In financial disputes involving research, the parties are traditionally individual researchers and their institutions, biotech and pharmaceutical companies, and other entities engaged in the commercial development of biomedical research. Occasionally, research subjects claim that researchers have misled them or misappropriated their biological materials to derive financial gain. The best known example is the case of Moore v. Regents of the University of California, decided in 1990.With new developments in genomics, large-scale repositories of tissue and other biological specimens are increasingly important. (...) Biobanks have been established by various researchers, commercial entities, health-care institutions, and even entire countries. Individuals who contribute specimens almost always retain no commercial interest in any resulting research and language to that effect is now customarily included in informed consent documents signed at the time the specimen is given. Suppose, however, that the research subjects actually collect the specimens themselves, recruit the researcher, and provide financial support for the research. (shrink)

The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it (...) is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify. (shrink)

The use of single-use items is now ubiquitous in medical practice. Because of the high costs of these items, the practice of reusing them after sterilisation is also widespread especially in resource-poor economies. However, the ethics of reusing disposable items remain unclear. There are several analogous conditions, which could shed light on the ethics of reuse of disposables. These include the use of restored kidney transplantation and the use of generic drugs etc. The ethical issues include the question of patient (...) safety and the possibility of infection. It is also important to understand the role of informed consent before reuse of disposables. The widespread practice of reuse may bring down high healthcare costs and also reduce the huge amount of hospital waste that is generated. The reuse of disposables can be justified on various grounds including the safety and the cost effectiveness of this practice. (shrink)

Despite the fact that the criteria for allocation of donated livers have been laid down for years, these criteria may not help to select a potential recipient from those with the same medical requirements. This study used conjoint analysis method to determine the importance of certain non-medical factors from the public’s point of view. Through a population based study, a sample of 899 randomly selected persons filled a questionnaire where in each question the respondents had to choose one out of (...) two hypothetical patients as the recipients of a donor liver considering their expressed characteristics. The collected data were analyzed by means of conjoint analysis method, and the importance of each characteristic was determined. According to the respondents the important criteria for allocation of donated livers included younger age, being married or breadwinner of the family, more than 3-year survival after transplantation, and having no role in causing the illness. Among the selected criteria, financial ability to pay post-operation costs had the least value on the selection. The findings of this study indicate that the public may values certain social and individual factors in case of multiple potential recipients with equal medical need for liver transplant. (shrink)

The current public health crisis has exposed deep cracks in social equality and justice for marginalised and vulnerable communities around the world. The reported rise in the number of ‘do not resuscitate’ orders being imposed on people with disabilities has caused particular concerns from a human rights perspective. While the evidence of this is contested, this article will consider the human rights implications at stake and the dangers associated with using ‘quality of life’ measures as determinant of care in medical (...) decision-making and triage assessments. (shrink)

Bioethicists often present ‘saving lives’ as a goal distinct from, and competing with, that of extending lives by as much as possible. I argue that this usage of the term is misleading, and provides unwarranted rhetorical support for neglecting the magnitudes of the harms and benefits at stake in medical allocation decisions, often to the detriment of the young. Equal concern for all persons requires weighting equal interests equally, but not all individuals have an equal interest in ‘life-saving’ treatment.

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)

Patients have received experimental pharmaceuticals outside of clinical trials for decades. There are no industry-wide best practices, and many companies that have granted compassionate use, or ‘preapproval’, access to their investigational products have done so without fanfare and without divulging the process or grounds on which decisions were made. The number of compassionate use requests has increased over time. Driving the demand are new treatments for serious unmet medical needs; patient advocacy groups pressing for access to emerging treatments; internet platforms (...) enabling broad awareness of compelling cases or novel drugs and a lack of trust among some that the pharmaceutical industry and/or the FDA have patients’ best interests in mind. High-profile cases in the media have highlighted the gap between patient expectations for compassionate use and company utilisation of fair processes to adjudicate requests. With many pharmaceutical manufacturers, patient groups, healthcare providers and policy analysts unhappy with the inequities of the status quo, fairer and more ethical management of compassionate use requests was needed. This paper reports on a novel collaboration between a pharmaceutical company and an academic medical ethics department that led to the formation of the Compassionate Use Advisory Committee. Comprising medical experts, bioethicists and patient representatives, CompAC established an ethical framework for the allocation of a scarce investigational oncology agent to single patients requesting non-trial access. This is the first account of how the committee was formed and how it built an ethical framework and put it into practice. (shrink)

