can at most have an end in a weak sense, which makes it inadequate as a paradigm. Furthermore, the physicalist conception of action for an end is itself flawed. I argue that they construe it anthropomorphically and falsely presuppose a symmetry between coming-to-be and ceasing-to-be. I would like to thank Hasse Hamalainen and Marcin Karas for looking at earlier drafts of this paper. I am also especially grateful for the numerous remarks and suggestions of three anonymous referees. (shrink)

Objective To develop an ethically, legally, and clinically appropriate ventilator allocation policy for AdventHealth Tampa and AdventHealth Carrollwood in Tampa, Florida, which could be enacted swiftly during the Covid-19 pandemic. Methods During Spring 2020, a subcommittee of the Medical Ethics Committee established consensus on the fundamental principles of the policy, then built on existing ethical, legal, and clinical guidance. Results The plan was finalized in May 2020. The plan triages patients based on exclusion criteria (imminent mortality), prognosis and expected (...) benefit of ventilation (using the Sequential Organ Failure Assessment), and change in prognosis over time. Decisions are made by committee in order to minimize moral distress among individual patient care providers. Conclusions Due to international concerns about healthcare resource shortages during the Covid-19 pandemic, hospitals need allocation policies informed by the crisis standard of care, the hospital’s ethical duty to plan for an emergency, and federal civil rights laws Policy Implications: This type of policy can serve as a model for other institutions to develop crisis standards of care resource allocation policies, which are a necessary component of disaster planning. (shrink)

The COVID‐19 pandemic has shaken the world through its first wave, and we have yet to experience the second wave. Even resourceful countries have failed to adequately prevent epidemics in their country, and for countries like Bangladesh, which already has strained an ineffective healthcare system, the challenges to contain the SARS‐CoV‐2 virus are that much more severe. Due to the scarcity of resources and systematic failures the Bangladeshi people deeply mistrust the healthcare system. The mistrust is further magnified (...) as healthcare providers are hesitant to treat the patients because of the lack of proper protective gear. Physicians have a moral obligation to serve and treat patients; however, they have a moral obligation to protect their families. This dilemma places healthcare providers in situations where they experience moral distress. This article specifically discusses the importance of interpersonal relationships in driving change, using the framework of Responsiveness, while stating the need for complementary systematic change in order to rebuild trust in the Bangladeshi healthcare system. (shrink)

After initially emerging in China, the coronavirus (COVID-19) outbreak has advanced rapidly. The World Health Organization (WHO) has recently declared it a pandemic, with Europe becoming its new epicentre. Italy has so far been the most severely hit European country and demand for critical care in the northern region currently exceeds its supply. This raises significant ethical concerns, among which is the allocation of scarce resources. Professionals are considering the prioritisation of patients most likely to survive over those (...) with remote chances, and this news has triggered an intense debate about the right of every individual to access healthcare. The proposed analysis suggests that the national emergency framework in which prioritisation criteria are currently enforced should not lead us to perceive scarce resources allocation as something new. From an ethical perspective, the novelty of the current emergency is not grounded in the devastating effects of scarce resources allocation, which is rife in recent and present clinical practice. Rather, it has to do with the extraordinarily high number of people who find themselves personally affected by the implications of scarce resources allocation and who suddenly realise that the principle of ‘equals should be treated equally’ may no longer be applicable. Along with the need to allocate appropriate additional financial resources to support the healthcare system, and thus to mitigate the scarcity of resources, the analysis insists on the relevance of a medical ethics perspective that does not place the burden of care and choice solely on physicians. (shrink)

