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)

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 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)

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)

Studies of how scientists select research problems suggest the process involves weighing a number of factors, including funding availability, likelihood of success versus failure, and perceived publishability of likely results, among others. In some fields, a strong personal interest in conducting science to bring about particular social and environmental outcomes plays an important role. Conservation biologists are frequently motivated by a desire that their research will contribute to improved conservation outcomes, which introduces a pair of challenging questions for managers of (...) science and scholars of policies governing science: 1) How do scientists integrate that goal into their processes of research priority evaluation, and 2) How can managers and funders of science utilize that knowledge in designing and administering funding programs? I use Q method to uncover four distinct schools of thought amongst researchers and knowledge-users about the merits of possible research priorities for coral reefs; one of the axes along which these schools of thought differ is in their interpretation of how science can and should interact with policy. The results reveal that perceived severity of reef stressors plays a role for some participants. Disciplinary training does not appear to be a major influence on research priority evaluation, but individual participants indicated professional expediency does prevent some researchers from pursuing or advocating that others pursue topics outside of that disciplinary specialty. Influences on and processes in research prioritization uncovered in this study have the potential to lead to counter-productive disciplinary path dependencies. From these results and building on outside literature, I conclude that better coordination and communication about research priorities across disciplines and with broader stakeholders – including knowledge users – could improve the research enterprise’s ability to contribute to meaningful societal and conservation goals. These findings are relevant to researchers and research administrators across disciplines that seek to conduct or fund science that is useful in addressing specific goals. (shrink)

_This article discusses some of the normative bases for the recent (2020) Norwegian policy prioritizing LGBTIQ+ refugees in refugee admissions. It argues that, when properly interpreted, this policy is compatible with the UNHCR vulnerability selection criteria but is not independently supported by it. Combined with some of the broader moral principles guiding refugee admissions – including both state-based and refugee-based reasons in refugee resettlement – the article provides qualified support for the Norwegian policy of LGBTIQ+ refugee prioritization. Drawing from (...) some of the specifics of LGBTIQ+ refugee resettlement and integration, the article nevertheless points to certain limitations of such a policy in so far as refugees’ own agency is concerned. The article emphasizes the need to listen to refugees’ own voices in the selection and resettlement processes, including cases where the default position of LGBTIQ+ prioritization may be overridden by LGBTIQ+ persons’ own interests in being resettled elsewhere__._ _Keywords_: LGBTIQ+, Norwegian refugee policy, priority setting, refugee selection, LGBTIQ+ integration. (shrink)

During a pandemic, demand for intensive care often exceeds availability. Experts agree that allocation should maximize benefits and must not be based on whether patients could have taken preventive measures. However, intensive care units are often overburdened by individuals with severe COVID-19 who have chosen not to be vaccinated to prevent the disease. This article reports an experiment that investigated the German public's prioritization preferences during the fourth wave of the coronavirus pandemic. In a series of scenarios, participants were (...) asked to decide on ICU admission for patients who differed in terms of health condition, expected treatment benefits, and vaccination status. The results reveal an in-group bias, as vaccinated individuals preferred to allocate more resources to the vaccinated than to the unvaccinated. Participants also favored admitting a heart attack patient rather than a COVID-19 patient with the same likelihood of benefiting from ICU admission, indicating a preference for maintaining regular ICU services rather than treating those with severe COVID-19. Finally, participants were more likely to admit a patient to intensive care when this meant withholding rather than withdrawing care from another patient. The results indicate that lay prioritizations violate established allocation principles, presaging potential conflicts between those in need of intensive care and those who provide and allocate it. It is therefore recommended that allocation principles should be explained to enhance public understanding. Additionally, vaccination rates should be increased to relieve ICUs and reduce the need for such triage decisions. (shrink)

