The coronavirus disease 2019 (COVID-19) pandemic has motivated medical ethicists and several task forces to revisit or issue new guidelines on allocating scarce medical resources. Such guidelines are relevant for the allocation of scarce therapeutics and vaccines and for allocation of ICU beds, ventilators, and other life-sustaining treatments or potentially scarce interventions. Principles underlying these guidelines, like saving the most lives, mitigating disparities, reciprocity to those who assume additional risk (eg, essential workers and clinical trial participants), and equal access may (...) compete with one another. We propose the use of a “categorized priority system” (also known as a “reserve system”) as an improvement over existing allocation methods, particularly because it may be able to achieve disparity mitigation better than other methods. (shrink)

Reserve systems are a tool to allocate scarce resources when stakeholders do not have a single objective. This paper introduces some basic concepts about reserve systems for pandemic medical resource allocation. At the onset of the Covid-19 pandemic, we proposed that reserve systems can help practitioners arrive at compromises between competing stakeholders. More than a dozen states and local jurisdictions adopted reserve systems in initial phases of vaccine distribution. We highlight several design issues arising in some of these implementations. We (...) also offer suggestions about ways practitioners can take advantage of the flexibility offered by reserve systems. (shrink)

As hospitals in the US and elsewhere fill again with patients with covid-19, discussions about how to fairly allocate scarce medical resources have come to the fore once again. One frequently voiced concern is that non-covid-19 patients with urgent health needs are facing indefinitely postponed surgeries, long-distance hospital transfers, or even are unable to access medical treatment. In our view, a reserve or categorised priority system could help. It could be used to fairly distribute scarce medical capacity—such as (...) staffing, physical space, and medical treatments—between covid-19 and non-covid-19 patients, just as it has been used or proposed to allocate covid-19 therapeutics and vaccines. (shrink)

'Everyone knows what attention is’ according to William James. Much work on attention in psychology and neuroscience cites this famous phrase only to quickly dismiss it. But James is right about this: ‘attention’ was not introduced into psychology and neuroscience as a theoretical concept. I argue that we should therefore study attention with broadly the same methodology that David Marr has applied to the study of perception. By focusing more on Marr's Computational Level of analysis, we arrive at a unified (...) answer to the question of what attention is, what role it plays in the mind, and why organisms like us have that capacity. I propose a methodology for studying attention at Marr's Computational Level that optimizes in a three-dimensional space: it should capture core aspects of our first-person experience of attention, be explanatorily powerful in psychology and neuroscience, and fertile in an interdisciplinary context. I show how this methodology leads to what I call the priority structure account of attention. Attention is what organizes current information to make it more useful for the organism. We can identify it by four features. Attention, in this way, helps a cognitive system to integrate its informational state with its current motivational state. I describe how this account improves on alternatives and shows why attention is a useful concept in many disciplines and for connecting them. -/- This article is categorized under: Philosophy > Psychological Capacities Psychology > Attention Philosophy > Foundations of Cognitive Science. (shrink)

Fair prioritization of healthcare resources has been on the agenda for decades, but resource allocation dilemmas in clinical practice remain challenging. Can clinical ethics committees be of help? The aim of the study was to explore whether and how CECs handle priority setting dilemmas and contribute to raising awareness of fairness concerns. Descriptions of activities involving priority setting in annual reports from Norwegian CECs were studied and categorized through qualitative content analysis. Three hundred thirty-nine reports from 38 (...) CECs were studied. We found 78 activities where resource use or priority setting were explicitly highlighted as main topics. Of these, 29 were seminars or other educational activities, 21 were deliberations on individual patient cases, whereas 28 were discussions of principled or general cases. Individual patient cases concerned various distributional dilemmas where values were at stake. Six main topics and seven roles for the CEC were identified. CECs handle issues concerning the introduction of new costly drugs, extraordinarily costly established treatment, the application of priority setting criteria, resource use for vulnerable groups, resource constraints compromising practice, and futility of care. The CEC can act as an analyst, advisor, moderator, disseminator, facilitator, watch dog, and guardian of values and laws. In order to fulfil their responsibilities in handling priority setting cases, CECs need knowledge of both the ethics and the institutionalized systems of priority setting. There is potential for developing this aspect of the CECs’ work further. The Norwegian CECs are involved in priority setting decisions where they can play multiple constructive roles. In particular, they advise and raise awareness of ethical aspects in resource allocations; bridge clinical practice with higher-level decisions; and promote fair resource allocation and stakeholder rights and interests. (shrink)