Background: The concept of patient advocacy is still poorly understood and not clearly conceptualized. Therefore, there is a gap between the ideal of patient advocacy and the reality of practice. In order to increase nursing actions as a patient advocate, a comprehensive and clear definition of this concept is necessary. Research objective: This study aimed to offer a comprehensive and clear definition of patient advocacy. Research design: A total of 46 articles and 2 books published between 1850 and (...) 2016 and related to the concept of patient advocacy were selected from six databases and considered for concept analysis based on Rodgers’ evolutionary approach. Ethical considerations: This study was approved by the Research Ethics Committee of Tarbiat Modares University. Findings: The attributes of patient advocacy are safeguarding (track medical errors, and protecting patients from incompetency or misconduct of co-workers and other members of healthcare team), apprising (providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, and providing information about discharge program), valuing (maintaining self-control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences), mediating (liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team), and championing social justice in the provision of healthcare (confronting inappropriate policies or rules in the healthcare system, identifying and correcting inequalities in delivery of health services, and facilitating access to community health services and health resources). Discussion and conclusion: The analysis of this concept can help to develop educational or managerial theories, design instruments for evaluating the performance of nurses in patient advocacy, develop strategies for enhancing patient advocacy, and improve the safety and quality of nursing care in the community and healthcare system. (shrink)

Despite recurring efforts, a gap exists across a variety of contexts between the protection of patients' safety in theory and in practice. This timely Research Handbook highlights these critical issues and suggests both legal and policy changes are necessary to better protect patients' safety. Multidisciplinary in nature, this Research Handbook features contributions from eminent academics, policy makers and medical practitioners from the Global North and South, discussing the essential facets concerning patient safety and the law. It highlights (...) how the role of legislation and case law has the potential to influence, both positively and negatively, medical practice and the quality of care. Chapters explore patient safety and the global health agenda; physiotherapy; 'non-therapeutic' clinical research with children; patient safety awareness in healthcare education; and the increasing use of robotics and artificial intelligence in healthcare. Outlining a wide range of international perspectives on patient safety and the law, this Research Handbook will appeal to academics and researchers specialising in health and medical law, human rights and healthcare regulation. It will also serve as a valuable resource for legal and medical practitioners alike, as well as clinicians and professionals working in healthcare governance. (shrink)

In a crisis, societal needs take precedence over a patient’s best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some (...) extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When “triaging” or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies. (shrink)

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

The sense of shame is part of human nature. What, then, is the role and significance of such a particular sensation, one that causes mental anxiety in a sick person’s weakest and the most vulnerable state? We know from historical documents going back as far as ancient Greece and Egypt that respecting patient privacy should be regarded as a moral duty for physicians in charge of treatment. However much today’s healthcare may have changed compared to centuries past, we note that (...) patient privacy has not lost its importance. In the current healthcare system, digital recording of private information and images enables others, in principle, to access these personal data quite easily. While we cannot reject the advantages offered by modern medicine, we need to consider how to design a healthcare system that respects patient privacy. What should be the standards of privacy in emergency services where urgent decisions and interventions have to be made? How should we guarantee patient privacy during medical education? The chapters of this book approach questions like these from the perspectives of different disciplines. The writings illustrate the increasing complexity of patient privacy issues in modern healthcare systems, particularly the growing difficulty to protect confidential data. At the same time, we can observe that patients are becoming more aware of their rights and their sensitivity in this area has increased. In our opinion, an approach that requires us to choose between the two values –health and privacy – would be wrong. Therefore, the question we should focus on is: “what kind of healthcare system should be developed to ensure the greatest respect for humans’ natural right to privacy?” If we want to answer this question and find sustainable solutions for these problems, it is crucial to use a multidisciplinary approach. From this perspective, the present volume is a first contribution to be published in Turkey to pursue this aim, including articles offered from various disciplines. (shrink)

Arnold J Toynbee was a historian whose 12-volume A Study of History had a huge impact on the thinking of his day. This epic, multi-volume work offered a grand synthesis of world history from the global perspective of the rise and fall of civilizations, rather than concentrating on the history of nation-states or of ethnic groups. For Time magazine Toynbee was 'an international sage' and certainly in the same bracket as 'Einstein, Schweitzer or Bertrand Russell'. Daisaku Ikeda is a figure (...) of global stature, the spiritual leader of a worldwide lay Buddhist organisation devoted to the promotion of education, culture and peace. Between 1971 and 1974 Toynbee and Ikeda discussed many of the vital issues which confronted their societies in the early 1970s, all of which remain current and significant. Indeed, topics such as the problems of pollution, dwindling natural resources, conflict and war, the role of religion, and population growth, are even more pressing than they were thirty years ago. In this volume - which still reads as freshly as it did when it was first published, and which is now reissued for a new generation of readers - the inspiring challenge issued by both men is framed as follows: will humankind choose to salvage its destiny by a revolution in thinking and morals? Or will disaster ensue if it pursues its present course towards self-destruction and the despoliation of the environment? While recognising that our survival is threatened by the imbalance between human immaturity and technological achievement, the optimistic message of this classic Dialogue is that man-made evils have a man-made cure. (shrink)

