Medical Resource Allocation

We propose six guideposts that states and hospitals should follow to respect disability rights when designing policies for the allocation of scarce, lifesaving medical treatments. Four relate to criteria for decisions. First, do not use categorical exclusions, especially ones based on disability or diagnosis. Second, do not use perceived quality of life. Third, use hospital survival and near-term prognosis (e.g., death expected within a few years despite treatment) but not long-term life expectancy. Fourth, when patients who use ventilators in their (...) daily lives (e.g., home ventilation) present to acute care hospitals, their personal ventilators should not be reallocated to other patients. Fifth, designate triage officers to assess patients individually on the basis of objective medical evidence, not stereotypes or assumptions. Sixth, include disability rights advocates in policy development and dissemination. (shrink)

Older minority Americans experience worse health outcomes than their white counterparts, exhibiting the need for social justice in all areas of their health care. Justice, fairness, and equity are crucial to minimizing conditions that adversely affect the health of individuals and communities. In this paper, Alzheimer's disease (AD) is used as an example of a health care disparity among elderly Americans that requires social justice interventions. Cultural factors play a crucial role in AD screening, diagnosis, and access to care, and (...) are often a barrier to support and equality for minority communities. The “conundrum of health disparities” refers to the interplay between disparity, social justice, and cultural interpretation, and encourages researchers to understand both (1) disparity caused by economic and structural barriers to access, treatment, and diagnosis, and (2) disparity due to cultural interpretation of disease, in order to effectively address health care issues and concerns among elderly Americans. (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.

Hundreds of millions of rare biospecimens are stored in laboratories and biobanks around the world. Often, the researchers who possess these specimens do not plan to use them, while other researchers limit the scope of their work because they cannot acquire biospecimens that meet their needs. This situation raises an important and underexplored question: how should scientists allocate biospecimens that they do not intend to use? We argue that allocators should aim to maximise the social value of the research enterprise (...) when allocating scarce biospecimens. We provide an ethical framework for assessing the social value of proposed research projects and describe how the framework could be implemented. (shrink)

The article by MacKay and Saylor (2020) claims that the principle of fair subject selection yields conflicting imperatives (e.g. in the case of pregnant women) and should be understood as “a bundle of four distinct sub-principles” (i.e. fair inclusion, burden sharing, opportunity, distribution of third-party risks), each having conflicting normative recommendations (MacKay and Saylor 2020). The authors also offer guidance as to how we should navigate between subprinciples that may conflict with each other. The problem is a crucial one since (...) fair subject selection is one of the principles regulating clinical research that produces generalizable knowledge with the potential of improving people’s health. Therefore, there may be cases where the way in which participants are selected directly influences the generalizability (or its lack) of the clinically relevant knowledge and its value (if any) to different groups. In my commentary article, written from the philosophical perspective, I notice a number of interrelated problems which I believe have not been discussed thoroughly in the target article: (1) the precise way in which health care priority setting should influence the content of health research priority setting and fair inclusion principles; (2) the distinction between group and individual benefits and burdens from clinical research; (3) the reference class problem in medical research. (shrink)

Churchill argues that every society rations health care-the problem is to do so justly. The central claim of the book is that a more "social" or communitarian starting point is needed. The book concludes with a brief discussion of health care rights and a sketchy account of the role of the physician in rationing.

Health policy is only one part of social policy. Although spending administered by the health sector constitutes a sizeable fraction of total state spending in most countries, other sectors such as education and transportation also represent major portions of national budgets. Additionally, though health is one important aspect of economic and social activity, people pursue many other goals in their social and economic lives. Similarly, direct benefits—those that are immediate results of health policy choices—are only a small portion of the (...) overall impact of health policy. This chapter considers what weight health policy should give to its “spill-over effects,” namely non-health and indirect benefits. (shrink)

