Vaccines, when available, will prove to be crucial in the fight against Covid-19. All societies will face acute dilemmas in allocating scarce lifesaving resources in the form of vaccines for Covid-19. The author proposes The Value of Lives Principle as a just and workable plan for equitable and efficient access. After describing what the principle entails, the author contrasts the advantage of this approach with other current proposals such as the Fair Priority Model.

This paper rebuts suggestions made by Littlejohns et al that NICE is not ageist by analysing the concept of ageism. It recognises the constraints that finite resources impose on decision making bodies such as NICE and then makes a number of positive suggestions as to how NICE might more effectively and more justly intervene in the allocation of scarce resources for health.

Originally published in 1980 this book argues that we are all responsible for the harm we could have prevented and explores the effect of this conclusion on a morality which makes fundamental the belief that we ought not to harm others if we can possibly avoid it. A theory of responsibility is developed and defended which has consequences for the way we live as well as for a number of problems in contemporary moral, political and social philosophy, and in jurisprudence. (...) In particular, the author attacks the view that there is a moral difference between killing and letting die and proposes a radical conception of violence. Among other controversial issues covered in the book are neutrality, the ethics of organ transplants and the allocation of scarce resources. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Catholic Social Teaching and the Allocation of Scarce ResourcesJohn Langan S.J. (bio)I shall approach the issue of justice in the allocation of scarce resources from the viewpoint of Catholic social teaching, as developed over the last century. This teaching is found primarily in the social encyclicals issued by popes from Leo XIII (1878–1903) to John Paul II (1978- ), but also in the (...) pastoral letters of the various bishops’ conferences, especially in the United States and in Latin America. These documents, which enjoy a high standing in Catholic teaching but which are not taken as binding in all their particulars, form part of a tradition of moral and social theorizing that a contemporary American would regard as “communitarian.” On social questions, this tradition also has shown itself to be historicist in that it is capable of modifying itself in significant ways in response to changing political and economic situations. It normally approaches issues from a universalist perspective, though it has shifted from a preoccupation with the concerns of the industrial societies of Europe to an advocacy of much of the reform agenda of the Third World.Rooted in classical and biblical sources and modified in the course of the last [End Page 401] century to include a principled acceptance of religious freedom, of human rights, and of democratic political institutions, the Catholic social tradition proposes a number of ideas that can serve as the basis for significant criticism of currently dominant liberal modes of organizing and interpreting advanced industrial societies. These ideas do not form a countertheory to liberalism so much as they indicate ways in which a religious organization that includes both hierarchical and egalitarian elements in its structure and that has both moral commitments and practical responsibilities with regard to health care can draw on its intellectual resources to develop alternative strategies for the reform of health care.I shall survey six ideas that figure prominently in Catholic social teaching and that are relevant to the allocation of scare resources in American health care. Space constraints require that I present them in a very condensed fashion, without tracing the complex development they have undergone in the internal Catholic debate or subjecting them to much criticism.First, Catholic social teaching, especially the great encyclical of John XXIII, Pacem In Terris (PT 1963), affirms the full range of human rights recognized in such modern documents as the Universal Declaration of Human Rights (1949). In addition to the civil and political rights enumerated in the Bill of Rights added to the original U.S. Constitution (1791), the Universal Declaration includes rights “to life, to bodily integrity, and to the means which are suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services” (PT 11). Catholic social teaching has not committed itself to one particular way of institutionalizing these rights, but it effectively endorses the comprehensive West European welfare states that the Christian Democratic political parties helped to construct in the period after 1945.Second, Catholic social teaching has accorded a central organizing role to the notion of the common good, the realization of which “is the whole reason for the existence of civil authorities” (PT 54). The common good, however, is not to be understood as identical with the interest or the power of the state; rather, it “embraces the sum total of those conditions of social living whereby men are enabled to achieve their own integral perfection more fully and more easily” (PT 58; quoting Mater et Magistra). John XXIII is particularly anxious to affirm that the common good cannot be construed so as to exclude some groups or to violate the rights of individuals and that it must include both physical and spiritual goods (PT 55–61). The notion of the common good has both an inherent attractiveness and a vagueness that cries out for specification and clarification. But in the contemporary situation it serves to remind us that “individual citizens and intermediate groups are obliged to make their specific contributions to the common welfare” (PT 53).Third, while an insistence on the primacy of the common good and on the [End Page 402... (shrink)