Background Fair prioritization of healthcare resources has been on the agenda for decades, but resource allocation dilemmas in clinical practice remain challenging. Can clinical ethics committees be of help? The aim of the study was to explore whether and how CECs handle priority setting dilemmas and contribute to raising awareness of fairness concerns. Method Descriptions of activities involving priority setting in annual reports from Norwegian CECs were studied and categorized through qualitative content analysis. Results Three hundred thirty-nine (...) reports from 38 CECs were studied. We found 78 activities where resource use or priority setting were explicitly highlighted as main topics. Of these, 29 were seminars or other educational activities, 21 were deliberations on individual patient cases, whereas 28 were discussions of principled or general cases. Individual patient cases concerned various distributional dilemmas where values were at stake. Six main topics and seven roles for the CEC were identified. CECs handle issues concerning the introduction of new costly drugs, extraordinarily costly established treatment, the application of priority setting criteria, resource use for vulnerable groups, resource constraints compromising practice, and futility of care. The CEC can act as an analyst, advisor, moderator, disseminator, facilitator, watch dog, and guardian of values and laws. Discussion In order to fulfil their responsibilities in handling priority setting cases, CECs need knowledge of both the ethics and the institutionalized systems of priority setting. There is potential for developing this aspect of the CECs’ work further. Conclusions The Norwegian CECs are involved in priority setting decisions where they can play multiple constructive roles. In particular, they advise and raise awareness of ethical aspects in resource allocations; bridge clinical practice with higher-level decisions; and promote fair resource allocation and stakeholder rights and interests. (shrink)

One of the most important issues in Islamic law is that either partially or completely, or temporary or permanently, a rule can be changed for a particular group of people or everyone. Since the concept of necessity can lead to a change of an important rule like ḥarām/prohibition, this concept should be examined meticulously both in theory and in practice. The thşs study aims to analyze how and why necessities make some ḥarāms permissible and to reveal the ultimate cause for (...) this ibāḥa (permission) from the point of view of Islamic legal theory and philosophy. To achieve this aim, first, the nature of the relationship between the prohibition and the act is examined. To understand how and why necessity gives permission to some ḥarāms, it is necessary to determine the changing and unchanging elements in the case at issue. In the case of necessity, there is no change in the nature of the act and the evil, which is considered as the reason of banning. Indeed, there is a change in the conditions surrounding the act and in the state of the obligated person. However, the main factor that enables the change in ḥarām is the change in the addressing of Shāri‘, who takes into account the changes mentioned. It is seen that the changes stemming from necessity do not lead to the same results as in all permitted ḥarāms. This observation requires a thourgh examination and elaboration on what the scholars of legal theory mean by abolition of prohibition and turning it into permissible. As a result, it has been observed that permitted ḥarāms do not equally function in terms of turning into permissible and that they do not have an equal effect on other acts in the field of mubāḥ. In that case, it is possible to evaluate the permitted ḥarām acts as al-maʻfuw ʻanh/forgiven acts. Although the act could be considered part of the category of mubāḥ, it would be more correct to place them close to the line of makrūh. From the point of view of the servant, the reason why necessity makes a ḥarām act permissible is the priority of avoiding greater evil. However, to reveal His sincere servants, Allah's command to them to avoid all ḥarāms even if they die, does not contradict with His wisdom. For this reason, the ultimate cause why Allah considers the case of necessity in passing judgment is His endless mercy. All these points helped reaching some broader conclusions about legal theory, as well as some conclusions specific to the case of necessity. It turns out that to understand how necessity makes some ḥarāms permissible, one needs to comprehend the relation between the act, the obligated person, the conditions surrounding them and the Shari‘ correctly. Understanding this relationship well is also extremely important to understand the theory of ruling and the Islamic legal theory. This research has substantiated once again that the issues addressed by the Islamic legal theory and practice are linked to the theological doctrines, more than, it is commonly perceived or considered. It turns out that it is important to know the deep or subtle differences between the terms such as ḥarām-ḥalāl, maḥẓūr-ḥarām, mubāḥ-ḥalāl, fundamental mubāḥ-ma‘fuw ‘anh, etc. as well as grasping each of the rule categories. Comprehending all these concepts constitutes an important step in acquiring a true understanding of religion and the maqāṣid al-sharī‘a. In this research, it has been proven once again that each category of the rule includes different levels of ruling in itself. The reason why the acts are categorized in different levels even if they are in the same rule category is the concepts of worldly and otherworldly; evil or good arising from the the ḥarām act. This study also confirmed that the obligated person is at the center of the law. This fact reveals how difficult it is to argue that the rules of Allah are based on divine will that is independent of and disregards the act, obligated person, and conditions. On the contrary, it is understood that the interests of the servant are considered both in the rules of necessity and in the whole of the divine legislation (and even the genesis). On the other hand, this indicates a legal system that is not inflexible and dull, but rather dynamic and parallel to life. Both the fact that the real and absolute source of the rule is Shāri‘ Almighty,and that a very large area of legislative was left to the mujtahid should be considered together. This truth has been observed once again in the matter of making prohibitions permissible on the basis of necessity, and the task of determining which evil is greater was often left to the mujtahid’s consideration. (shrink)

