What kind of life best ensures human welfare? Since the ancient Greeks, this question has been as central to ethical philosophy as to ordinary reflection. But what exactly is welfare? This question has suffered from relative neglect. And, as Stephen Darwall shows, it has done so at a price. Presenting a provocative new "rational care theory of welfare," Darwall proves that a proper understanding of welfare fundamentally changes how we think about what is best for people.Most philosophers have (...) assumed that a person's welfare is what is good from her point of view, namely, what she has a distinctive reason to pursue. In the now standard terminology, welfare is assumed to have an "agent-relative normativity." Darwall by contrast argues that someone's good is what one should want for that person insofar as one cares for her. Welfare, in other words, is normative, but not peculiarly for the person whose welfare is at stake. In addition, Darwall makes the radical proposal that something's contributing to someone's welfare is the same thing as its being something one ought to want for her own sake, insofar as one cares. Darwall defends this theory with clarity, precision, and elegance, and with a subtle understanding of the place of sympathetic concern in the rich psychology of sympathy and empathy. His forceful arguments will change how we understand a concept central to ethics and our understanding of human bonds and human choices. (shrink)

Although “rationing” continues to be a dirty word for the public in health policy discourse, Nir Eyal and colleagues handle the concept exactly right in their article in this issue of the Hastings Center Report. They correctly characterize rationing as an ethical requirement, not a moral abomination. They identify the key health policy question as how rationing can best be done, not whether it should be done at all. They make a cogent defense of what they call “rationing through inconvenience” (...) as a justifiable allocational technique. And they wisely call for research on the effectiveness and fairness of this approach and other methods of rationing. I fully agree with their approach to rationing and with their argument that the process they provocatively label “rationing through inconvenience” should not be rejected out of hand. But I believe they have underestimated two ways in which the practical impacts of rationing through inconvenience limit its potential usefulness: the asymmetry of its effect on patients and physicians and the way in which it reduces the capacity of health systems to learn from experience. (shrink)

George, feeling stressed and anxious about the criminal investigation into his firm’s accounting practices, decides that it would do him good to get away and take a long, relaxing vacation in Bermuda. According to popular informed-desire accounts of a person’s good, if George would desire to take a vacation to Bermuda upon being made fully aware of what his experience of the vacation would be like and of all the consequences therein, then this course of action would benefit him. This (...) does not mean that George must actually be privy to whether his fully informed self would desire to travel to Bermuda, but whether he would, according to such an account, determines whether going to Bermuda would benefit George, whether he or anyone else is capable of knowing it. (shrink)

Stephen Darwall's understanding of what kind of life is a good life, good for the person whose life it is, belongs in the same family as, among others, Scanlon's and mine. It is a family of views about well-being which descends from Aristotle, and Darwall has much of interest to say about the good life, and particularly about Aristotle's views on the subject. Many of the observations central to his position seem to me cogent, and are shared by other writers. (...) These include three important propositions: 1. that a good life, one which is good for those whose life it is, is not necessarily the same as a life which they think is good for them, nor does it necessarily consist in their desires being satisfied, nor in the satisfaction of any subset of their desires . 2. that people aim or intend to do what is worth doing, to have relationships worth having, and engage in goals worth pursuing, and so on, and that all of these, and their combination, are distinct from having a good life , and 3. that what makes the well-being of people worth pursuing, to the extent that it is, what provides reasons for those same people and for others to protect or promote it, is that people are valuable in themselves. (shrink)

Darwall's subject is a person's welfare – or to use his synonyms, a person's ‘good’, ‘interest’, ‘well-being’, ‘benefit’, or ‘eudaimonia’. Darwall is satisfied that there is a univocal notion here. I am unsure and shall come back to that question at the end.

In recent human rights and legal instruments, individuals with impairments are increasingly recognised as agents who are worthy of respect for their inherent dignity and capacity to make autonomous decisions regarding treatment and care provisions. These legal developments could be understood using Stephen Darwall’s normative framework of the second person standpoint. However, this paper draws upon phenomena – both in legal developments and recent court cases – to illustrate theoretical difficulties with the contractualist underpinnings of Darwall’s account if applied (...) to questions of what is owed to individuals with disabilities. I argue that, under Darwall’s framework, whether the threshold for second-personal competence has been met will determine whether respect or rational care is owed to them. This fact distorts our understanding of what we owe to persons with mental impairments—in part because it limits respect to relations that are symmetrical and reciprocal. In light of these challenges the paper offers an account of hermeneutic competency, which can be applied to non-reciprocal and asymmetrical relationships. This alternative account will be of practical import to judicial determinations of best interests under the Mental Capacity Act 2005 in England and Wales. It will also be of broader theoretical interest to any legal system that deals with people with mental disabilities. (shrink)

In his book Welfare and Rational Care, Stephen Darwall proposes to give an account of human welfare. Or rather, he offers two accounts, a metaethical and a normative account. The two accounts, he suggests, are somewhat supportive of each other though they are logically independent.