This paper introduces a new, expanded range of relevant cognitive psychological research on collaborative recall and social memory to the philosophical debate on extended and distributed cognition. We start by examining the case for extended cognition based on the complementarity of inner and outer resources, by which neural, bodily, social, and environmental resources with disparate but complementary properties are integrated into hybrid cognitive systems, transforming or augmenting the nature of remembering or decision-making. Adams and Aizawa, noting this distinctive (...) complementarity argument, say that they agree with it completely: but they describe it as “a non-revolutionary approach” which leaves “the cognitive psychology of memory as the study of processes that take place, essentially without exception, within nervous systems.” In response, we carve out, on distinct conceptual and empirical grounds, a rich middle ground between internalist forms of cognitivism and radical anti-cognitivism. Drawing both on extended cognition literature and on Sterelny’s account of the “scaffolded mind” (this issue), we develop a multidimensional framework for understanding varying relations between agents and external resources, both technological and social. On this basis we argue that, independent of any more “revolutionary” metaphysical claims about the partial constitution of cognitive processes by external resources, a thesis of scaffolded or distributed cognition can substantially influence or transform explanatory practice in cognitive science. Critics also cite various empirical results as evidence against the idea that remembering can extend beyond skull and skin. We respond with a more principled, representative survey of the scientific psychology of memory, focussing in particular on robust recent empirical traditions for the study of collaborative recall and transactive social memory. We describe our own empirical research on socially distributed remembering, aimed at identifying conditions for mnemonic emergence in collaborative groups. Philosophical debates about extended, embedded, and distributed cognition can thus make richer, mutually beneficial contact with independently motivated research programs in the cognitive psychology of memory. (shrink)

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of prioritisation of (...) the resources available for healthcare or of rationing such resources must be governed by this principle. -/- This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational ‘reasons based consequentialism’ is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended. (shrink)

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I (...) argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I (...) argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

Intuitively we feel that we ought (to attempt) to save the lives, or ameliorate the suffering, of identifiable individuals where we can. But this comes at a price. It means that there may not be any resources to save the lives of others in similar situations in the future. Or worse, there may not be enough resources left to prevent others from ending up in similar situations in the future. This chapter asks whether this is justifiable or whether (...) we would be better served focusing on public health in the form of preventative medicine. It looks briefly at the supposed difference between benefiting individuals and benefiting populations by considering the difference between interventions aimed at ‘rescue’ and those which are preventative. It then considers the rule of rescue in the health care setting, and looks at some of the reasons stemming from this that we might have for allocating resources to rescue interventions. If these reasons do not provide adequate justification for preferring these types of interventions, then the implication is that our current mode of resource allocation may need to be revised in favour of a more public health-oriented model. (shrink)

Intuitively we feel that we ought to (attempt) to save the lives, or ameliorate the suffering, of identifiableIdentifiable individuals where we can (Rulli and Millum, 2016, p. 261). But this comes at a price. It means that there may not be any resources to save the lives of others in similar situations in the future. Or worse, there may not be enough resources left to prevent others from ending up in similar situations in the future. This chapter asks (...) whether this is justifiable or whether we would be better served focusing on public health in the form of preventative medicine. It looks briefly at the supposed difference between benefiting individuals and benefiting populations by considering the difference between interventions aimed at ‘rescue’ and those which are preventative. It then considers the rule of rescueRule of rescue in the health care setting, and looks at some of the reasons stemming from this that we might have for allocating resources to rescue interventions. If these reasons do not provide adequate justification for preferring these types of interventions, then the implication is that our current mode of resource allocation may need to be revised in favour of a more public health-oriented model. (shrink)

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.

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that (...) all are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.

There is no necessary connection between leadership in basic science and leadership in the applications of science, because scientific progress is a cooperative endeavour and not a competitive game; indeed, there may be a conflict between basic research and applied science. The notion of “a position of leadership”; in science raises questions of what leadership consists in and what its value is to the nation. The two main arguments for government support of science are cultural-social, and economic. The cultural-social argument (...) stresses scientific activity as a form of social consumption of wealth and raises the question of whether other uses of the resources employed would contribute more to the greatness of the society. The economic argument stresses basic scientific research as a form of investment for the future, and raises the questions of what the rate of return on such investment is and whether and to what extent government support is called for. Relevant economic research results bearing on this problem are scarce. Economic theory suggests that competition in the market will supply less than the optimal amount of basic research; but our society substantially supplements the market through private contributions to and government support of science, and the question is whether this supplementation is deficient or excessive. Here difficult problems arise, on which more economic research is needed; one of these concerns the relative merits of government and private support of science. The rule-of-thumb procedures generally recommended for determining the volume and allocation of government support to basic scientific research generally ignore these problems, and amount to endorsing the present level of government support or recommending that it be increased. Allocation of federal support of science should take account of the possibility of stimulating the economic development of poor regions of the country by locating scientific research facilities in them. (shrink)