The proposed study would be a single-arm interventional trial in a community where HIV is endemic. The proposed observational design can provide confirmatory data for the initial clinical observation, data that would be necessary before considering whether a randomized controlled trial is appropriate. A previous ethical analysis has argued for conducting such a study in a country with limited resources and with higher HIV prevalence, and to recruit those with the highest risk of transmission. The primary rationale was to address (...) the scientific question in the most efficient timeframe and to expose the smallest number of infants to the uncertain benefits and risks of the study. However, there are.. (shrink)

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, (...) and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. (shrink)

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, where theorizing about just (...) principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives. (shrink)

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical question is whether efficiency is the (...) correct criterion, in terms of social justice and individual needs. (shrink)

For a long time, discussion about scarce health care resource allocation was limited to allocation of medical resources, with the paradigmatic case being kidney transplants. This narrow focus on medical resource prevents us from seeing that there are many cases-- perhaps even the majority--in which time is the real scarce resource, particularly nurse time. What ethical principles should apply to nurse time as a scarce health care resource?

Larry Temkin draws on the work of Angus Deaton to argue that countries with poor governance sometimes rely on charitable giving and foreign aid in ways that enable them to avoid relying on their own citizens; this can cause them to be unresponsive to their citizens’ needs and thus prevent the long-term alleviation of poverty and other social problems. I argue that the implications of this “lack of government responsiveness argument” (or LOGRA) are both broader and narrower than they might (...) first appear. I explore how LOGRA applies more broadly to certain types of charitable giving in developed countries, with a focus on medical crowdfunding. I then highlight how LOGRA does not apply to charitable giving aimed at alleviating the suffering of the absolutely politically marginalized, or those especially vulnerable people to whom governments are never responsive. (shrink)

This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cases where quality of life suffers because of disability-focused exclusion or (...) injustice differently from cases where lower quality of life results from laws of nature, resource scarcity, or appropriate tradeoffs. Decisionmakers should ignore quality-of-life losses that result from injustice or exclusion when ignoring them would improve the prospects of individuals with disabilities; in contrast, they should consider quality-of-life losses that are unavoidable or stem from resource scarcity or permissible tradeoffs. On this proposal, while health systems should not amplify existing injustice against individuals with disabilities, they are not required to altogether ignore the potential effects of disability on quality of life. (shrink)

Waiting time is widely used in health and social policy to make resource allocation decisions, yet no general account of the moral significance of waiting time exists. We provide such an account. We argue that waiting time is not intrinsically morally significant, and that the first person in a queue for a resource does not ipso facto have a right to receive that resource first. However, waiting time can and sometimes should play a role in justifying allocation decisions. First, there (...) is a duty of fairness prohibiting line-cutting where a sufficiently just queue exists. Second, waiting time has several morally attractive features that can justify its incorporation into allocation schemes. Where candidates are in relevantly similar circumstances, allocating by waiting time is relatively efficient, maximizes distribution equality relative to other Pareto efficient distributions, and treats candidates fairly. The claim that allocation using waiting time is fair is controversial. Some have claimed that formal lotteries are a fairer way to select among equal beneficiaries. We argue that lotteries are no fairer than allocation based on waiting time when it is equiprobable how a prospective queue will be ordered. In practice, lotteries share many of the disadvantages of queues; which is fairer will depend on contingent features of the allocation scenario. The upshot is that first-come, first-served is in fact a just way to allocate resources in many of the cases where it seems pre-theoretically compelling, and waiting time has unique normative properties which frequently justify its incorporation into resource allocation schemes. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to drop their (...) financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

How much by way of economic reward is due to health care providers? Although this problem usually presents itself as a practical matter of policy, it has buried within it a number of philosophical issues, for it can be regarded as a question in the theory of economic justice. The formal principle of justice is that we should render persons what is due to them. But on what consideration in the case of health care providers can we make an assessment (...) of what is due? The answer we give to this question has significant implications for the ethical appraisal of the allocation of resources in the health care system. Some of the most difficult issues of ethical appraisal emerge when we consider the problems of allocating potentially life-saving resources between different groups of patients. Many of the most significant current issues in medical ethics—the role of QALYs, the meaning of equality and the economic evaluation of life—find their point of reference in the ‘tragic choices’ that are created when there are insufficient resources to meet apparently legitimate medical need. Yet, as Robert Evans has pointed out, it is a simple matter of accounting identity that health care expenditures must equal health providers' incomes. So, in asking how we limit or allocate costly health care resources, we are implicitly offering an answer to the question of how much we should pay providers. I hope by seeking an answer explicitly to that question to throw light on the problems that are raised when considering ethically the allocation of health care resources. (shrink)