When we speak of a “good life” there are several different things we might mean. We might mean a morally good life. We might mean a life good for others, or good for the world in general. We might mean a life good in itself for the one who lives it. This last may also be described as the life high in individual welfare.

The purpose of this study was to investigate nurses’ decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses’ are able to provide care (...) for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses’ role and responsibility when resources are limited. (shrink)

Rationing in healthcare remains very much a taboo topic. Before COVID-19, it rarely received public attention, even when it occurred in everyday practices, mainly in the form of implicit rationing, as it continues to do today. There are different definitions, types and levels of healthcare rationing, according to different perspectives. With the aim of contributing to a more coherent debate on such a highly emotional healthcare issue as rationing, here are provided a number of reflections from a patient advocate perspective (...) which are specifically focused on bedside rationing, the most troublesome level, both for patients and clinicians, particularly in regard to cancer care. Oncology, with its numerous expensive therapies and increasing number of patients, is undeniably one of the main areas contributing to the increase in healthcare costs. However, the fixed budgets of today's publicly financed health systems cannot allow unlimited access to the potentially beneficial treatments to all patients. Bedside rationing constitutes the last phase of many decision-making processes occurring at different interrelated levels (macro-levels), both inside and outside healthcare systems, which implicitly and inevitably result in a bottleneck determined by the upstream decisions themselves. Shifting from implicit to explicit bedside rationing essentially means moving from a paternalistic to a citizen-before-patient approach; this implies, first of all, a cultural change. Practical bedside rationing is an ethically complex topic, but one that needs to be urgently addressed in a transparent and open debate. In this scenario, the oncological community – patients, patient advocates and clinicians – can and should play an important role. (shrink)

Book Information Welfare and Rational Care. Welfare and Rational Care Stephen Darwall, Princeton: Princeton University Press, 2003, pp. xi + 135, US$24.95 (cloth). By Stephen Darwall. Princeton: Princeton University Press. Pp. xi + 135. US$24.95 (cloth:).

This article explores the accounts of Canadian-trained health professionals working in humanitarian and development organizations who considered not treating a patient or group of patients because of resource limitations. In the narratives, not treating the patient(s) was sometimes understood as the right thing to do, and sometimes as wrong. In analyzing participants’ narratives we draw attention to how medications and equipment are represented. In one type of narrative, medications and equipment are represented primarily as scarce resources; in another, they are (...) represented as patient care. In the contexts respondents were working, medications and equipment were often both patient care interventions and scarce resources. The analytic point is that health professionals tend to emphasize one conceptualization over the other in coming to assert that not treating is right, or wrong. Rendering tacit ethical frameworks more explicit makes them available for reflection and debate. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more modest and (...) limited topic of medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

BackgroundRationing of care in nursing is nurses' inability to complete all care activities for patients because of scarcity in time and resource. Literature suggests that rationing of care is closely related to patient safety and quality of care. The phenomena have been defined and studied from varied perspectives and contexts. A systematic review of studies related to the concept was aimed at identifying and synthesizing the finding.MethodsThe review followed Preferred Reporting Items for Systematic Reviews and Meta‐analysis (...) guidelines, and literature searches were conducted in MEDLINE, CINAHL, PsycInfo, Web of Science and EMBASE databases. Fifty‐seven quantitative studies were included in the review.FindingsThe review observed that nursing activities addressing the emotional, educational, mobility and hygiene needs of the patients were commonly rationed. Antecedents of rationing included resource inadequacy and organizational work environment. Rationing influenced patient satisfaction, mortality and a number of adverse events and was associated with decreased job satisfaction, increased intention to leave and high turnover among nurses.DiscussionsThis review concludes that rationing in nursing is ubiquitous, embedded in the work environment and poses a threat to the professional health and philosophical base of nursing in addition to having serious implications on patients' safety. Strategies to reframe and reconsider organizational traits, and open discussion with other healthcare stakeholders can reduce rationing of nursing care. The review suggests future researchers adopt different methodological layout to study rationing. (shrink)