Libertarian views on rights tend to rule out coercive redistribution for purposes of public health care guarantees, whereas liberal conceptions support coercive funding of potentially unlimited access to medical services in the name of medical needs. Taking the “priority of liberty” seriously as supreme political value, a plausible prudential argument can avoid these extremes by providing systematic reasons for both delivering and limiting publicly financed guarantees. Given impending demographic change and rapid technical progress in medicine, only a two-tier (...) class='Hi'>system with explicitly limited public guarantees and optional privately financed health services seems acceptable. (shrink)

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and to purchase medication; and, primary care is (...) free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing. (shrink)

Germany has just started a public debate on priority-setting, rationing and cost-effectiveness due to the cost explosion within the German health care system. To date, the costs for German health care run at 11,6 % of its Gross Domestic Product (GDP, 278,3 billion €) that represents a significant increase from the 5,9 % levels present in 1970. In response, the German Parliament has enacted several major and minor legal reforms over the last three decades for the sake of (...) cost containment and maintaining stability of the health care system. The Statutory Health Insurance—SHI (Gesetzliche Krankenversicherung—GKV) is based on the fundamental principle of solidarity and provides an ethical and legal framework for implementing equity, comprehensiveness and setting the principles and rules for financing and providing health care services and benefits. Within the SHI system, several major actors can be identified: the Federal Ministry of Health, the 16 state ministries of health, the Federal Joint Committee (G-BA), the physicians (with their associations) and the hospitals (with their organizations) on the provider side, and the sickness funds with their associations on the purchasers’ side. This article reviews the structure and complexities of the German health care system with its major players and participants. The focus will be put on relevant ethical, legal and economic aspects for prioritization, rationalization, rationing and cost-effectiveness of medical benefits and services. In conclusion, this article pleads for open discussion on the challenging subject of priority-setting instead of accepting the implicit and non-transparent rationing of medical services that currently occurs at many different levels within the health care system, as it stands today. (shrink)

Livestock are important assets in Africa, helping improve the nutritional status of their owners, and contributing to economic growth. Can these roles continue and can livestock production systems be further developed so that they will be sustainable? A key feature of livestock in Africa is that they fulfill multiple roles, ranging from draught power, to providing manure, milk, and meat. Constraints to increasing productivity include both physical and institutional. In the former category, constraints to adopting draught power include insufficient numbers (...) at the individual household level. Lack of adequate pasture is probably the most important constraint. Diseases are also notable constraints to improving productivity, particularly those categorized as Group I (highly contagious — e.g., rinderpest) or Group II (vector-borne parasitic and viral—e.g., trypanosomiasis). Institutional constraints include lack of research and market distortions. To improve productivity, at the macroeconomic level, governments must continue or start policies aimed at liberalizing markets and revaluing exchange rates. Also, research institutions need an increase in funding for periods of ten or more years. Research and other livestock institutions may be able to leverage limited resources by forming more collaborative relationships at the regional level. Research priorities include breeding on specific aspects, such as increased milk production. However, it must be realized that breeding programs have an inherent problem in disseminating improved breeds in a rapid and equitable manner. Quality of pasture may be improved by further research on more accurately calculating stocking rates and on developing mechanisms to control numbers on pastures (e.g., community controlled grazing schemes). Other research priorities include new technologies to improve animal health, funding of micro-enterprises to add value to livestock products, and market information systems for small-scale farmers. Schemes to increase livestock production in Africa will only occur if innovations closely match the local sets of circumstances. Given the multiple roles of livestock, research into innovations that local communities will readily adopt must take a systems approach. (shrink)

While the list of 17 Sustainable Development Goals proposed by the United Nations’ Open Working Group comprises a catalog of highly important post-2015 development priorities, one of the key issue that has not received the attention it deserves is the need to safeguard the Earth's life-support system. Over the course of the past decades, we have concentrated much more on socioeconomic development rather than on environmental sustainability while putting a number of the Earth's systems at risk, and with it (...) poverty eradication and sustainable development. There is thus a need to put the spotlight on global environmental change and to take account of the insights from the latest Earth system science and its implications for the future of global development and global ethics. The ongoing debate on the post-2015 SDGs offers an important occasion for this endeavor. Going beyond the current proposal of the Open Working Group and building on the planetary boundaries or guard rails framework, the SDGs.. (shrink)

Increasingly sophisticated and expensive medical technologies, chronic illness and aging, and a population that insists upon the best health care and coverage, together demand that priorities be set in the public funding of health care. This article describes Spanish initiatives in dealing with such problems and analyses the ethical implications of health care legislation and rationing.