Counting QALYs has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they can't. There need be (...) no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task , and make a start on the second. (shrink)

A new word has recently entered the British medical vocabulary. What it stands for is neither a disease nor a cure. At least, it is not a cure for a disease in the medical sense. But it could, perhaps, be thought of as an intended cure for a medicosociological disease: namely that of haphazard or otherwise ethically inappropriate allocation of scarce medical resources. What I have in mind is the term ‘QALY’, which is an acronym standing for quality adjusted life (...) year . Just what this means and what it is intended to do I shall explain in due course. Let me first, however, set the scene. (shrink)

Non‐governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non‐governmental organizations play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self‐mandating and self‐regulating. What is needed in terms of accountability is some means by which all the relevant stakeholders (...) can have their interests represented and considered. An ideally accountable decision‐making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate‐based justifications and advocacy‐based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long‐term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole. (shrink)

This paper engages in the ongoing dialog on "justice and the health care 'industry"'1 and addresses the question of whether market strategies are consistent with an ethical distribution of resources in health care. As it pertains to the development of perinatal services over the past twenty-five to thirty years in the United States, my short answer to this question is "no." Business organization and market-oriented strategies have contributed to the creation and extensive growth of perinatal intensive care centers located in (...) large medical centers. This growth, which has aggravated the neglect of primary care, has been incongruent with known health needs and represents an ethically questionable distribution of resources. (shrink)

While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution (...) of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well. (shrink)

This paper seeks to provide an overview of some of the main areas of debate that have emerged in recent years at the interface between theories of justice and health care. First, the paper consi- ders various positions as to what the index of justice with respect to health ought to be. It warns on practical and principled grounds against conceptual inflation of the notion of "health" as it appears in theories of distributive justice. Second, it considers how various standards (...) according to which goods ought to be distributed in a just society apply to debates within health care. (shrink)

Diminishing resources seem to be forcing rationing of medical services. Rationing the public health care system means that there needs to be ethical discussion on justice. Several years before resource allocation could impact on the levels of morbidity and mortality, economic problems created numerous methods of regulating medical and nursing services. In clinical practice, regularisation means a reduction of the possibility to decide autonomously and therefore requires specific ethical discussion. The different methods of regularisation from standards and quality control to (...) managed care are discussed with respect to their influence on medical thinking and decision making. Formalised decisions in severe disease can also be a field for regularisation, for example guidelines on the termination of life sustaining treatment (vs. Do-Not-Attempt-Resuscitation Orders). The debate on futility is discussed as a part of the economic discussion, with special regard to the impact of the macroeconomic situation on ”peripheral” medical decisions, which very often are made unconsciously, as shown by a new German study. It is impossible to discuss the influence of macroeconomy, different attempts at regularisation and the individual decision of the doctor without reflecting on their principle interdependency. Ethical reflection in this field cannot be sectioned into an economic, medical decision-making and futility sections. (shrink)

What is immediately striking about the general problem of how to allocate resources equitably is that although the task cannot be done, it nevertheless requires to be done. Imperfection is the most we can hope for. But of course some instances of imperfection are considerably worse than others: and those evidenced in all too much of the thinking of medical specialists, whether in the current discussion concerning cancer care or, for instance, by those involved in the management of kidney transplants (...) are frightening in their resolute refusal even to consider, let alone take adequately into account, the impact on the wider polity of their policies and practices. (shrink)