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

This paper discusses the attempt in this issue of the journal by Peter Singer, John McKie, Helga Kuhse and Jeff Richardson, to defend QALYs against the argument from double jeopardy which I first outlined in 1987. In showing how the QALY and other similar measures which combine life expectancy and quality of life and use these to justify particular allocations of health care resource, remain vulnerable to the charge of double jeopardy I am able to clarify some of the (...) central issues concerning the value of life. In particular, the idea that the value of a life varies with its life expectancy and with its quality, understood in terms of its richness, variety, success etc, is subjected to special examination. It is shown how defenders of QALYs are committed to the view that so far from all lives being of equal value, all lives are necessarily of subtly different value. The paper then analyses the use to which the notorious 'veil of ignorance' has been put both by Singer et al and by others and shows how this device of John Rawls's cannot do the work so often assigned to it. The paper then considers the issue of hypothetical consent and the role that it can play in justifying disposing of the lives of people who have not in fact consented to their lives being disposed of in particular ways. Finally, the paper makes some points about the comprehensive nature of the data collection and storage which would be required by QALY advocates and points out the independent problems attaching to licensing such comprehensive collection and use of personal data. (shrink)

Many ecological and environmental economists take a microeconomic approach to envi­ronmental valuation and view the macroeconomy as an amalgam of firms whose primary task is to efficiently allocate scarce resources. In this framework, replacing freely provided ecosystem services with costly human-provided substitutes is by definition inefficient. Although destroying and replacing the free gifts of nature can sometimes be an economic benefit, in the case of apple-tree pollination in Maoxian County, China, the positive economic benefits do not justify eliminating (...) the natural processes. To the contrary, the Maoxian case illustrates the danger of allowing the logic of the market and its apologetic models to drive conservation policy. The conflict between the market economy and the natural world must be recognized and addressed in a more substantial way. The bees of Maoxian County are a parable for the relationship between humans and the natural world and show clearly the danger of leaving the fate of nature to the whims of the markets even if prices are “corrected.”. (shrink)

Among industrialized nations the United States is relatively unique in relying on a mix of public and private financing and delivery of healthcare: federal and federal-state programs, such as Medicare and Medicaid; employment-based health insurance ; and state-subsidized insurance pools for high-risk individuals. In recent years, however, there have been efforts to apply the principles of private employment-based health insurance to the other forms of healthcare, and there is speculation that rising healthcare costs can only be addressed by further extending (...) capitated payment plans. This suggests that U.S. healthcare may increasingly be organized according to market principles. For some, this represents a historic departure from an emphasis on public responsibility for healthcare and a sacrifice of the value principles embodied in health relationships between patient and provider. But defenders of HMOs and a larger role for markets argue that managed care allows for a more rational allocation of scarce healthcare resources by minimizing inefficient low-benefit–high-cost care. More individuals receive essential care if inessential care is eliminated. HMOs are also said to encourage non-HMOs to provide lower priced healthcare. (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)

Since the birth of the first test-tube baby, Louise Brown, in 1977, we have seen truly remarkable advances in biotechnology. We can now screen the fetus for Down Syndrome, Spina Bifida, and a wide range of genetic disorders. We can rearrange genes in DNA chains and redirect the evolution of species. We can record an individual's genetic fingerprint. And we can potentially insert genes into human DNA that will produce physical warning signs of cancer, allowing early detection. In fact, biotechnology (...) has progressed to such a point that virtually any kind of genetic manipulation, if not already possible, is just around the corner. But these breakthroughs also raise serious ethical and moral dilemmas that we are only now beginning to confront. In Wonderwoman and Superman, noted medical ethicist John Harris offers the first thorough analysis of the moral dilemmas created by the revolution in molecular biology. Covering a wide array of recent innovations, Harris discusses, for example, the moral decisions involved and the consequences of creating egg and embryo banks. Who should be allowed to use such resources? Should recipients be screened? Should such banks be open for public or private use? And does it cheapen life to make embryos available for sale? In another chapter, Harris examines the question of conceiving children chiefly for organ donation, focusing on the recent case of a woman who wanted to have a second child to provide a bone marrow donor for her first child sick with leukemia (she intended to abort the fetus if its bone marrow did not genetically match that of her living child). In this case, the medical staff had to decide whether they should perform in-vitro fertilization, knowing that the mother did not satisfy the clinic's criteria (there was no father), and also knowing the potential for abortion. Discussing the ethics of the mother's choice and the clinic's choice, Harris asks whether it is morally correct to create a child as an organ donor, whether the future child would suffer, whether it is worth any suffering to be born, and who has the right to weigh the various factors (both moral and physiological) involved in making these decisions. Delving into a multitude of issues such as when life begins, when suffering is needless, and whether we should play God, Wonderwoman and Superman provides not only a thought-provoking inquiry into the potential and actual ethical dilemmas created by the many advances in biotechnology, but challenges us to learn to choose responsibly and to face the moral implications of the choices that confront us. (shrink)