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally (...) studies highlight instances of covert rationing/missed care/care left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. (shrink)

Background: Rationing of various needed services, for example, nursing care, is inevitable due to unlimited needs and limited resources. Rationing of nursing care is considered an ethical issue since it requires judgment about potential conflicts between personal and professional values. Objectives: The present research sought to explore aspects of rationing nursing care in Iran. Research design: This study applied qualitative content analysis, a method to explore people’s perceptions of everyday life phenomena and interpret the subjective content of (...) text data. Data collection was performed through in-depth, unstructured, face-to-face interviews with open-ended questions. Participants and research context: The study population included Iranian nurses of all nursing positions, from clinical nurses to nurse managers. Purposive sampling was employed to select 15 female and 3 male nurses (11 clinical nurses, 3 supervisors, 1 matron, 1 nurse, and 2 members of the Nursing Council) working in hospitals of three cities in Iran. Ethical considerations: The study protocol was approved by Tehran University of Medical Sciences (91D1302870). Written informed consent was also obtained from all participants. Findings: According to the participants, rationing of nursing care consisted of two categories, that is, causes of rationing and consequences of rationing. The first category comprised three subcategories, namely, patient needs and demands, routinism, and VIP patients. The three subcategories forming the second category were missed nursing care, patient dissatisfaction, and nurses’ feeling of guilt. Conclusion: Levels at which healthcare practices are rationed and clarity of the rationing are important structural considerations in the development of an equal, appropriate, and ethical healthcare system. Moreover, the procedure of rationing is critical as it not only influences people’s lives but also reflects the values that dominate in the society. Therefore, in order to minimize the negative consequences of rationing of nursing care, further studies on the ethical dimensions of this phenomenon are warranted. (shrink)

Caring is a complex attitude. At first look, it appears very complex: it seems to involve a wide range of emotional and other dispositions, all focused on the object cared about. What ties these dispositions together, so that they jointly comprise a single attitude? I offer a theory of caring, the Attentional Theory, that answers this question. According to the Attentional Theory, caring consists of just two, logically distinct dispositions: a disposition to attend to an object and hence to considerations (...) pertaining to it, and a disposition to respond to the real or apparent reasons those considerations provide. The emotional and other attitudes involved in caring are instantiations of these two, more general dispositions; and these apparently diverse emotional and other dispositions are connected because the real or apparent reasons to which they are dispositions to respond are connected, in structured “packages.” The fact that the reasons to which a caring agent responds are connected in this way provides the basis for an error theory, explaining why it appears as if the emotions involved in caring are governed by rational coherence requirements. (shrink)

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear (...) and much-needed introduction to this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

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

The age-rationing debate of fifteen years ago will inevitably reemerge as health care costs escalate. All age-rationing proposals should be judged in light of the current system of rationing health care by price in the U.S., and the resulting pattern of excess and deprivation. Age-rationing should be rejected as public policy, but recognized as a personal virtue of stewardship among the elderly.

Death can be bad for an individual who has died, according to the “deprivation approach,” by depriving that individual of goods. One worry for this account of death’s badness is the Lucretian symmetry argument: since we do not regret having been born later than we could have been born, and since posthumous nonexistence is the mirror image of prenatal nonexistence, we should not regret dying earlier than we could have died. Anthony Brueckner and John Martin Fischer have developed a response (...) to the Lucretian challenge by arguing that it is rational to have asymmetric attitudes toward posthumous and prenatal nonexistence. Recently, Jens Johansson has criticized the Brueckner/Fischer position, claiming that it is irrelevant whether it is actually rational to care about future pleasures but not past pleasures. What matters, according to Johansson, is whether it would be rational for us to care about past pleasures had we come into existence earlier. In this paper, I add to the conversation between Johansson and Brueckner/Fischer by suggesting a way to defend the latter side’s position in a way that has not yet been suggested. I do this by considering a suggestion of Johansson’s for interpreting the Brueckner/Fischer position and by arguing that Johansson’s worry for the position I consider is actually incoherent. (shrink)

Several quantitative surveys have been conducted internationally to gather empirical information about physicians’ general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician–patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, but it (...) is mostly hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