It is sometimes said that a society should be judged ethically by how it treats its least-fortunate or worst-off members. In one interpretation this is not a point about justice, but instead about moral virtues such as compassion and charity. In our response to the least fortunate among us, we display, or show that we lack, fundamental moral virtues of fellow feeling and concern for others in need. In a different interpretation, however, this point is about justice and a just (...) society—the justice of a society is shown especially in how it treats its least-fortunate members. (shrink)

The assumption that procuring more organs will save more lives has inspired increasingly forceful calls to increase organ procurement. This project, in contrast, directly questions the premise that more organ transplantation means more lives saved. Its argument begins with the fact that resources are limited and medical procedures have opportunity costs. Because many other lifesaving interventions are more cost‐effective than transplantation and compete with transplantation for a limited budget, spending on organ transplantation consumes resources that could have been used to (...) save a greater number of other lives. This argument has not yet been advanced in debates over expanded procurement and could buttress existing concerns about expanded procurement. To support this argument, I review existing empirical data on the cost‐effectiveness of transplantation and compare them to data on interventions for other illnesses. These data should motivate utilitarians and others whose primary goal is maximizing population‐wide health benefits to doubt the merits of expanding organ procurement. I then consider two major objections: one makes the case that transplant candidates have a special claim to medical resources, and the other challenges the use of cost‐effectiveness to set priorities. I argue that there is no reason to conclude that transplant candidates’ medical interests should receive special priority, and that giving some consideration to cost‐effectiveness in priority setting requires neither sweeping changes to overall health priorities nor the adoption of any specific, controversial metric for assessing cost‐effectiveness. Before searching for more organs, we should first ensure the provision of cost‐effective care. (shrink)

Recent disputes over whether older people should pay more for health insurance, or receive lower priority for transplantable organs, highlight broader disagreements regarding the legality of using age-based criteria in health care. These debates will likely intensify given the changing age structure of the American population and the turmoil surrounding the financing of American health care. This Article provides a comprehensive examination of the legality and normative desirability of age-based criteria. I defend a distributive justice approach to age-based criteria and (...) contrast it with two prevailing theoretical approaches to age-based criteria, nondiscrimination and discretion. I propose a detailed normative framework for the use of age-based criteria in health care, the lifetime justice approach, that considers the future life patients can gain from treatment and the past years of life they already have experienced. -/- This paper is available by open access from the Boston College Law School Digital Commons. (shrink)

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health – should be considered a social primary (...) good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient. -/- . (shrink)

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free‐Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market failure” in health insurance (...) and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. -/- . (shrink)

Disturbing international inequalities in health abound. Life expectancy in Swaziland is half that in Japan. A child unfortunate enough to be born in Angola has 73 times as great a chance of dying before age 5 as a child born in Norway. A mother giving birth in southern sub-Saharan Africa has 100 times as great a chance of dying from her labor as one birthing in an industrialized country. For every mile one travels outward toward the Maryland suburbs from downtown (...) Washington, DC on its underground rail system, life expectancy rises by a year – reflecting the race and class inequities in American health. Are the glaring, even larger, international health inequalities also unjust? -/- All of us no doubt think they are grossly unfortunate. Many of us think they are unfair or unjust. Why should some people be at such a health disadvantage through no fault of their own, losers in a natural and social lottery assigning them birth in an unhealthy place? Others of us are troubled by the absence of the kinds of human relationships that ordinarily give rise to the claims of egalitarian justice that we make on each other – for example, being fellow citizens or even interacting in a cooperative scheme. Who has obligations of justice to reduce these international inequalities? And do those obligations hold regardless of how the inequalities came about? What institutions are accountable for addressing them? (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or demands in and by the ‘exterior environment’. Social systems must (...) be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

This chapter argues that rather than viewing transparency as a right, we should regard it as a finite resource whose allocation involves tradeoffs. It then argues that those tradeoffs should be resolved by using a multi-principle approach to distributive justice. The relevant principles include maximizing welfare, maximizing autonomy, and giving priority to the worst off. Finally, it examines some of the implications for law of recognizing the tradeoffs presented by transparency proposals.