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as (...) well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (shrink)

This article considers the possible relation between the idea of parity and some past work on the allocation of scarce resources. Parity of value is first connected with the idea of some goods being irrelevant in interpersonal comparisons. The notion of moral parity is introduced to describe the recognition that people who are moral equals (even when they are not on a par in terms of value) as not substitutable. The relation between a Separability Test and nonsubstitutability (...) of persons is considered. These ideas are then used to discuss various cases in which one must choose to whom to provide medical assistance, including whether and when to distinguish morally between a disabled and a nondisabled person. (shrink)

BackgroundECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a (...) small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations.MethodsAn online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic.ResultsWhen initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%).ConclusionsWe found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic. (shrink)

People live and age together in social groups. Across a range of outcomes, research has identified interdependence in the cognitive and health trajectories of ageing couples. Various types of memory decline with age and people report using a range of internal and external, social, and material strategies to compensate for these declines. While memory compensation strategies have been widely studied, research so far has focused only on single individuals. We examined interdependence in the memory compensation strategies reported by spouses within (...) 58 older couples. Couples completed the Memory Compensation Questionnaire, as well as an open-ended interview about their memory compensation practices. We found that internal, intra-individual memory compensation strategies were not associated within couples, but external, extra-individual strategies showed interdependence. Individuals’ scores on material/technological compensation strategies were positively correlated with their partners’. Reported reliance on a spouse was higher for men and increased with age. Our open-ended interviews yielded rich insights into the complex and diverse resources that couples use to support memory in day-to-day life. Particularly evident was the extent of interaction and coordination between social and material compensation, such that couples jointly used external compensation resources. Our results suggest that individuals’ reports of their compensation strategies do not tell the whole story. Rather, we propose that older couples show interdependence in their memory compensation strategies, and adopt complex systems of integrated material and social memory compensation in their day-to-day lives. (shrink)

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

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life (...) care, bioethics, and health policy discuss if age should guide rationing decisions. (shrink)

Whenever the government makes medical resource allocation choices, there will be opportunity costs associated with those choices: some patients will have treatment and live longer, while a different group of patients will die prematurely. Because of this, we have to make sure that the benefits we get from investing in treatment A are large enough to justify the benefits forgone from not investing in the next best alternative, treatment B. There has been an increase in spending and reallocation of (...) resources during the COVID-19 pandemic that may have been warranted given the urgency of the situation. However, these actions do not bypass the opportunity cost principle although they can appear to in the short term, since spending increases cannot continue indefinitely and there are patient groups who lose out when resources are redirected to pandemic services. Therefore, policy-makers must consider who bears the cost of the displaced healthcare resources. Failure to do so runs a risk of reducing overall population health while disproportionally worsening health in socially disadvantaged groups. We give the example of ethnic minorities in England who already had the worst health and, due to structural injustices, were hardest hit by the pandemic and may stand to lose the most when services are reallocated to meet the resource demands of the crisis. How can we prevent this form of health inequity? Our proposal is forward-looking: we suggest that the government should invest our resources wisely while taking issues of equity into account–that is, introduce cost–equity analysis. (shrink)

The behavior of people in the presence of scarce resources has long been a source of ethical concern and debate. Many of the responses, ranging from outright brutality and cheating on the one hand to altruism, nobility, and sacrifice on the other, were most recently demonstrated in the movie Titanic. It should come as no surprise, then, that rational efforts to allocate the very scarce life-saving resource of organs are sometimes circumvented by these natural human impulses and (...) sheer human creativity. This is especially true when the organs in question are required for continued life and cannot be temporarily or permanently replaced by technology. Thus the focus of this paper will be on the competition for livers. (shrink)

The prelims comprise: Micro‐v. Macro‐Allocation, and a Quandary for Clinical Practice Allocation and Theories of Justice Cost‐Utility Analysis as a Framework for Allocation Accounting for Specific Factors Other than Health‐Related Utility Further Questions and a Concluding Note References Further Reading.