In order to create sustainable health systems, many countries are introducing ways to prioritize health services underpinned by a process of health technology assessment. While this approach requires technical judgments of clinical effectiveness and cost-effectiveness, these are embedded in a wider set of social (societal) value judgments, including fairness, responsiveness to need, non-discrimination and obligations of accountability and transparency. Implementing controversial decisions faces legal, political and public challenge. To help generate acceptance for the need for health prioritization and the resulting (...) decisions, the purpose of this paper is to develop a novel way of encouraging key stakeholders, especially patients and the public, to become involved in the prioritization process. (shrink)

A central aim of the contemporary reductive scientistic project is the task, inherited from the French Enlightenment, of producing a machine model of man. Cognitive science is the attempt at that most difficult part of this project, namely, to do for mind what Newton had already allegedly done for corporeal nature. Kant has recently been claimed as a precursor of this French project. The most detailed picture of a cognitive-scientistic Kant is defended by Kitcher. Contra Strawson, she claims that in (...) his transcendental psychology Kant is “offering hypotheses about the mechanisms that carry out [cognitive] tasks.”. (shrink)

Prioritized bases, i.e., weakly ordered sets of sentences, have been used for specifying an agent’s ‘basic’ or ‘explicit’ beliefs, or alternatively for compactly encoding an agent’s belief state without the claim that the elements of a base are in any sense basic. This paper focuses on the second interpretation and shows how a shifting of priorities in prioritized bases can be used for a simple, constructive and intuitive way of representing a large variety of methods for the change of belief (...) states—methods that have usually been characterized semantically by a system-of-spheres modeling. Among the methods represented are ‘radical’, ‘conservative’ and ‘moderate’ revision, ‘revision by comparison’ in its raising and lowering variants, as well as various constructions for belief expansion and contraction. Importantly, none of these methods makes any use of numbers. (shrink)

Priority setting in health care means making distributional decisions, which inherently involves limiting access to some health services. Public health ethics involves many ethical principles like efficiency, equity and individual choice, which are frequently appealed to but rarely analysed. How these concepts are understood and applied impacts on healthcare planning and delivery policies. This article discusses findings of a research study undertaken in the context of the Iranian health system in which two main ethical values appear to be (...) operating: equity and personal choice. It asserts that the pro-market perspective, driven by individual choice appears to be dominant as it is influenced by the powerful medical profession. This is despite egalitarian intentions proclaimed in the Constitution and the majority of national laws. The study argues that the market influence in healthcare priority setting is unlikely to diminish because of weak implementation of existing laws. In conclusion, the article suggests that the private health sector could help to achieve the state’s proclaimed egalitarian goals only if new regulatory systems and new systems of governance are implemented. Such measures should be aimed at monitoring and controlling the performance of the private sector, to better manage and harness its capacities. (shrink)

Science's priority rule rewards those who are first to make a discovery, at the expense of all other scientists working towards the same goal, no matter how close they may be to making the same discovery. I propose an explanation of the priority rule that, better than previous explanations, accounts for the distinctive features of the rule. My explanation treats the priority system, and more generally, any scheme of rewards for scientific endeavor, as a device for (...) achieving an allocation of resources among different research programs that provides as much benefit as possible to society. I show that the priority system is especially well suited to finding an efficient allocation of resources in those situations, characteristic of scientific inquiry, in which any success in an endeavor subsequent to the first success brings little additional benefit to society. (shrink)

This study considered the range of ethical issues and potential stakeholder priorities associated with the application of genomic technologies applied to animal production systems, in particular those which utilised genomic technologies in accelerated breeding rather than the application of genetic modification. A literature review was used to inform the development of an ethical matrix, which was used to scope the potential perspectives of different agents regarding the acceptability of genomic technologies, as opposed to genetic modification techniques applied to animal production (...) systems. There are very few studies carried out on stakeholder attitudes regarding the application of genomics to animal production in the human food chain and it may be that this technology is perceived as no more than an extension of traditional breeding techniques. While this is an area which needs more research, it would appear from this study that genomics, because it avoids many of the disadvantages and consumer perceptions associated with GM, is likely to prove a more publicly acceptable route than is GM for the development of healthier and more productive animals. However, stakeholders also need to have an approach to the moral status of the animals involved that finds credibility and acceptability with civil society. (shrink)

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA (...) is neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry. (shrink)

The study examined the question of who should make decisions for a National Health Scheme about the allocation of health resources when the health states of beneficiaries could change because of adaptation. Eight semi-structured small group discussions were conducted. Following focus group theory, interviews commenced with general questions followed by transition questions and ended with a ‘focus’ or ‘key’ question. Participants were presented with several scenarios in which patients adapted to their health states. They were then asked their views about (...) the appropriate role of the public, patients and health professionals in making social judgements of quality of life. After discussion and debate, all groups were asked the key question: ‘In light of adaptation, who should evaluate quality of life for the purpose of setting priorities in the allocation of health care?’ In all groups participants presented strong arguments for and against decision making by patients, the public and health professionals. However, most groups thought a representative body which included a range of perspectives should make the relevant judgements. This is at odds with the recommendations in most national pharmaceutical guidelines. The main conclusion of the paper is that health economists and other researchers should explore the possibility of adopting a deliberative, consensus-based approach to evaluating health-related quality of life when such judgements are to be used to inform priority setting in a public system. (shrink)