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

In the metaphysics of modality, one finds a distinction between two families of modalities: the so-called ‘objective’, ‘real’ or ‘circumstantial’ modalities and the ‘non-objective’, ‘non-real’ or ‘non-circumstantial’ modalities. The guiding thought is that in some intuitive sense the former modalities pertain to contingency in worldly circumstance—how things could have genuinely otherwise been—whereas the latter do not. Moreover the distinction has acquired importance through attempts to elucidate the modality of metaphysical necessity by assigning it a distinctive role within the (...) objective modalities. In this paper I use the resources of higher-order modal logic to explore how one might systematize these ideas. I present a formal tension which shows that one natural way of systematizing them is unstable. And whilst I show that there are ways of stabilizing the guiding picture, even the best of them involves deeply non-trivial departures from how that picture is ordinarily understood. I conclude by revisiting the motivation for the underlying picture of modalities. (shrink)

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

In lieu of an abstract, here is a brief excerpt of the content:Volitional Necessity and Volitional Shift:A Key to Sobriety?John Talmadge (bio)As a long-time amateur student of philosophy, I think my most effective contribution to this discussion of Dr. Rego's paper will be to discuss Harry Frankfurt's ideas from precisely the point of view of the beginner and the novice. After all, I had never experienced the pleasure of reading Frankfurt until reading Rego, so I can hardly be considered (...) proficient and conversant in analytical philosophy. To pretend to be so would be, in Frankfurt's way of thinking, to construe what I really am (a novice) as what I would ideally like to be (an expert). He calls this "the equation of the real with the ideal," and he certainly gets us thinking. He also says that our failure to mark the distinctions among our many passions (and our attitudes toward our passions) gets us into considerable confusion and trouble.Because I am most familiar with the diagnosis and treatment of addictions, I confine my comments to that domain. I have enjoyed over the years over the puzzling question of whether addiction should actually be called a "disease." This puzzle confounds us for one reason apparent to any armchair philosopher: how can we name something a disease when the removal of the offending agent banishes the problem? I have come to believe that Locke had it right when he said, "We would have a great many fewer disputes in the world if words were taken for what they are, the signs of our ideas only, and not for things themselves." (1994, 122) Addiction is not so much a disease as it is an idea. And this is where I think that Dr. Rego's insights have their most value.In his essay "The Importance of What We Care About," Frankfurt offers a particularly helpful example for those of us interested in the addictions. He observes that there are occasions when we care about something powerfully, and we care about it in such a fashion that we cannot avoid the consequences of the caring. His example from history is Martin Luther, who nailed his declaration to the door of the church with the statement, "Here I stand; I can do no other."It is clear, of course, that the impossibility to which Luther referred was a matter neither of logical nor of causal necessity. After all, he knew well enough that he was in one sense quite able to do the very thing he said he could not do; that is, he had the capacity to do it. What he was unable to muster was not the power to forbear, but the will.(Frankfurt 1988, 86)When an alcoholic finds success through Alcoholics Anonymous, he experiences what I would term a "volitional shift." No longer in the grip of alcohol itself, the alcoholic is constrained by what Frankfurt terms "volitional necessity." The alcoholic has a new constraint to which he declares he is subject, that is, "Today I will remain sober." [End Page 327]Frankfurt says that this capacity—the ability to reflect on ourselves—is precisely what separates us as uniquely human. As Frankfurt sees the world, the will of an agent is identical with the desire that motivates him (or would motivate him if he should act).1A first-order desire, such as the alcoholic's craving for a drink, may be contradicted by a second-order desire, specifically a desire not to crave a drink. The second-order desire is born of the individual's knowledge that the use of alcohol, in his case, will lead to dire consequences in terms of health, happiness, and stability. Frankfurt believes that an addict, for example, typically experiences a desire for the destructive chemical but also a desire not to use the chemical. This second-order desire is the one with which the addict identifies, and this reflects the addict's true self (Frankfurt 1988, 14).If we take Dr. Rego's point and notice how a therapist might approach a patient and define a problem, we see obvious distinctions between different schools of thought. To take three simple examples, consider the following: (a) a... (shrink)