The amount allocated to publicly funded health care for 2005/06 in New Zealand, a small country of some four million people, is $NZ 9.68 billion, or 6.2% of GDP, an increase from the 5.7% of GDP in 2000/01. The Minister of Finance has recently signalled that spending in health and education has outpaced economic growth, and that the present rate of growth in health spending, which has grown at about 7% a year over the last decade, is unsustainable. Despite these (...) big funding increases in recent years, the perception of New Zealanders is that the extra spending has made little difference, at least to hospital services and to people’s ability to access treatment. In surveys, health emerges as a leading concern for New Zealanders. Their concern is apparently less about the quality of services, than about their ability to access treatment - whether they will be able to access timely health care when they or their family members need it. (shrink)

The amount allocated to publicly funded health care for 2005/06 in New Zealand, a small country of some four million people, is $NZ 9.68 billion, or 6.2% of GDP, an increase from the 5.7% of GDP in 2000/01. The Minister of Finance has recently signalled that spending in health and education has outpaced economic growth, and that the present rate of growth in health spending, which has grown at about 7% a year over the last decade, is unsustainable. Despite these (...) big funding increases in recent years, the perception of New Zealanders is that the extra spending has made little difference, at least to hospital services and to people’s ability to access treatment. In surveys, health emerges as a leading concern for New Zealanders. Their concern is apparently less about the quality of services, than about their ability to access treatment - whether they will be able to access timely health care when they or their family members need it. (shrink)

We distinguish the set of explicit beliefs of a reasoner, his "belief base", from the beliefs that are merely implicit. Syntax-based belief change governed by the structure of the belief base and the ranking ("prioritization") of its elements is reconstructed with the help of an epistemic entrenchment relation in the style of Gärdenfors and Makinson. Though priorities are essentially different from entrenchments, distinguished relations of epistemic entrenchment may be obtained from prioritized belief bases by a number of different constructions. (...) An approximate reconstruction of syntax-based belief change is possible, which can be strengthened to a strict identity in some important special cases. A competitive interpretation and a minimal change interpretation of the basic idea of entrenchment are discussed. It is argued that entrenchment essentially involves multiple belief changes, i.e., changes by sets of sentences. (shrink)

The Danish healthcare system must meet the need for easy and equal access to healthcare for every citizen. However, investigations have shown unfair prioritization of cancer patients and unfair prioritization of resources for expensive medicines over care. What is needed are principles for proper prioritization. This article investigates whether American ethicists Tom Beauchamp and James Childress’s principle of justice may be helpful as a conceptual framework for reflections on prioritization of expensive biological therapies in the Danish (...) healthcare system. We present an empirical study exploring the principles for prioritizing new expensive biological therapies. This study includes qualitative interviews with key Danish stakeholders experienced in antibody therapy and prioritizing resources for expensive medicines. Beauchamp and Childress’s model only covers government-funded primary and acute healthcare. Based on the interviews, this study indicates that to be helpful in a Danish context this model should include equal access for citizens to government-funded primary and acute healthcare, costly medicine, and other scarce treatments. We conclude that slightly modified, Beauchamp and Childress’s principle of justice might be useful as a conceptual framework for reflections on the prioritization of expensive biological therapies in the Danish healthcare system. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by markets. (...) Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

In times of ongoing resource shortages, appropriate evaluation criteria are crucial for the ethical prioritization of medical care. While the use of scoring models as tools for prioritization is widespread, they are barely discussed in the medical-ethical discourse in the context of the COVID-19 pandemic. During this time, the challenge of providing care for patients in need has promoted consequentialist reasoning. In this light, we advocate for the integration of time- and context-sensitive scoring (TCsS) models in prioritization (...) policies that foster treatment opportunities for patients with subacute and chronic conditions. We argue, first, that TCsSs enable a more efficient use of resources, reducing avoidable harm to patients by preventing arbitrary postponement of necessary but nonurgent interventions. Second, we contend that on an interrelational level, TCsSs render decision-making pathways more transparent, which promotes the information requirement of patient autonomy and raises confidence in the resulting prioritization decision. Third, we claim that TCsS contributes to distributive justice by reallocating available resources to the benefit of elective patients. We conclude that TCsSs promote anticipatory measures that extend the timeframe for responsible action into the future. This strengthens patients' ability to exercise their right to healthcare—primarily during times of crisis, but ultimately in the longer term too. (shrink)

Discrimination is an important real-life issue that affects many individuals and groups. It is also a fruitful field of study that intersects several disciplines and methods. This Special Section brings together papers on discrimination and prioritization in healthcare from leading scholars in bioethics and closely related fields.