Background:The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction.Aim:Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway.Research design:A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020.Ethical considerations:Ethical approval granted by the Regional Research Ethics Committee (...) in Western Norway (131421).Findings:Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful.Discussion:By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority.Conclusion:Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms. (shrink)

This article analyzes some aspects of the modern Ukrainian values, including religion and religiosity in the system of values and priorities in life. It describes the relationship between religious self-identification and some of their values and philosophical positions. It is concluded that the primary value in contemporary Ukrainian society, regardless of religious self-identify, is a family. Having faith is a kind of internal moral and ethical code. According to empirical indicators of people who consider themselves believers, they are more (...) responsible towards institute of family. Individuals with certain religious beliefs, compared to non-believers are more negative towards social issues such as bribery, using office, prostitution, homosexuality, drug addiction and have higher moral expectation for their own behavior. (shrink)

Aim: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system.Background: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion.Method: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical (...) content analysis. The informants were five physicians and four nurses from dialysis wards.Findings: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met.Conclusions: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated. (shrink)

This article proposes a systematic application of recent developments in the logic of preference to a number of topics in deontic logic. The key junction is the well‐known Hansson conditional for dyadic obligations. These conditionals are generalized by pairing them with reasoning about syntactic priority structures. The resulting two‐level approach to obligations is tested first against standard scenarios of contrary‐to‐duty obligations, leading also to a generalization for the Kanger‐Anderson reduction of deontic logic. Next, the priority framework is applied (...) to model two intuitively different sorts of deontic dynamics of obligations, based on information changes and on genuine normative events. In this two‐level setting, we also offer novel takes on vexed issues such as the Chisholm paradox and modelling strong permission. Finally, the priority framework is shown to provide a unifying setting for the study of operations on norms as such, in particular, adding or deleting individual norms, and even merging whole norm systems in different manners. (shrink)

BackgroundThe idea that individuals are responsible for their health has been the focus of debate in the theoretical literature and in its concrete application to healthcare policy in many countries. Controversies persist regarding the form, substance and fairness of allocating health responsibility to the individual, particularly in universal, need-based healthcare systems.ObjectiveTo examine how personal health responsibility has been framed and rationalised in Norwegian key policy documents on priority setting.MethodsDocuments issued or published by the Ministry of Health and Care Services (...) between 1987 and 2018 were thematically analysed. We developed a predefined conceptual framework that guided the analysis. The framework included: the subject and object of responsibility, the level of conceptual abstraction, temporality, normative justificatory arguments and objections to the application of personal health responsibility.ResultsAs an additional criterion, personal health responsibility has been interpreted as relevant if: the patient’s harmful behaviour is repeated after receiving treatment, and if the success of the treatment is conditional on the patient’s behavioural change. When discussed as a retrospective criterion, considerations of reciprocal fairness have been dominant. When discussed as a prospective criterion, the expected benefit of treatment justified its relevance.ConclusionPersonal health responsibility appears to challenge core values of equality, inclusion and solidarity in the Norwegian context and has been repeatedly rejected as a necessary criterion for priority setting. However, the responsibility criterion seems to have some relevance in particular priority setting decisions. (shrink)

All health care systems face problems of justice and efficiency related to setting priorities for allocating a limited pool of resources to a population. Because many of the central issues are the same in all systems, the United States and other countries can learn from the successes and failures of countries that have explicitly addressed the question of health care priorities. We review explicit priority setting efforts in Norway, Sweden, Israel, the Netherlands, Denmark, New Zealand, the United Kingdom and (...) the state of Oregon in the US. The approaches used can be divided into those centered on outlining principles versus those that define practices. In order to establish the main lessons from their experiences we consider the process each country used, criteria to judge the success of these efforts, which approaches seem to have met these criteria, and using their successes and failures as a guide, how to proceed in setting priorities. We demonstrate that there is little evidence that establishment of a values framework for priority setting has had any effect on health policy, nor is there evidence that priority setting exercises have led to the envisaged ideal of an open and participatory public involvement in decision making. (shrink)

