Prioritarianism pertains to the generic idea that it matters more to benefit people, the worse off they are, and while prioritarianism is not uncontroversial, it is considered a generally plausible and widely shared distributive principle often applied to healthcare prioritisation. In this paper, I identify social justice prioritarianism, severity prioritarianism and age-weighted prioritarianism as three different interpretations of the general prioritarian idea and discuss them in light of the effect of pandemic consequences on healthcare priority setting. On this analysis, the (...) paper arrives at the following three conclusions: that we have strong prioritarian reasons for special concern about the vulnerable and socially disadvantaged in reference to pandemic effects, that severity of illness is an important factor in identifying the worse off in priority setting but that this must not over-ride the special priority to the socially disadvantaged and that the maximisation rationale of the age-weighted view runs against the core prioritarian idea, and the age-weighted prioritarianism is thus unfitting as a prioritarian response to the COVID-19 case. (shrink)

As individuals grow older, they usually require assistance with the daily tasks of self-care. This type of assistance, ancillary care, is essential to maintaining the health of those who need these services. In his prudential lifespan account, Norman Daniels includes access to such services making his account an attractive proposal given the current demographic shift. In this paper, I examine the prudential lifespan account through the lens of old age and I focus on the two concepts on which the lifespan (...) account relies. I show that these two concepts, normal species functioning and opportunity cannot buttress Daniels’s lifespan account; at least it cannot do so for older persons. The tensions that I identify in the prudential lifespan account in relation to aging are instructive for the more recent proposals to include aging in a theory of health and health justice. In addition, my analysis allows me to demonstrate that Daniels’s view of opportunity is irreconcilable to capabilities, the latter being more adaptable to the realities of aging. If capabilities appear more promising, it is nonetheless imperative that the specificities of extended care, such as the need for unpaid caregiving, be taken into consideration. (shrink)

Triage protocols can exclude older patients for the sake of effectiveness and this may be defended as the older have already had their fair share of life, which can mean fair amounts or complete lives. Nevertheless, if life is considered as a narrative, mentioning amounts might be nonsensical. Narratives have a quality of unity; so, life events are fragments whose meanings are dependent on the meaning of the whole. Thus, time units do not represent a reliable measure of the content (...) of life. In addition, people's experience is different from the external flow of time, making its significance relative. Moreover, to compare the completeness of lives qualitatively, it is necessary to have a common cultural understanding, which is improbable to agree on in a modern society. Therefore, basic assumptions of the accounts that refer to fair shares of lives are mistaken, and these accounts do not support age-based rationing. (shrink)

Lockdowns were a morally and medically appropriate anti-contagion policy to stop the spread of Covid. However, lockdowns came with considerable costs. Specifically, lockdowns imposed harms and losses upon the young in order to benefit the elderly, who were at the highest risk of severe illness and death from Covid. This represented a shifting of the (epidemiological) burden of Covid for the elderly to a systemic burden of lockdown upon the young. This article argues that even if lockdowns were a morally (...) permissible response to Covid, the harms and losses they imposed on the young ground a claim of compensation. I defend an intergenerational compensation argument that defends a claim for an egalitarian intergenerational transfer to compensate the young for the harms of lockdown. (shrink)

Societal aging raises challenging ethical questions regarding the just distribution of health care between young and old. This article considers a proposal for age-based rationing of health care, which is based on the prudential life span account of justice between age groups. While important objections have been raised against the prudential life span account, it continues to dominate scholarly debates. This article introduces a new objection, one that develops out of the well-established disability critique of social contract theories. I show (...) the implications of this critique for the prudential life span account and for the special case of age-group justice. The result is that age-based rationing based on the prudential life span approach is not supported, and that the prudential life span approach itself is not the best way to think about allocating health care between age groups. I propose an alternative approach that avoids the disability objection, and consider its implications for specific proposals for age-based rationing of health care. (shrink)

This article considers attempts to include the issues of ageing and ill health in a Rawlsian framework. It first considers Norman Daniels’ Prudential Lifespan Account, which reduces intergenerational questions to issues of intrapersonal prudence from behind a Rawslian veil of ignorance. This approach faces several problems of idealisation, including those raised by Hugh Lazenby, because it must assume that everyone will live to the same age, undermining its status as a prudential calculation. I then assess Lazenby's account, which applies Rawls’ (...) general theory of justice more directly to healthcare. Lazenby suggests that we should apply Rawls’ difference principle – which claims that any inequalities in social goods must benefit the worst off – to conclude that we should significantly prioritise treatment of young patients. I argue first that the existence of young terminally ill patients undermines a number of Rawlsian arguments for the difference principle. I then argue that the structure of ageing undermines the Rawlsian decision mechanism of the ‘veil of ignorance’ on which Lazenby relies. I conclude that age and terminal illness present significant problems for any comprehensive Rawlsian account of justice. (shrink)

This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and James Wilson argues that healthcare is not of special importance if social determinants of health have a major causal impact on population health. Annette Rid is concerned that the (...) relevance condition in accountability for reasonableness is unclear and does little work. Harald Schmidt aims to flesh out where an account of responsibility for health should go since one is under-developed in Just health. Michael Schefczyk and Susanne Brauer challenge aspects of the prudential lifespan account. Samia Hurst asks what impact a population view should have on clinician obligations. (shrink)

We clarify options for conceptualizing equity, or what we refer to as justice, in resource allocation. We do this by systematically differentiating, expounding, and then illustrating eight different substantive principles of justice. In doing this, we compare different meanings that can be attributed to “need” and “the capacity to benefit”. Our comparison is sharpened by two analytical tools. First, quantification helps to clarify the divergent consequences of allocations commended by competing principles. Second, a diagrammatic approach developed by economists Culyer and (...) Wagstaff offers a visual and conceptual aid. Of the eight principles we illustrate, only two treat as relevant both a person’s initial health state and a person’s CTB per resource unit expended: allocate resources so as to most closely equalize final health states and allocate resources so as to equally restore health states to population norms. These allocative principles ought to be preferred to the alternatives if one deems relevant both a person’s initial health state and a person’s CTB per resource unit expended. Finally, we examine some possibilities for conceptualizing benefits as relative to how badly off someone is, extending Parfit’s thought on Prioritarianism. Questions arise as to how much intervention effects accruing to the worse off count for more and how this changes with improving health. We explicate some recent efforts to answer these questions, including in Dutch and British government circles. These efforts can be viewed as efforts to operationalize need as an allocative principle. Each effort seeks to maximize in the aggregate quanta of effect that are differentially valued in favor of the worst off. In this respect, each effort constitutes one type of Prioritarianism, which Parfit failed to differentiate from other types. (shrink)

This article develops the argument that the state must provide parental subsidies if, and to the extent that, individuals would, under certain specified hypothetical conditions, purchase ‘insurance cover’ that would provide the funds they need for adequate childrearing. I argue that most citizens would sign up to an insurance scheme, in which they receive a guarantee of a means-tested parental subsidy in return for an obligation to pay a progressive income tax to fund the scheme. This argument from insurance bolsters (...) the weaker case that proponents of parental subsidies might offer were they to rely exclusively on arguments from fair play and efficiency. (shrink)