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the (...) major ethical challenges encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

Background: Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic. Objective: To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency. Research design: A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 (...) nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020. Ethical considerations: We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore. Results: We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies. Discussion/Conclusion: Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses’ moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences. (shrink)

In the metaphysics of modality, one finds a distinction between two families of modalities: the so-called ‘objective’, ‘real’ or ‘circumstantial’ modalities and the ‘non-objective’, ‘non-real’ or ‘non-circumstantial’ modalities. The guiding thought is that in some intuitive sense the former modalities pertain to contingency in worldly circumstance—how things could have genuinely otherwise been—whereas the latter do not. Moreover the distinction has acquired importance through attempts to elucidate the modality of metaphysical necessity by assigning it a distinctive role within the (...) objective modalities. In this paper I use the resources of higher-order modal logic to explore how one might systematize these ideas. I present a formal tension which shows that one natural way of systematizing them is unstable. And whilst I show that there are ways of stabilizing the guiding picture, even the best of them involves deeply non-trivial departures from how that picture is ordinarily understood. I conclude by revisiting the motivation for the underlying picture of modalities. (shrink)

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

The operating assumption in mostdiscussions of health policy is that governmenthas some responsibility for the health of itscitizens and that it may legitimately tax,subsidize, and regulate its citizens in theexercise of that responsibility. On thisassumption, public obligations to HIV/AIDSpatients are a function of their needs inrelationship to other health needs. This paperchallenges the operating assumption by arguingthat it cannot be grounded in the obligationsthat individuals have to each other.The paper rests on its own assumption: themoral theory of individualism. On this (...) theory,individuals are ends in themselves who have theright to choose their own actions and uses oftheir resources; they do not have unchosenobligations to help others. In regard toHIV/AIDS patients, consequently, individualshave no duty to help, nor any other obligationbeyond that of respecting their rights; andthere is no valid basis for governmentregulations or subsidies on their behalf.The paper argues against the two approachescommonly used to defend a more expansive viewof individual obligations and the role ofgovernment. The first is the assumption ofwelfare rights to goods and services; thesecond is the assumption that distributivejustice requires some redistribution of healthcare resources. (shrink)

The central thesis of this paper is that cost-containment challenges to an Ideal Advocate model of the physician-patient relationship can be met under proper circumstances. More specifically, it is possible for physicians to constrain costs while still making clinical decisions that are free from considerations of the physician's own interests and are uninfluenced by judgements about the patient's worth. But what is required is a closed distributive system, in which savings of resources at one point are applied to others' (...) care of higher priority and a just system, that is, a system whose distributive priorities are consistent with relevant principles of justice under moderate scarcity. The historical context of the argument and a stopgap, palliative, step are also developed. (shrink)

The thesis of the paper is that For Profit Hospitals are morally inappropriate health care delivery institutions. The thesis is established first by elaborating on the beneficent nature of medicine, hospitals, and the physician/patient relationship. The primary obligation of the physician, who draws on the resources of medicine and the hospitals, is to restore personal autonomy that is diminished by illness and suffering within the constraints of the canon of loyalty that frames the physician patient relationship. Hospitals have historically (...) played the role of facilitator enhancing a physician's ability to administer treatment. Next it is argued that For Profit Hospitals may neglect the role of facilitator. This neglect may occur given the institutions' motivations to return a profit to investors by exploiting the patient/physician relationship. This exploitation is clearly shown to be contrary to the canon of loyalty that ought to exist between the patient and physician. (shrink)