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; (...) whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward. (shrink)

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving (...) the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work. (shrink)

ZusammenfassungDie Uterustransplantation ermöglicht Frauen mit einer absoluten uterinen Infertilität eine Schwangerschaft mit biologisch eigenem Kind. Das neuartige experimentelle Verfahren wirft eine Reihe von ethischen Fragen auf. Ziel dieses Artikels ist es, relevante ethische Problemkonstellationen im Kontext der Uterustransplantation überblickshaft darzulegen und kritisch zu diskutieren. Als systematischer Rahmen der Darstellung dienen die vier Prinzipien der Medizinethik Autonomie, Nicht-Schaden, Wohltun und Gerechtigkeit nach Beauchamp und Childress. Nach eingehender ethischer Betrachtung plädieren die Autorinnen mit Blick auf die Akkumulation schwerwiegender ethischer Probleme für die (...) Notwendigkeit einer grundlegenden und umfassenden ethischen Debatte über Uterustransplantation. Ausgangspunkt einer solchen Debatte muss eine kritische Reflexion des normativen Stellenwerts des Leidens an einem unerfüllten Kinderwunsch sein. (shrink)

The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight—and (...) as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 44-46, December 2011.

Moving forward rapidly in the clinical research phase, uterus transplantation may be a future treatment option for women with uterine factor infertility, which accounts for three per cent of all infertility in women. This new method of treatment would allow women, who currently rely on gestational surrogacy or adoption, to gestate and birth their own genetic offspring. Since uterus transplantation carries significant risk when compared with surrogacy and adoption as well as when compared with other organ transplants, it requires greater (...) justification because its goals are quality of life, not life-saving, in their scope. It is important to address questions regarding the physical, psychosocial and ethical risks and benefits of uterus transplantation for all three parties involved—the patient, the donor and the potential child—as well as discuss the regulatory implications as research on uterus transplantations moves forward. (shrink)

BackgroundResuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit, meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people regarding resource allocation decisions in the NICU.MethodsThe study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were (...) 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.ResultsThe majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival, life expectancy, and cost of treatment. In the classic ‘lifeboat’ scenario, all but two respondents were utilitarian.ConclusionsThis survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment. (shrink)

In terminally ill individuals who would otherwise end their own lives, active voluntary euthanasia (AVE) can be seen as life-extending rather than life-shortening. Accordingly, AVE supports key pro-euthanasia arguments (appeals to autonomy and beneficence) and meets certain sanctity of life objections. This paper examines the extent to which a terminally ill individual’s wish to donate organs after death contributes to those life-extension arguments. It finds that, in a terminally ill individual who wishes to avoid experiencing life he considers to be (...) not worth living, and who also wishes to donate organs after death, AVE maximizes the likelihood that such donations will occur. The paper finds that the wish to donate organs strengthens the appeals to autonomy and beneficence, and fortifies the meeting of certain sanctity of life objections, achieved by life-extension arguments, and also generates appeals to justice that form novel life-extension arguments in favour of AVE in this context. (shrink)

Volume 20, Issue 2, February 2020, Page 38-41.

Enormous gaps between HIV burden and health care availability in low-income countries raise severe ethical problems. This article analyzes four HIV-priority dilemmas with interest across contexts and health systems. We explore principled distributive conflicts and use the Atkinson index to make explicit trade-offs between health maximization and equality in health. We find that societies need a relatively low aversion to inequality to favor treatment for children, even with large weights assigned to extending the lives of adults: higher inequality aversion is (...) needed to share resources equally between high-cost and low-cost treatment; higher inequality aversion is needed to favor treatment rather than prevention, and the highest inequality aversion is needed to favor sharing treatment between urban and rural regions rather than urban provision of treatment. This type of ethical sensitivity analysis may clarify the ethics of health policy choice. (shrink)

Kerstein and Bognar (2010) and Persad, Wertheimer, and Emanuel (2009) defend specific principles for the allocation of health care resources, but their choice of principles is influenced by the exa...