The completion of the human genome project in 2000 dramatically emphasized the imminent success of the genetic revolution. The ethical and social consequences of this scientific development are immense. From human reproduction to life-extending therapies, from the impact on gender and race to public health and public safety, there is scarcely a part of our lives left unaffected by the impact of the new genetics. A Companion to Genethics is the first substantial study of the multifaceted dimensions of the genetic (...) revolution and its philosophical, ethical, social, and political significance. It brings together the best and most influential contemporary writing about genethics. Newly commissioned essays from prominent figures in the current debate provide a wide-ranging and fascinating scholarly analysis of all the issues that arise from this explosive science. (shrink)

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

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

This response to a commentary on “Allocation of scarce resources, disability, and parity” considers whether a difference that would be morally relevant when choosing which of two people to save retains its relevance if this would affect other people’s chances of being saved.

Volume 20, Issue 10, October 2020, Page 77-79.

In his contribution to the first issue of Memory Studies, Jeffrey Olick notes that despite “the mutual affirmations of psychologists who want more emphasis on the social and sociologists who want more emphasis on the cognitive”, in fact “actual crossdisciplinary research … has been much rarer than affirmations about its necessity and desirability” (2008: 27). The peculiar, contingent disciplinary divisions which structure our academic institutions create and enable many powerful intellectual cultures: but memory researchers are unusually aware that uneasy faultlines (...) and glaring gulfs lie in the uncertain zones between them. The processes of memory are simultaneously natural and cultural. But our difficulties in imagining even fragments of a genuinely integrated framework for understanding diverse memory-related phenomena do not arise from a simple ‘two-cultures’ problem: it’s not as if there are substantially unified visions of memory within either ‘the sciences’ or ‘the humanities’. (shrink)

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

This book addresses the problem of how to make democratically-legitimate public policy on issues of contentious bioethical debate. It focuses on ethical contests about research and their legitimate resolution, while addressing questions of political legitimacy. How should states make public policy on issues where there is ethical disagreement, not only about appropriate outcomes, but even what values are at stake? What constitutes justified, democratic policy in such conflicted domains? Case studies from Canada and Australia demonstrate that two countries sharing historical (...) and institutional characteristics can reach different policy responses. This book is of interest to policymakers, bioethicists, and philosophers, and will deepen our understanding of the interactions between large-scale socio-political forces and detailed policy problems in bioethics. (shrink)

The COVID-19 pandemic has placed an enormous burden on health systems, and guidelines have been developed to help healthcare practitioners when resource shortage imposes the choice on who to treat. However, little is known on the public perception of these guidelines and the underlying moral principles. Here, we assess on a sample of 1033 American citizens’ moral views and agreement with proposed guidelines. We find substantial heterogeneity in citizens’ moral principles, often not in line with the guidelines recommendations. As the (...) guidelines are likely to directly affect a considerable number of citizens, our results call for policy interventions to inform people on the ethical rationale behind physicians or triage committees decisions to avoid resentment and feelings of unfairness. (shrink)

In this paper, we aim to show that the framework of embedded, distributed, or extended cognition offers new perspectives on social cognition by applying it to one specific domain: the psychology of memory. In making our case, first we specify some key social dimensions of cognitive distribution and some basic distinctions between memory cases, and then describe stronger and weaker versions of distributed remembering in the general distributed cognition framework. Next, we examine studies of social influences on memory in cognitive (...) psychology, and identify the valuable concepts and methods to be extended and embedded in our framework; we focus in particular on three related paradigms: transactive memory, collaborative recall, and social contagion. Finally, we sketch our own early studies of individual and group memory developed within our framework of distributed cognition, on social contagion of autobiographical memories, collaborative flashbulb memories, and memories of high school at a high school reunion. We see two reciprocal benefits of this conceptual and empirical framework to social memory phenomena: that ideas about distributed cognition can be honed against and tested with the help of sophisticated methods in the social cognitive psychology of memory; and conversely, that a range of social memory phenomena that are as yet poorly understood can be approached afresh with theoretically motivated extensions of existing empirical paradigms. (shrink)

This interdisciplinary collection of essays highlights the relevance of Buddhist doctrine and practice to issues of globalization. From philosophical, religious, historical, and political perspectives, the authors show that Buddhism—arguably the world’s first transnational religion—is a rich resource for navigating todays interconnected world.