BackgroundNusinersen is one of an increasing number of new, expensive orphan drugs to receive authorization. These drugs strain public healthcare budgets and challenge principles for resource allocation. Nusinersen was introduced in the Norwegian public healthcare system in 2018. A national expert group consisting of physicians was formed to oversee the introduction and continuation of treatment in light of specific start and stop criteria.MethodsWe have studied experiences within the expert group with a special emphasis on their application of the start (...) and stop criteria, rationing of treatment, and experienced moral dilemmas. A research interview with six members of the national expert group was performed, then analysed with manifest content analysis. The analysis was supplemented with publically available sources on priority setting and the process leading up to the introduction of nusinersen and the establishment of the expert group.ResultsSixty-six patients have received treatment within the first 25 months since the national expert group’s establishment. Treatment has not been discontinued for any patient. No patients under 18 years of age have been denied treatment, as those who were referred at this age were all deemed to fulfill the start criteria. The expert group has, however, increased geographical treatment equity and facilitated important cooperation at the national level. Furthermore, it has enhanced open and critical discussions of both medical issues and new ethical dilemmas.ConclusionAlthough facilitating equal access to treatment for SMA patients, the national expert group has not discontinued treatment for any patient. It is suggested that in order for clinicians to be able to ration care for individual patients, they require both adequate support and sufficient formal authority. Start and stop criteria need to be re-evaluated as more knowledge and experience are gained regarding the treatment. (shrink)

As its title suggests this book's main area of inquiry is the rationale for, and methodology of, public involvement in priority setting. Mullen and Spurgeon set out to evaluate a number of assumptions and hard issues in priority setting. In doing so they have a produced a volume that is both a useful introduction to this area and a worthy piece of research on an important theme. They begin by contextualising the debate about prioritisation within the recent history (...) of health system reform in the UK and other nations. This move enables them to give an analysis of considerable scope. They are not just interested in rationing …. (shrink)

For many years there has been a debate about the role of the parietal lobe in the generation of behavior. Does it generate movement plans (intention) or choose objects in the environment for further processing? To answer this, we focus on the lateral intraparietal area (LIP), an area that has been shown to play independent roles in target selection for saccades and the generation of visual attention. Based on results from a variety of tasks, we propose that LIP acts as (...) a priority map in which objects are represented by activity proportional to their behavioral priority. We present evidence to show that the priority map combines bottom-up inputs like a rapid visual response with an array of top-down signals like a saccade plan. The spatial location representing the peak of the map is used by the oculomotor system to target saccades and by the visual system to guide visual attention. (shrink)

In the effort to address the persistent organ shortage it is sometimes suggested that we should incentivize people to sign up as organ donors. One way of doing so is to give priority in the allocation of organs to those who are themselves registered as donors. Israel introduced such a scheme recently and the preliminary reports indicate increased donation rates. How should we evaluate such initiatives from an ethical perspective? Luck egalitarianism, a responsibility-sensitive approach to distributive justice, provides one (...) possible justification: Those who decide against being organ donors limit the health care resources available to others. As such, a priority rule can be justified by a luck egalitarian approach to distributive justice. Furthermore, a priority rule inspired by luck egalitarianism is well equipped to avoid prominent criticisms of such a procurement system. Luck egalitarianism provides us with reaons to exempt people who are not responsible for their inability to donate from receiving lower priority, provide sufficient information about donation, and mitigate social and natural circumstances affecting people’s choice to donate. (shrink)

This paper develops an account of the normative basis of priority setting in health care as combining the values which a given society holds for the common good of its members, with the universal provided by a principle of common humanity. We discuss national differences in health basket in Europe and argue that health care decision-making in complex social and moral frameworks is best thought of as anchored in such a principle by drawing on the philosophy of need. We (...) show that health care needs are ethically ‘thick’ needs whose psychological and social construction can best be understood in terms of David Wiggins’s notion of vital need: a person’s need is vital when failure to meet it leads to their harm and suffering. The moral dimension of priority setting which operates across different societies’ health care systems is located in the demands both of and on any society to avoid harm to its members. (shrink)

This essay examines the argumentative context in which early Neo-Kantian philosophers defined and defended "epistemology." The paper defends Richard Rorty's claim that the priority of epistemology influenced how the history of modern philosophy was written but corrects his story by showing that epistemology was defended mainly via antifoundational arguments. The essay begins with a few programmatic arguments by Kuno Fischer and Eduard Zeller but focuses mainly on Otto Liebmann's Kant und die Epigonen. I argue that Liebmann completes the agenda (...) of Fischer and Zeller by giving a detailed account of how a metaphysical system is impossible for anyone who begins with modest, Kantian epistemological principles. (shrink)

The Scandinavian welfare states have public health care systems which have universal coverage and traditionally low influence of private insurance and private provision. Due to raises in costs, elaborate public control of health care, and a significant technological development in health care, priority setting came on the public agenda comparatively early in the Scandinavian countries. The development of health care priority setting has been partly homogeneous and appears to follow certain phases. This can be of broader interest as (...) it may shed light on alternative models and strategies in health care priority setting. Some general trends have been identified: from principles to procedures, from closed to open processes, and from experts to participation. Five general approaches have been recognized: The moral principles and values based approach, the moral principles and economic assessment approach, the procedural approach, the expert based practice defining approach, and the participatory practice defining approach. There are pros and cons with all of these approaches. For the time being the fifth approach appears attractive, but its lack of true participation and the lack of clear success criteria may pose significant challenges in the future. (shrink)