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

This chapter examines how social- scientific research on public preferences bears on the ethical question of how those resources should in fact be allocated, and explain how social-scientific researchers might find an understanding of work in ethics useful as they design mechanisms for data collection and analysis. I proceed by first distinguishing the methodologies of social science and ethics. I then provide an overview of different approaches to the ethics of allocating scarce medical interventions, including an approach—the complete lives system—which (...) I have previously defended, and a brief recap of social-scientific research on the allocation of scarce medical resources. Following these overviews, I examine different ways in which public preferences could matter to the ethics of allocation. Last, I suggest some ways in which social scientists could learn from ethics as they conduct research into public preferences regarding the allocation of scarce medical resources. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was (...) 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

The global Covid-19 crisis raises at least three moral questions, which my contribution answers as follows: (1) Which patient should get treatment according to triage criteria? The patient whose treatment has the best prospect of success. (2) How should we resolve the conflict between public health measures and economic needs? Public health should have priority, but reaches its limits where the individual right to stay afloat through one’s own work is violated. (3) How should we resolve the conflict between public (...) health measures and civil liberties? Public health should have priority, but reaches its limits where the restriction of freedom violates the integrity of individual health and personal freedom. The answers and the arguments behind these are developed through the discussion of a wide range of current public health policies, concrete measures, and competing approaches to moral questions in the Covid-19 pandemic. (shrink)

Are there some newborn infants whose short- and long-term care costs are so great that treatment should not be provided and they should be allowed to die? Public discourse and academic debate about the ethics of newborn intensive care has often shied away from this question. There has been enough ink spilt over whether or when for the infant's sake it might be better not to provide life-saving treatment. The further question of not saving infants because of inadequate resources has (...) seemed too difficult, too controversial, or perhaps too outrageous to even consider. However, Roman Catholic ethicist Charles Camosy has recently challenged this, arguing that costs should be a primary consideration in decision-making in neonatal intensive care. In the first part of this paper I will outline and critique Camosy's central argument, which he calls the ‘social quality of life (sQOL)’ model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal ‘quality of life’ and Camosy's ‘sQOL’ should factor into these decisions, and I outline two practical proposals. (shrink)

Background The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access. Main text This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different (...) groups as priorities. Different reasons were often suggested as a means of justifying such priority groupings. We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature. Conclusions The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and ‘principles’. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available. (shrink)

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment...

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively (...) weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

The dominant rule of economic evaluation within health care posits that resources are distributed in order to maximize health benefit. There are instances, however, where the public has demonstrated that they do not prefer such an allocation scheme, particularly in the context of life-saving interventions. Objectives Deviations from preferences of maximizing health benefit have important implications on both financial and distributive levels. This study sought to specify the circumstances in which respondent preferences are inconsistent with maximizing health benefit. Methods Ninety (...) respondents recruited from the London School of Economics and Political Science completed a questionnaire comprised of a series of paired profiles involving various combinations of life-saving or quality-of-life enhancing interventions. Results The results indicate that saving a life holds value beyond that captured by traditional health benefit measurement and that the value of saving a life is not consistent across ages. More specifically, the value of saving a life was age-dependent and markedly attenuated for older-age patients. Conclusions Many respondents were willing to overlook maximizing health benefit in order to rescue a life in immediate peril, and showed a diminished sense of moral imperative to rescue older-age patients. In light of difficulties related to the implementation of larger-scale policies incorporating Rule of Rescue concerns, the most realistic approaches will likely involve adopting smaller-scale policies that address issues such as do not resuscitate and living wills. Potential policy solutions such as age or monetary thresholds for life-saving interventions may be favoured in a research context; however, their overall social feasibility is questionable. (shrink)