Developing a way to address troublesome issues in areas such as urban planning is a chal-lenging undertaking. It includes making decisions that involve humans, nonhumans, future generations, and historical and cultural artifacts. All of these groups deserve consideration, but not equally. Figuring out how to approach this topic involves overcoming the problem of moral prioritization. The structure of weak anthropocentrism can help with this problem, suggesting that future research on the environmental aspects of metropolitan regions should make use of (...) its applicability. Despite its strengths, weak anthropocentrism must be expanded to address complicated urban issues. A multitiered weak-anthropocentric measure, a “complex moral assessment,” is needed to address these concerns. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by markets. (...) Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

: Calls for ethics education for members of hospital ethics committees presume that the effects and benefits of such education are well-established. This is not the case. A review of the literature reveals that studies consistently have failed to uncover any significant effect of ethics education on the moral reasoning, moral competency, and/or moral development of medical professionals. The present paper discusses this negative result and describes the author's national study of the value priorities of members of hospital ethics committees. (...) This study discovered correlations between moral decision making and factors like age and type of institution where the committee operates. The results of this study also resemble those of previous studies in finding no correlation between ethics education and moral decision making. The author concludes that there is a need for more research on the effects of nonmoral personal, societal, and institutional factors on the moral reasoning of members of hospital ethics committees. Further, in the absence of any firm empirical basis, calls for ethics education for medical professionals and ethics committee members should be rethought. (shrink)

Vaccine scarcity and availability distinguish two central ethics questions raised by the Covid-19 pandemic. First, in situations of scarcity, which groups of persons should receive priority? Second, in situations where safe and effective vaccines are available, what circumstances and reasons can support mandatory vaccination? Regarding the first question, normative approaches converge in prioritizing most-vulnerable groups. Though there is room for prudential judgement regarding which groups are most vulnerable, the human dignity principle is most relevant for prioritization consideration of both (...) medical and non-medical issues. The second question concerning mandates is distinct from considerations about persons’ individual moral duty to receive vaccines judged reasonably safe and critical for individual and public health. While there is consensus regarding the potential normative support for mandated vaccination, the paternalistic government intervention of vaccine mandates requires a high bar of demonstrated vaccine safety and public health risk. We discuss stronger and weaker forms of paternalism to deal with the Covid-19 pandemic from an “integrative” approach that integrates leading normative approaches. We argue against a population-wide compulsory vaccination and support prudential measures to 1) protect vulnerable groups; 2) focus upon incentivizing vaccine participation; 3) maintain maximum-possible individual freedoms, and 4) allow schools, organizations, and enterprises to implement vaccine requirements in local contexts. (shrink)

RATIONALE AND AIMS: Total hip and knee replacements, usually, have long waiting lists. There are several prioritization tools for these kind of patients. A new tool should undergo a standardized validation process. The aim of the present study was to validate a new prioritization tool for primary hip and knee replacements. METHODS: We carried out a prospective study. Consecutive patients placed on the waiting list were eligible for the study. Patients included were mailed a questionnaire which included, among (...) other questions, the seven items of the priority tool and the Western Ontario and McMasters Universities Arthritis Index (WOMAC) specific questionnaire. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the content and construct validity. We used Student's t-test or one-way analysis of variance. Correlational analysis was used to evaluate convergent and discriminate validity. RESULTS: The sample consisted of 838 patients (62.3% were female), with mean age of 70.2 years (SD 8.4). A total of 55.5% patients underwent knee replacement. Given that the tool was elaborated by patients and orthopaedic surgeons, it shows a good content validity. The priority score was statistically different (P < 0.001) among the three urgency categories created. The scores of the three WOMAC dimensions showed differences (P < 0.001) by the three urgency categories created. The correlations between the priority score and WOMAC dimensions were 0.79 (function), 0.69 (pain) and 0.51 (stiffness). The correlations between WOMAC items and items from priority tool were greater (0.47-0.69) between items measuring similar constructs than those measuring different constructs (0.27-0.49). These data are similar in both joints. CONCLUSIONS: Results support the validity of the prioritization tool to be used with patients waiting for hip or knee replacement. (shrink)