It is the aim of this work to examine the pivotal role of Johann Joachim Winckelmann (1717-1768) as a judge of classical sculpture and as a major contributor to German art criticism. John Harry North seeks to identify the key features of his treatment of classical beauty, particularly in his famous descriptions of large-scale classical sculpture. Five case studies are offered to demonstrate the academic classicism that formed the core of his philosophy of art. North aims to establish Winckelmann's (...) place in the development of the German language. His prose contributed to a literary style that was suitable for the expression of an emotional response to visual experiences. His use of rhetoric in the assessment of classical art, however, make his judgements propagandist rather than analytical. The published works of Winckelmann, his draft essays and his collected private correspondence are advanced as criteria in the evaluation of his impact on the development of German classicism that culminated in the Weimar group of poets and writers. His Grecophile enthusiasm, however, led him to introduce stylistic categories in the development of classical marble sculpture that are no longer regarded as truly reflecting the evolution of Greco-Roman art. Thus his historicity and his classification of styles remain in doubt. Winckelmann proposed that the training of modern artists should concentrate on the observation and imitation of classical models instead of looking to nature as the source of inspiration. This plan succeeded to some extent in the generation that followed his untimely death. Throughout the succeeding century, artists and their sponsors did favour classical models and developed stylistic classicism in European freestanding sculpture, in painting and in architecture. (shrink)

NICE must not say people are not worth treatingThe National Institute for Health and Clinical Excellence has proposed that drugs for the treatment of dementia be banned to National Health Service patients on the grounds that their cost is too high and “outside the range of cost effectiveness that might be considered appropriate for the NHS”i.1This is despite NICE’s admission that these drugs are effective in the treatment of Alzheimer’s disease and despite NICE having approved even more expensive treatments. The (...) effect is that thousands of Alzheimer’s patients will be denied the only treatment available. It is difficult to think of this as anything but wickedness or folly or more likely both. At the same time, and with no apparent sense of irony, NICE has launched a public consultation document3 on its guidelines on social value judgments. As we shall see these guidelines are ethically illiterate as well as socially divisive.Assuming permanently scarce resources it is clearly crucial that such healthcare resources as are available are not wasted. This point is often made in terms of cost effectiveness and it is argued, not implausibly, that to talk of cost effectiveness implies that we are able to measure just how cost effective each treatment is. To do so of course we need a standard of measurement. NICE has adopted the ubiquitous, but justly infamous QALY, the Quality Adjusted Life Year.The QALY combines life expectancy after treatment with measures of the expected quality of that life. There are two ways in which QALYS can be used. They might be used to determine which of rival therapies to give to a particular patient or which procedure to use to treat a particular condition, in short which of two different treatments is the more …. (shrink)

Barkdull examines the land ethic in the contexts of just war theory, economic liberalism, and international environmental law, offering a new outlook for the behavior of states in matters affecting ecosystems.

Michael Rawlins and Andrew Dillon start their defence of Nice in fine polemical style, unfortunately polemics is all they have to offer. They totally fail to justify the Nice proposals on dementia treatments nor do they make any more plausible than formerly their use of the notorious QALY. They say:"Harris’s recent editorial, It’s not NICE to discriminate, is long on both polemic and invective – but short on scholarship. He offers nothing to illuminate the debate about allocating healthcare in (...) circumstances of finite resources; he has no understanding of the quality adjusted life year and its use in health economic evaluation; and he makes ill-researched, unsubstantiated and offensive charges against the Institute and its advisory bodies."Accusations are easy to make, difficult to substantiate. There are a number of claims here, only one of which is true. It is true that my editorial was robust, polemical if you like, but editorials are not the same as research papers and these are important issues which deeply affect real lives. Although Rawlins and Dillon affect to take the high ground their own article contains even more vigorous and much more personal invective than my editorial, I make no complaints. But as to the rest of what they say, well, let’s just see!They claim I offer nothing to illuminate resource allocation and that I have no understanding of the QALY. Both of these claims may well be true, but nothing they say goes any way to support these claims or even towards making them plausible. I have studied and written about the QALY for almost 20 years1,2,3,4,5,6,7,8,9,10,11,12,13,14,15 and Rawlins and Dillon show no evidence of any awareness or indeed any understanding of the issues, whether …. (shrink)

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