One of the strongest objections to the development and use of substantially life-extending interventions is that they would exacerbate existing unjust disparities of healthy lifespans between rich and poor members of society. In both popular opinion and ethical theory, this consequence is sometimes thought to justify a ban on life-prolonging technologies. However, the practical and ethical drawbacks of banning receive little attention, and the viability of alternative policies is seldom considered. Moreover, where ethicists do propose alternatives, there is scant effort (...) to consider their merits in light of developing world priorities. In response to these shortcomings, I distinguish four policy options and, on the basis of a plausible intuition about fairness, evaluate their implications for a fair distribution of healthy lifespans. I claim that even in developing nations it would be fairest to favor policies that promote equal access to at least one promising category of substantially life-extending intervention: calorie restriction mimetics. (shrink)

African ethical theories tend to hold that moral agents ought to be partial, in the sense that they should favour members of their family or close community. This is considered an advantage over the impartiality of many Western moral theories, which are regarded as having counterintuitive implications, such as the idea that it is unethical to save a family member before a stranger. The partiality of African ethics is thought to be particularly valuable in the context of bioethics. Thaddeus Metz, (...) in particular, argues that his African-derived theory best accounts for a number of plausible intuitions, such as the intuition that health care practitioners ought to be biased towards the patients for whom they are directly responsible. In this article, I claim that the plausible intuitions drawn on in favour of partiality can be satisfactorily explained on the basis of impartial moral theories. Moreover, I argue that blanket acceptance of partiality has problematic consequences for distributive justice in resource allocation in biomedical contexts. By contrast, impartial theories can justify plausible instances of partiality whilst avoiding the pitfalls of fully partial moral theories. Although this provides grounds for abandoning partiality in principle, I claim that this finding should not be seen as damaging to African medical ethics. Instead, it prompts investigation of underexplored possibilities of impartial African moral theories. To demonstrate the value of this direction, I sketch some novel and attractive conceptions that combine impartiality with elements of African ethics. (shrink)

Drawing on Ezekiel Emanuel’s controversial piece ‘Why I hope to die at 75,’ I distinguish two types of concern in ethical debates about extending the human lifespan. The first focusses on the value of living longer from prudential and social perspectives. The second type of concern, which has received less attention, focusses on the value of aiming for longer life. This distinction, which is overlooked in the ethical literature on life extension, is significant because there are features of human psychology (...) and the structure of a life that should give pause when considering how long one should aim to live, but which do not neatly coincide with considerations about how valuable additional life is likely to be. I argue that, while Emanuel’s case for hoping to die at 75 is unconvincing, he nonetheless provides weak pro tanto considerations in favour of taking a moderate life span as a prudential aim around which to base at least some significant life plans. (shrink)

Disability has been traditionally understood as a medical condition. However, people with disabilities have claimed in recent decades for a dephatologized social model of disability—i.e. the functi...

The ever-debated question of triage and allocating the life-saving ventilator during the COVID-19 pandemic has been repeatedly raised and challenged within the ethical community after shortages propelled doctors before life and death decisions. The British Medical Association’s ethical guidance highlighted the possibility of an initial surge of patients that would outstrip the health system’s ability to deliver care “to existing standards,” where utilitarian measures have to be applied, and triage decisions need to maximize “overall benefit” In these emergency circumstances, triage (...) that “grades according to their needs and the probable outcomes of intervention” will prioritize or eliminate patients for treatment, and health professionals may be faced with obligations to withhold or withdraw treatments to some patients in favour of others. This piece is a response and extension to articles published on the manner of involvement for ethics and ethicists in pandemic triage decisions, particularly examining the ability and necessity of establishing triage committees to ameliorate scarce allocation decisions for physicians. (shrink)

This article approaches the ethical dilemma of healthcare allocation and rationing from the perspective of pragmatist ethics, mainly following John Dewey’s ethics. The moral dilemma of healthcare allocation arises whenever we allocate limited resources, and rationing is a necessary option for distributing available resources. In a broader sense, the moral problems of healthcare allocation also encompass the issue of access to primary healthcare, especially for low-income sections of communities. In this sense, allocation always entails rationing – denying service to someone (...) for the benefit of others. Such aspects of allocation and rationing and the relational aspect of disease and health make the problem morally controversial, which makes it difficult to agree on a principle or principles of allocation and rationing applicable across different contexts. Hence, this paper argues that moral challenges of healthcare rationing ought not to be addressed through the appeal to principles, but rather through deliberation that embraces a more pragmatic and democratic approach to negotiating health resource allocation and rationing. However, this does not mean that moral principles and values are insignificant in healthcare allocation. (shrink)

Volume 20, Issue 7, July 2020, Page 174-177.