The recent Ebola virus disease outbreak in Western African countries has raised questions regarding the feasibility of adopting conventional trial designs such as randomized controlled trials for conducting experimental trials in the midst of a fatal epidemic. In the context of Ebola ça Suffit trial conducted in Guinea for testing the efficacy and effectiveness of rVSV–ZEBOV, a candidate vaccine, I argue that the trial design and the methodologies adopted for the trial have been rightly chosen for their ethical appropriateness and (...) social utilities rather than only epistemic advantages. In this paper, I propose and defend the view that in varying scientific research contexts, it is entirely legitimate that non-epistemic values may be prioritized over epistemic considerations. Two vital methodological choices scientists should make while designing a clinical trial are: the choice of appropriate control group and the choice of appropriate randomization. Given this background, I show that the choice of delayed vaccination arm as the control group over placebo control group and the choice of cluster randomization over individually controlled randomization for conducting Ebola ça Suffit trial are perfect instances of such a scenario where addressing social and ethical issues have been justifiably prioritized over epistemic values so that the research in a specific scientific context could be conducted in a socially relevant manner. (shrink)

In 1990 the landmark Americans with Disabilities Act (ADA) became federal law with the express purpose to “establish a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities."l The act includes separate titles prohibiting discrimination on the basis of disability in employment, public services, transportation and public accommodations. Since it prohibits discrimination on the basis of disability in both public and private services and programs, in health care “it applies to programs provided by the government, (...) benefits provided by employers, and services pro- ”2 vided by physicians.Moreover, the ADA defines disability broadly to include “any.. (shrink)

Regression testing is applied whenever a code changes, ensuring that the modifications fixed the fault and no other faults are introduced. Due to a large number of test cases to be run, test case prioritization is one of the strategies that allows to run the test cases with the highest fault rate first. The aim of the paper is to present an optimized test case prioritization method inspired by ant colony optimization, test case prioritization–ANT. The criteria used (...) by the optimization algorithm are the number of faults not covered yet by the selected test cases and the sum of severity of the faults. The cost, i.e. time execution, for test cases is considered in the computation of the pheromone deposited on the graph’s edges. The average percentage of fault detected metric, as best selection criterion, is used to uncover maximum faults with the highest severity, and reducing the regression testing time. Several experiments are considered, detailed and discussed, comparing various algorithm parameter’s alternatives. A benchmark project is also used to validate the proposed approach. The obtained results are encouraging, being a cornerstone for new perspectives to be considered. (shrink)

The rapid development of vaccines against COVID‐19 represents a huge achievement, and offers hope of ending the global pandemic. At least three COVID‐19 vaccines have been approved or are about to be approved for distribution in many countries. However, with very limited initial availability, only a minority of the population will be able to receive vaccines this winter. Urgent decisions will have to be made about who should receive priority for access. Current policy in the UK appears to take the (...) view that those who are most vulnerable to COVID‐19 should get the vaccine first. While this is intuitively attractive, we argue that there are other possible values and criteria that need to be considered. These include both intrinsic and instrumental values. The former are numbers of lives saved, years of life saved, quality of the lives saved, quality‐adjusted life‐years (QALYs), and possibly others including age. Instrumental values include protecting healthcare systems and other broader societal interests, which might require prioritizing key worker status and having dependants. The challenge from an ethical point of view is to strike the right balance among these values. It also depends on effectiveness of different vaccines on different population groups and on modelling around cost‐effectiveness of different strategies. It is a mistake to simply assume that prioritizing the most vulnerable is the best strategy. Although that could end up being the best approach, whether it is or not requires careful ethical and empirical analysis. (shrink)