This article proposes a systematic application of recent developments in the logic of preference to a number of topics in deontic logic. The key junction is the well-known Hansson conditional for dyadic obligations. These conditionals are generalized by pairing them with reasoning about syntactic priority structures. The resulting two-level approach to obligations is tested first against standard scenarios of contrary-to-duty obligations, leading also to a generalization for the Kanger-Anderson reduction of deontic logic. Next, the priority framework is applied (...) to model two intuitively different sorts of deontic dynamics of obligations, based on information changes and on genuine normative events. In this two-level setting, we also offer novel takes on vexed issues such as the Chisholm paradox and modelling strong permission. Finally, the priority framework is shown to provide a unifying setting for the study of operations on norms as such, in particular, adding or deleting individual norms, and even merging whole norm systems in different manners. (shrink)

Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy (...) choices, but insufficient because different approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context. (shrink)

This paper advances a philosophical interpretation of Hegel's Logic as defending a metaphysics, which includes an absolute, itself comparable to God in other systems of metaphysics of interest to Hegel, including Aristotle's and Spinoza's. Two problems are raised which can seem to block the prospects for such a metaphysically inflationary interpretation. The key to resolving these problems is consideration of the kinds of metaphysical priority that Hegel sees in Aristotle. This allows us to build a philosophical model of Hegel's (...) absolute, and to demonstrate how the model fits the argument of Hegel's Logic. Application of this model provides a philosophical explanation of the senses in which Hegel's metaphysics is idealist; he argues that thought is absolute and comparable to God in other systems of metaphysics: thought is both self-determining and metaphysically prior to being. (shrink)

It has often been proposed to restrict access to postmortal organs to registered donors, or at least to give them priority on the waiting list. Such proposals are motivated by considerations of fairness: everyone benefits from the existence of a pool of available organs and of an organised system of distributing them and it is unfair that people who are prepared to contribute to this public good are duped by people who are not. This paper spells out this (...) rationale and goes on to discuss the main principled objections that have been brought forward to such proposals. The most fundamental objection is that healthcare resources should be allocated in accordance with need, not with merit. The reply to this objection is that the principle of allocation according to need only holds in cases in which the provision of such resources and the fair distribution of the burdens of contribution are independently secured, as they are in an obligatory insurance system. (shrink)

In a number of works, I have argued that social morality—a system of internalized “social-moral rules”—is fundamental to human social cooperation. Russell Hardin disputed this, arguing instead for the primacy of conventions, based largely on self-interest, in developing cooperative social order. This chapter considers three challenges for my view raised by Hardin. The chapter commences by considering small-scale cooperation; I believe that the evidence indicates that even in very small groups of face-to-face cooperators, the internalization of moral rules is (...) fundamental to their cooperation and cheater suppression. I then consider Hardin’s charge that accounts of social cooperation based on moral rules, in which individuals act on the rules despite their interests, are stuck with invoking a variety of somewhat dubious and weak “claims of moral commitment or shared values through [to] Rawls’s magical ‘addition of the sense of justice and moral sentiment’ to make justice work at a large scale.” I argue that the evidence in support of internalized rule compliance, even in the face of high costs to personal interests, is impressive, and the underlying mechanisms are not mysterious. Lastly, I briefly turn to the fundamental issue of how social morality functions in large-scale settings and, importantly, whether it is largely displaced by formal legal and political institutions. (shrink)

This monograph is a defence of the Fregean take on logic. The author argues that Frege ́s projects, in logic and philosophy of language, are essentially connected and that the formalist shift produced by the work of Peano, Boole and Schroeder and continued by Hilbert and Tarski is completely alien to Frege's approach in the Begriffsschrift. A central thesis of the book is that judgeable contents, i.e. propositions, are the primary bearers of logical properties, which makes logic embedded in our (...) conceptual system. This approach allows coherent and correct definitions of logical constants, logical consequence, and truth and connects their use to the practices of rational agents in science and everyday life. (shrink)