Physicians are increasingly confronted with the consequences of allocation policies. In several countries, physicians have been assigned a gatekeeper role for secondary health care. Many ethicists oppose this assignment for several reasons, concentrating on the harm the intrusion of societal arguments would inflict on doctor-patient relations. It is argued that these arguments rest on a distinction of spheres of values and of rationality, without taking into account the mixing of values and rationalities that takes place in everyday medical practice. (...) If medical practice, then, does not follow a single, pure rationality, can it also incorporate the societal rationality of the gatekeeper role?Using a case from general practice, I try to show how physicians may integrate societal arguments into their practice in a morally acceptable way. A version of the model of reflective equilibrium and especially Beauchamp and Childress's safeguards, may be helpful both to analyse and teach such balancing of values and rationalities. (shrink)

Health reform must include health care rationing, both for reasons of fairness and efficiency. Few politicians are willing to accept this claim, including the Clinton Administration. Brown and others have argued that enormous waste and inefficiency must be wrung out of our health care system before morally problematic cost constraining options, such as rationing, can be justifiably adopted. However, I argue that most of the policies and practices that would diminish waste and inefficiency include implicit (and therefore morally (...) problematic) rationing. Critics of rationing see as its most morally and psychologically troubling feature that an identified individual is denied potentially beneficial care. That psychic anguish may not be eliminable, and perhaps ought not be eliminated. But if rationing protocols are fairly adopted through a process of free and informed rational democratic deliberation to which all have access, the moral objections are largely overcome. Such a process is possible only if implicit rationing is recognized and rejected. Keywords: Justice, health care rationing, health reform, democratic decision-making CiteULike Connotea Del.icio.us What's this? (shrink)

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical (...) forms of rationality, has seen the word ‘unavoidable’ used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken‐for‐granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care. (shrink)

Recognition of the need to ration care has focused attention on the concept of "basic care." It is often thought that care that is "basic" is also morally prior. This article questions that premise in light of the usual definitions of "basic." Specifically, it argues that Oregon's rationing scheme, which defines "basic" in terms of cost-effective care, fails to pay sufficient attention to important ethical principles such as justice.

This article focuses on rationing of expensive medical care in the Czech Republic. It distinguishes between political and clinical decision levels and reviews the debate in the Western literature on explicit and implicit rules. The contemporary situation of the Czech health care system is considered from this perspective. Rationing reoccurred in the mid 90s after the shift in health care financing from fee-for-service to prospective budgets. The lack of explicit rules is obvious. Implicit forms of rationing, done (...) by physicians at the clinical level prevail, implying uncontrolled power of the medical profession and lacking transparency for ethical considerations of equity to access. It seems to be acceptable for physicians to play the role of allocators, probably because of their experience with rationing during the socialist period. Traditional rationing stereotypes from the previous regime seem to persist despite the health care system transformation during the 90s. (shrink)

In this article, I discuss the implications of the neoliberal transformations on healthcare that are justified under the aegis of economic efficiency. Drawing on the work of German critical philosopher Axel Honneth, I present a critical‐social and philosophical perspective that reinterprets these transformations as pathological consequences with devastating impacts on how we understand what human beings and social relations are. I argue that in a neoliberal context, nursing care becomes a form of reification defined as ‘forgetfulness of recognition’ of (...) the human identity of the patient which contradicts the assumed ethical foundations of nursing. The article provides a detailed account on how neoliberal rationality that governs nursing performance promotes an objective and a ‘neutral stance’ of care that neglects emotional engagement and deals with the patient as an object or a thing which violates all dimensions of patient recognition. I also emphasize that neoliberalism must rather be understood as a specific form of governmentality that goes beyond mere economization and structures a specific way of understanding people in the healthcare context. Neoliberal rationality, as conceptualized in this article, not only considers human being as homo economicus, where decisions are based on economic ideals, but also neutralizes relationships and disseminates an ‘objective’ and purely scientific stance in caring interactions. This leads to the detachment of nurses and reification of patients. Thus, nursing care is reduced to an instrumental rationality that focuses on technical care, which diminishes any possibility for nurses to engage with patients and understand their unique phenomenological world necessary for coping and recognition. Finally, nurses are urged to raise their voices against neoliberal rationality that programs their ideas of what ‘good care’ is. A critical emancipatory mode of thinking provides an opportunity to challenge neoliberal rationality and revitalize nursing agency to resist the devastating transformations taking place in health care. (shrink)

With a global commitment to scaling up AIDS care and treatment in resource-poor settings for some of the most HIV-affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life-saving treatment to all patients in need. Physician-centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse-centered AIDS patient (...) class='Hi'>care is effective and can alleviate severe physician shortages that currently obstruct treatment scale-up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable. (shrink)