In the face of the most recent developments in digital and visual art, the Internet, the latest frontiers and currents, the new languages and technologies, Souriau’s schema does not work, but his reflections on the aesthetic notions of instauration and skeuopoetics do, and they pertain both to classical painting and to future perspectives. In fact, we note strong connections with research that the philosopher had had conducted on feelings, relations, forms, and processes, in terms of synaesthesia and structural correspondences. On (...) the basis of his thinking, we can still argue the importance of these concepts and these relations as they relate to physical and phenomenal existence, to materiality and transcendence: a conceptual and imaginative universal that is considered to be eternal. Art is seen as the producer of things capable of performing actions that are purely physical. He makes this claim because these actions expressly and intentionally create things whose existence is their sole purpose. (shrink)

In their article, Bruno and Arora (2018) conclude that if deceased donor uterus transplantation has equivalent outcomes and the supply of deceased donors is sufficient, then living uterus donation...

This chapter examines whether an individual’s being worse off than others should be a relevant consideration in the allocation of limited medical resources. It reviews arguments pressed by proponents of different theories of justice about whether being worse off than others makes special demands on health care resource prioritization. Even if there is good reason to restrict the concern for the worse off to those with worse health in the prioritization and allocation of health care resources, additional issues (...) remain. One is how to determine who has worse health, and whether the worse off are those with the worse overall health or those with the most serious medical condition now in need of treatment. Another issue is whether only individuals’ present health, or instead their lifetime health, including past and expected future health, is relevant. (shrink)

The purpose of this article is to examine stakeholder identification and prioritization by managers using the power, legitimacy, and urgency framework of Mitchell et al. (Academy of Management Review 22, 853–886; 1997). We use a multi-method, comparative case study of two large-scale sporting event organizing committees, with a particular focus on interviews with managers at three hierarchical levels. We support the positive relationship between number of stakeholder attributes and perceived stakeholder salience. Managers’ hierarchical level and role have direct and (...) moderating effects on stakeholder identification and perceived salience. We also found that most stakeholders were definitive, dominant, or dormant types – the other five types were rare. Power has the most important effect on salience, followed by urgency and legitimacy. Based on our case study, we offer several ways to advance the theory of stakeholder identification and salience. (shrink)

In this essay I question an assumption of Card's, which seems to place the (Kantianstyle) ethical in a directive relationship with respect to the political. I call attention to the rupture between the two as a marker of modernity and suggest that the political is not only a sphere of power but also a value-sedimented field, with the values in question developing historically as in the case of liberal democracy.

In this essay I question an assumption of Card's, which seems to place the ethical in a directive relationship with respect to the political. I call attention to the rupture between the two as a marker of modernity and suggest that the political is not only a sphere of power but also a value-sedimented field, with the values in question developing historically as in the case of liberal democracy.

The term "stakeholder engagement" has gained increasing prominence over the last few years. This prominence is fueled by a range of issues such as an increased dissatisfaction with business's focus on stockholder/shareholder interests and the demands for greater transparency from business following major business scandals. A perceived response to this issue in South Africa has been the inclusion of guidelines on stakeholder engagement in the King II Report on Corporate Governance. Despite this growing interest, there has not been clarity on (...) how companies engage with their stakeholders and specifically with how they identify and prioritize their stakeholders. The study sought to establish the reporting practices of South African business in relation to stakeholder identification and prioritization through a content analysis of their annual reports. The findings are discussed and recommendations on the two aspects of stakeholder engagement presented. (shrink)

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions regarding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare resources. A large proportion of doctors in both countries supported including responsibility for illness in (...) prioritization decisions. This finding was more prominent in zero‐sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsibility (through patient contracts), and low support for integrating responsibility into co‐payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)—potentially because of the certainty of impact and direct link to ill health. In zero‐sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced—and clear—policy. Such policy should account for the distinctions we draw between responsibility‐sensitive and prognostic justifications for deprioritization. (shrink)