Background Although it is the moral duty of physicians to protect vulnerable patients, there are no data on how vulnerability is perceived in clinical practice. This study explores how physicians classify someone as “vulnerable”. Method Thirty-three physicians were initially questioned about resource allocation problems in their work. The results of these interviews were examined with qualitative study software to identify characteristics associated with vulnerability in patients. Data were conceptualized, classified and cross-linked to highlight the major determinants of vulnerability. The findings (...) revealed the principal factors that make patients vulnerable in clinical practice, according to our definition of vulnerability: the likelihood of having one’s interests unjustly considered. Results Vulnerability can arise as a result of a mismatch between the characteristics of patients and physicians, the healthcare system, the treatment, or the communication between physicians and patients. Vulnerability appears as a gap between a patient’s needs and the means intended to meet them. Vulnerability can further be the result of doing too little or too much for patients. This result suggests that structures provided by healthcare systems are not as differentiated as they should be to cover all situations. Our initial definition of vulnerability was illustrated and supported by our results, showing that it encompasses all factors involved, not solely personal characteristics, indicating the need for a more pragmatic approach for use in clinical practice. Conclusion Vulnerability is not due to a single factor but appears under certain circumstances when there is a discrepancy between a patient’s interests and the care provided, despite existing compensation systems. (shrink)

BackgroundThe state of the world is one with scarce medical resources where longevity is not equally distributed. Given such facts, setting priorities in health entails making difficult yet unavoidable decisions about which lives to save. The business of saving lives works on the assumption that longevity is valuable and that an early death is worse than a late death. There is a vast literature on health priorities and badness of death, separately. Surprisingly, there has been little cross-fertilisation between the academic (...) fields of priority setting and badness of death. Our aim is to connect philosophical discussions on the badness of death to contemporary debates in health priorities.DiscussionTwo questions regarding death are especially relevant to health priorities. The first question is why death is bad. Death is clearly bad for others, such as family, friends and society. Many philosophers also argue that death can be bad for those who die. This distinction is important for health priorities, because it concerns our fundamental reasons for saving lives. The second question is, ‘When is the worst time to die?’ A premature death is commonly considered worse than a late death. Thus, the number of good life years lost seems to matter to the badness of death. Concerning young individuals, some think the death of infants is worse than the death of adolescents, while others have contrary intuitions. Our claim is that to prioritise between age groups, we must consider the question of when it is worst to die.ConclusionsDeprivationism provides a more plausible approach to health priorities than Epicureanism. If Deprivationism is accepted, we will have a firmer basis for claiming that individuals, in addition to having a health loss caused by morbidity, will have a loss of good life years due to mortality. Additionally, Deprivationism highlights the importance of age and values for health priorities. Regarding age, both variants of Deprivationism imply that stillbirths are included in the Global Burden of Disease. Finally, we suggest that the Time-Relative Interest Account may serve as an alternative to the discounting and age weighting previously applied in the Global Burden of Disease. (shrink)

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

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the types of (...) moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses’ moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care. (shrink)

This study aimed to determine if people would use social usefulness as a criterion when allocating a kidney to potential recipients. Participants ranked hypothetical patients in order of priority to receive the kidney, using only information on the patients’ volunteering record, intelligence, emotional intelligence, and attractiveness. The results showed that volunteers were prioritized over nonvolunteers, highly intelligent patients over those with average intelligence, patients with high emotional intelligence over those with average emotional intelligence, and good-looking patients over average-looking patients. There (...) was little evidence of personal favoritism. Implications and limitations are discussed. (shrink)

Volume 20, Issue 2, February 2020, Page 20-22.