During disasters, clinicians may be forced to play dual roles, as both a provider and an allocator of scarce resources. At present, a clear framework to govern resource stewardship at the bedside is lacking. Clinicians who find themselves practicing in this ethical gap between clinical and public health ethics can experience significant moral distress. One provider describes her experience allocating an oxygen tank in the intensive care unit at a hospital in Port-au-Prince, Haiti, immediately following the 2010 earthquake. (...) Using a clinical vignette and reflective narrative she attempts to identify the factors that influenced her allocation decision, opening up the factors for commentary and debate by an ethicist. A better paradigm for the ethical care of patients during disasters is needed to better guide provider choices in the future. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Existence and the Good: Metaphysical Necessity in Morals and Politics by Franklin I. GamwellWilliam MeyerExistence and the Good: Metaphysical Necessity in Morals and Politics FRANKLIN I. GAMWELL Albany: State University of New York Press, 2011. 219 pp. $24.95In the current era, a few prominent philosophers have called into question the antiteleological tendencies of modern thought. For instance, Thomas Nagel argues that we should reject the antiteleology (...) of science and its “comprehensive, speculative world picture” of “reductive materialism” (Mind and Cosmos, Oxford 2012, 4). As a nontheist, Nagel proposes a “natural teleology” as a secular alternative to theism and to the nonteleology of science as a way to offer a more intelligible and holistic understanding of existence; yet he admits at one point: “Without God, it is unclear what we should aspire to harmony with” (Secular Philosophy & the Religious Temperament, Oxford 2010, 6). With less notoriety but with greater insight, Franklin Gamwell challenges not only modernity’s nonteleology but also its postmetaphysical outlook. By developing a neoclassical or process form of metaphysical theism informed by the works of Charles Hartshorne and Alfred North Whitehead, Gamwell spells out with thoughtful clarity what we should aspire to harmonize with in our individual and collective lives.Focusing on moral and political theory, Gamwell demonstrates that a coherent understanding of ethics (The Divine Good: Modern Moral Theory and the Necessity of God, HarperSanFrancisco, 1990) and politics (Democracy on Purpose: Justice and the Reality of God, Georgetown University Press, 2000) presupposes a neoclassical metaphysical teleology. Here, in Existence and the Good, he offers [End Page 228] a more concise, refined, and integrated formulation of these previous arguments as well as new engagements with important thinkers such as Martin Heidegger and Jeffrey Stout.Gamwell pursues metaphysics in both a “strict” and a “broad” sense: the former refers to critical reflection on the most general characteristics of existence as such, while the latter refers to reflection on the necessary conditions of existence with understanding (17–19). Beginning with the former, he argues that metaphysics properly conceived––in terms of becoming rather than being––is a valid and essential enterprise because “something exists” is necessarily true while “nothing exists” cannot possibly be true (25). He then seeks to show that metaphysics in a broad sense includes metaphysics in the strict sense because existence with understanding necessarily presupposes a metaphysical telos. Toward this end, he engages Heidegger on the metaphysics of subjectivity (chap. 2). Whereas the later Heidegger maintains that all understandings of totality are wholly dependent upon some lifeworld, Gamwell counters that “totality is prior to meaning” because “exemplifications of subjectivity are constituted by prior or nonconscious relations to an order of actualities and possibilities” (49).In chapter 3 Gamwell explicates his neoclassical theism by arguing that the metaphysical telos must be an all-inclusive divine individual. Distinct from Hartshorne, he posits that God does not relate to the world merely in terms of an integration of all past actualities but rather “cooccupies the locus of all contemporaries.” Thus, all “worldly enactment localizes the divine” (90). Gamwell offers here a metaphysical version of incarnation: “Localization of the divine means relation to a becoming that cooccupies one’s place in the world and, therefore, means a communion unlike any other, so that God, we may say, is ‘closer than hands or feet.’ As the metaphysical individual, God is literally the one ‘in whom we live and move and have our being’” (92).Gamwell concludes by engaging Stout on the underlying necessity of metaphysics for democracy. Whereas Stout offers an “ethics without metaphysics” in the form of a “specific pragmatism,” which holds that citizens can coordinate actions on the basis of “moral norms [that] are entirely creatures of historically located social practices” (134), Gamwell maintains that democracy requires “a metaphysical pragmatism,” because “the practice of democratic discourse itself, as all human practices, implies the necessary principle or principles of morality” (146). The key distinction here is between implicit and explicit: Gamwell submits that democracy implicitly presupposes the divine metaphysical telos because that telos is rooted in the very character of reality as such. However, this does not mean that citizens must explicitly recognize or hold... (shrink)