In this paper, for the benefit of reflection processes in clinical and in local, regional, and national priority-setting, we aim to develop an ethical theoretical framework that includes both ethical principles and medium-range narratives. We present our suggestion in the particular case of having to choose between treatment interventions for attention deficit hyperactivity disorder (ADHD) and treatment interventions for other conditions or diseases, under circumstances of scarcity. In order to arrive at our model, we compare two distinct ethical approaches: a (...) generalist (principles) approach and a particularist (narratives) approach. Our focus is on Sweden, because in Sweden prioritization in healthcare is uniquely governmentally regulated by the “ethics platform.” We will present a (fictional) scenario to analyse the strengths and weaknesses of the generalist principled perspective of the ethics platform and the particularist perspective of narrative ethics. We will suggest an alternative (moderately particularist) approach to prioritization, which we dub a “principles plus medium-range narratives” approach. Notwithstanding the undeniably central role of principles in distributive justice, we claim that medium-range narratives concerning individuals or groups who stand to benefit or lose from ADHD prioritization practices should also be read or listened to and taken into account at all levels of priority-setting. These narratives are expected to ethically optimize clinical priority-setting, as well as that undertaken at local, regional, and national levels. (shrink)

With the limited initial availability of COVID-19 vaccines in the first months of 2021, decision-makers had to determine the order in which different groups were prioritized. Our aim was to find out what normative approaches to the allocation of scarce preventive resources were embedded in the national COVID-19 vaccination schedules. We systematically reviewed and compared prioritization regulations in 27 members of the European Union, the United Kingdom, and Israel. We differentiated between two types of priority categories: groups that have (...) increased infection fatality rate (IFR) compared to the average for the general population and groups chosen because their members experience increased risk of being infected (ROI). Our findings show a clear trend: all researched schedules prioritized criteria referring to IFR (being over 65 years old and coexisting health conditions) over the ROI criteria (eg occupation and housing conditions). This is surprising since, in the context of treatment, it is common and justifiable to adopt different allocation principles (eg introducing a saving more life-year approach or prioritizing younger patients). We discuss how utilitarian, prioritarian, and egalitarian principles can be applied to interpret normative differences between the allocation of curative and preventive interventions. (shrink)

In this survey study of 4735 US adults, respondents of all demographic and political affiliations agreed with prioritizing COVID-19 vaccine access for health care workers, adults of any age with serious comorbid conditions, frontline workers (eg, teachers and grocery workers), and Black, Hispanic, Native American, and other communities that have been disproportionately affected by COVID-19. Older adult respondents were less likely than younger respondents to list healthy people older than 65 years as 1 of their top 4 priority groups. These (...) findings suggest that the US public agrees with the high-priority groups proposed by the National Academies of Science, Engineering, and Medicine but appears to disagree with approaches advanced by others that prioritize older adults but not essential workers or disproportionately affected communities. (shrink)

The dominant methodology in health policy for prioritizing and rationing health care resources is cost-effectiveness analysis, typically using quality adjusted life years (QALYs) or disability adjusted life years (DALYs) to measure health outcomes. The construction of these measures involves a number of moral or value choices, including: How should states of health and disability be evaluated, and whose preferences (e.g., the disabled or non-disabled) should be used? How should these evaluations reflect that prioritization will involve tradeoffs between health benefits (...) for different persons or groups? Do all QALYs count equally, no matter what age at which they are received? Should discount rates be applied to health benefits? I will show the nature of the moral issues at stake in answering these questions, and briefly argue how they should be answered. (shrink)

The aim of this study was to describe the reasoning of people aged 60 years and over about prioritization in health care with regard to age and willingness to pay. Healthy people (n = 300) and people receiving continuous care and services (n = 146) who were between 60 and 101 years old were interviewed about their views on prioritization in health care. The transcribed interviews were analysed using manifest and latent qualitative content analysis. The participants' reasoning on (...) prioritization embraced eight categories: feeling secure and confident in the health care system; being old means low priority; prioritization causes worries; using underhand means in order to be prioritized; prioritization as a necessity; being averse to anyone having precedence over others; having doubts about the distribution of resources; and buying treatment requires wealth. (shrink)