Priority setting remains a big challenge for health managers and planners, yet there is paucity of literature on evaluating priority setting. The purpose of this paper is to present a framework for evaluating priority setting in low and middle income countries. We conducted a qualitative study involving a review of literature and Delphi interviews with respondents knowledgeable of priority setting in low and middle income countries. Respondents were asked to identify the measures of successful priority (...) setting in low and middle income countries. Responses were grouped as: immediate internal or external/delayed internal or external. We also identified some pre-requisites for successful priority setting. The immediate internal measures included increased efficiency in decision making, improved quality of decisions and fairer priority setting. Immediate External measures included—improved public understanding and acceptance of decisions, increased public participation, increased trust. Delayed Internal measures included increased satisfaction, understanding, compliance, balanced budget, achievement of organization goals, and improved internal accountability. Delayed External measures include impact on policy and practice, improved population health and reduction of health inequalities, achievement of health system goals and strengthening of health care systems. Identified pre-requisites for successful priority setting included; the presence of credible priority setting institutions, incentives for participation and implementation and resources, capacity and political will to implement. These would be augmented in a conducive political, social and economic context. This framework, although not exhaustive, provides a practical basis for planning and evaluating priority setting in low and middle income countries. (shrink)

Next SectionBackground International and national agencies play a major role in setting HIV care-and-treatment priorities in low-income-countries. Little is known about priority setting at lower health-system levels. The objective of this article is to explore experiences of HIV priority decisions, at what levels these decisions are made and how they might influence the distribution of health benefits in a high-endemic region in Tanzania. Methods This is a qualitative study using observations, key documents and semistructured focus-group and individual (...) interviews (43) with health workers, patients and administrators at one regional and one district hospital. The analysis was based on an editing analysis style. Results Health workers did not perceive themselves as bedside rationing agents and they reported following national recommendations and felt they have little impact on important priority decisions. Health benefit distributions were largely determined by priority decisions made at a national level. External factors, such as eligibility criteria, inadequate funding and barriers to access seemed to play a major role in the actual distribution of health services and benefits in the region. Patient groups who were actually given high priority were the sickest patients, those living near a facility and those who could afford long journeys and frequent visits. Low-priority groups were those experiencing other co-morbidities or treatment failure, children, asymptomatic patients and the poorest. Conclusions/significance The interaction of priority setting across health-system levels and their impact on distribution of health outcomes in the population has been underestimated. The distributional pattern of health outcomes calls for further normative assessment. (shrink)

Explicit forms of rationing have already been implemented in some countries, and many of these prioritization systems resort to Norman Daniels’ “accountability for reasonableness” methodology. However, a question still remains: is “accountability for reasonableness” not only legitimate but also fair? The objective of this paper is to try to adjust “accountability for reasonableness” to the World Health Organization’s holistic view of health and propose an evolutionary perspective in relation to the “normal” functioning standard proposed by Norman Daniels. To accomplish this (...) purpose the authors depart from the “normal” functioning standard to a model that promotes effective opportunity for everyone in health care access, because even within the “normal” functioning criteria some treatments and medical interventions should have priority upon others. Equal opportunity function is a mathematical function that helps to hierarchize moral relevant necessities in health care according to this point of view. It is concluded, first, that accountability for reasonableness is an extremely valuable tool to address the issue of setting limits in health care; second, that what is called in this paper “equal opportunity function” might reflect how accountability for reasonableness results in fair limit-setting decisions; and third, that this methodology must be further specified to best achieve fair limit-setting decisions. Indeed, when resources are especially scarce the methodology suggested in this paper might allow not only prioritizing in an “all or nothing” basis but can contribute to a hierarchy system of priorities in health care. (shrink)

I argue for a plausible view of the African idea and practice of substantive individual rights. This view indicates that rights are a means of enhancing individual dignity in the context of a communal system of correlativity of duties and rights. This view is exemplified in Menkiti’s idea of the priority of duties. I explicate this idea and indicate how it highlights the inherent social-communal nature of humans that is implicated in African normative conception of “personhood”.

This paper summarizes a theory of cognitive development and elaborates on its educational implications. The theory postulates that development occurs in cycles along multiple fronts. Cognitive competence in each cycle comprises a different profile of executive, inferential, and awareness processes, reflecting changes in developmental priorities in each cycle. Changes reflect varying needs in representing, understanding, and interacting with the world. Interaction control dominates episodic representation in infancy; attention control and perceptual awareness dominate in realistic representations in preschool; inferential control and (...) awareness dominate rule-based representation in primary school; truth and validity control and precise self-evaluation dominate in principle-based thought in adolescence. We demonstrate that the best predictors of school learning in each cycle are the cycle’s cognitive priorities. Also learning in different domains, e.g., language and mathematics, depends on an interaction between the general cognitive processes dominating in each cycle and the state of the representational systems associated with each domain. When a representational system is deficient, specific learning difficulties may emerge, e.g., dyslexia and dyscalculia. We also discuss the educational implications for evaluation and learning at school. (shrink)

Healthcare providers have been central actors in containing the COVID-19 pandemic. Although potentially very beneficial, the implementation of large-scale rapid serological tests raises ethical dilemmas and affects HCPs’ capacity to work in optimal conditions. In this regard, we call for attention to address specific and urgent ethical issues distinctively affecting HCPs following the availability and possible mandatory use of rapid serological tests for COVID-19.