This work critically examines the philosophical basis underlying methods of health-care distribution. It advocates taking an inclusive view in which access, availability, uptake, and quality all form part of the process of evaluation. Different methods of health-care organization are considered and I examine models for distributing health-care, specifically in the US, UK, and Australia. Concerns are addressed in terms of how systems are evaluated, as well as meanings attached to key terms such as equity and equality. Meeting the health-care needs (...) of whole populations places demands on a number of social institutions, and while reform is essentially a political process, philosophical considerations require examining the basis of interaction between law, morality and justice. This study seeks to establish a conceptual framework in which public policy considerations and distributive justice can be assessed, according to ethical criteria and jurisprudential reasoning. It considers the social justice implications of poor distribution, uncertain quality of care, and the question of medical error. It also examines the so-called right to health-care, and the basis of distribution and redistribution of assets within society. To this end, different ethical theories are discussed, starting with Aristotelian conceptions of justice, the application of utilitarian ideals, and modern deontological conceptions of justice in relation to health-care. In analyzing principles of justice and the relationship between law and morality, the assertion is made that contemporary legal theory can be usefully employed in helping to construct an ethical framework for determining public policy on health-care distribution. (shrink)

In extending the entitlement theory to health care, I will lay the groundwork for a scheme which takes into account historical entitlement, preserves patient and physician autonomy, and conceives health care on the maximum possible level. The entire health care delivery system will be governed by the crucial point for the entitlement theorist, that the appropriation of an unowned object not worsen the situation of others. The constraint is absolute. Any violation of the constraint calls for a halt to the (...) permissible use of entitlement as a theory of justice in health care. Theories of Justice in Health Care is comprised of five chapters. The first is an examination of theories of justice in general and the health care systems that arise from the application of these theories. Norman Daniels' "fair equality of opportunity account" is closely scrutinized in order to evaluate whether his extension of John Rawls' theory of justice leads to a just health care system. Daniels' extension of Rawls is then contrasted with an extension of Robert Nozick's entitlement theory, in order to evaluate whether Nozick's theory of entitlement leads to a more just health care system than that achieved by Rawls' "fair equality of opportunity account." The practical question is whether a private health care system should co-exist with the publicly funded system. The second chapter is an analysis of theories of community. Through an understanding of community, we should broaden our conception to be international in scope. Conceiving health care as community-based, coupled with an international perspective, brings to human beings a new philosophy of healing. The remaining chapters apply the theories of justice and community as developed. Chapter three is a community-based approach to a crisis in an individual's health care and examines the resolution of the crisis through mediation rather than in the traditionally adversarial medical malpractice lawsuit. Chapter four applies theories of justice and community and considers a community-driven, internationally based perspective to alleviate the distinct problem of scarcity when there are insufficient resources independently of funding, specifically in the case of vital organ procurement, and in particular through a model of presumed consent. Chapter five applies the theories of justice and community once more and provides a framework within entitlement as a conception of justice to improve the health care system in Canada. A health care system which includes the integration of a public/private sphere is considered and then proposed, provided that there be a constraint that the position of others not be worsened. The implementation of this system would maximally respect the autonomy of physicians and patients, and in essence would produce greater resources in the public sector, since those who can pay would be able and allowed to do so, there would be more funding for technology, the strain on the public system would be alleviated, and the health care system would provide the additional incentive for physicians and patients to remain in Canada. (shrink)

The dissertation Aristotelian Justice and Health Policy: Capability and Incompletely Theorized Agreements , Jerry Green, and Joseph Newhouse) focuses on the implications for health policy of Aristotelian/Capability lines of reasoning to social justice and efficiency. The monograph draws on philosophical and economic analysis and social choice theory in the examination of health capabilities as: a central focal variable for the assessment of equality and efficiency in health policy; the product of health and other public policies; and the object of social (...) choice. Drawing on moral and political philosophy, the Aristotelian/Capability lines of reasoning provide the basis for the special moral importance of health capabilities as the central focal variable for assessing equality and efficiency in health policy. These lines of thought take a universal view of humans' capability to flourish as an end of political activity and provide an analytical framework to address questions of justice and efficiency in public policy in a way that other philosophical schools do not. Drawing on economic analysis, the monograph makes a case for focusing attention in health economics and health policy on the economics of health, per se, as differentiated from the economics of medical care, and as such emphasizes the analysis of empirical evidence on the instrumental effectiveness and cost-effectiveness of the various determinants of health and the public policies associated with these determinants. Further investigations of the determinants and consequences of variations in health capabilities is necessary to fully understand the patterns and public policies associated with health production. And finally, drawing on social choice literature, this monograph identifies and defends a particular approach to collective decision making in public policy--incompletely theorized agreements . In matters of social decision making about health capabilities in health policy, the ICTA framework is particularly useful and complementary to the capability approach. Health, and thus health capabilities, is a multidimensional concept about which different people have different, and sometimes conflicting, views. Since no unique view of health capabilities exists and is ideal for all evaluative purposes, the pragmatism of both the incomplete ordering of the capability approach and the incompletely theorized agreement on that ordering of the ICTA approach allow for reasoned public policy decision making and analysis in particular situations in the face of plural goods and different, even conflicting, views. (shrink)

This dissertation is a study of issues of justice that arise in the practice of health care and an examination of the potential contributions that John Rawls' theory can yield towards a resolution of those issues. The primary goal is to define and defend a perspective from which individual health care practitioners can address problems of justice in health care. The dissertation begins with a discussion of the concept of justice, including the circumstances under which questions of justice arise, and (...) the scope and role that principles of justice are thought to have in schemes of social cooperation. An important distinction between comparative and non-comparative justice is used to evaluate the role that justice can play in resolving various problems in biomedical ethics. Following an exposition and evaluation of Rawls' theory of justice, various proposals for applying this theory to health care institutions are assessed. Norman Daniels' attempt to use fair equality of opportunity as a principle for regulating these institutions is described and defended, along with certain important modifications. The implementation of this principle is then illustrated by sketching a procedure for determining the obligations of persons who occupy offices within health care institutions. A procedure based on Rawls' original position is elucidated for resolving problems of comparative justice. In situations where a scarce good must be rationed among a group of identifiable individuals, a "relativized" original position may be constructed in which the parties, who represent the individuals holding claims on the good, are imagined to hold those beliefs about the situation which it is reasonable to expect of the relevant health care practitioner but to be ignorant about which specific individuals they represent. The primary goal of these parties is to protect and/or restore the basic capabilities of the affected individuals so as to ensure an adequate range of opportunity for their pursuit of subjective ends. So long as the good is distributed in accordance with such parties' rational preferences, the outcome of the procedure will be fair. Applications and limitations of this procedure are presented by looking at specific examples. (shrink)

John Rawls' theory of justice holds special appeal for those who wish to apply a deontological moral theory to issues in medical ethics. This study is undertaken to examine Rawls' theory to see if it is, in fact, a worthwhile evaluative tool in judging the justice of social issues in medicine. ;In the first three chapters, issues are clarified and Rawls' theory is analyzed. The conclusion is that an unmodified Rawlsian theory is not applicable to distributive issues in medicine like (...) access to the health-care delivery system without significant modification. Two notable modifications of Rawls' theory are analyzed and found to be conceptually and methodologically inconsistent. The author's own modification is undertaken, arguing for health as a social primary good with health care as a right subsumed into the second principle of justice. As a result, criteria for evaluating the justice of social issues in medicine are developed and applied to the issue of access in four health-care delivery systems. The criteria are found to be workable evaluative tools. Thus, Rawls' theory, although a "minimalist" theory with reference to second principle social primary goods, is applicable for evaluating social issues in medicine. (shrink)

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to the interests of clients, their personal interests, and the interest of the state. These conflicts are related to power differentials among clients and professionals, professionals from various disciplines, and professionals and (...) organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics. (shrink)