Four ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.

When the demand for a medical resource exceeds the supply, we have a problem of scarcity. There are many instantiations of this issue. The time of health care providers during an emergency, organs for transplantation, a bed in an intensive care unit, and a slot in a research protocol can all be scarce resources. Interest in this issue has been renewed because of recent concerns about a pandemic and shortages of vaccines. In each of these cases there (...) is a problem of distributive justice. If the resource is lifesaving, then the question is especially poignant: Who shall be saved when not all can be? This was the problem faced by Sir Dr. Colenso Ridgeon in Bernard Shaw's 'The Doctor's Dilemma', a play first performed a century ago. (shrink)

When discussing the allocation of medical resources, it is common to distinguish between macroallocation and microallocation. The former refers to an entire system of healthcare; it determines who gets access to what healthcare and on the basis of what criteria.

BACKGROUND: A programmatic research effort investigated how lay people weigh information on hypothetical patients when making decisions regarding the allocation of scarce medical resources. This study is partly replicative and partly innovative, and looks particularly at whether overweight patients would be discriminated against in allocating resources. AIMS: This study aims to determine the importance given to specific patient characteristics when lay participants are asked to allocate scarce medical resources. SAMPLE: In all, 156 British (...) adults (82 males, 73 females), aged 19 to 84 years, took part. There were few students. METHOD: Participants completed a questionnaire requiring them to rank 16 hypothetical patients for access to a kidney dialysis machine.The demographic information presented regarding each hypothetical patient differed on four dimensions: gender, weight, mental health, and religiousness. RESULTS: There were significant main effects for gender, weight, and mental health; females, patients of normal weight, and the mentally well were ranked the highest priority for access to a kidney dialysis machine. Participants discriminated most regarding the weight of hypothetical patients. CONCLUSION: Different patient characteristics, unrelated to medical prognoses, particularly being overweight, may have an impact on decisions regarding the use of scarce medical resources. (shrink)

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

Some controversies have a staying power because they spring from unavoidable moral and conceptual puzzles. The debates concerning transplantation are a good example. To begin with, they are not a single controversy. Rather, they are examples of the scientific debates with heavy political and ethical overlays that characterize a large area of public-policy discussions.

The aim of this article is to consider whether, when, and why it is morally right to treat members of socially disadvantaged racial or ethnic groups favorably when allocating scarce medical resources. Since the COVID 2019 pandemic has had different impacts on racial and ethnic groups, some U.S. states have given racial and ethnic minorities preferential access to COVID-19 vaccines, leading to controversy over the moral and legal permissibility of doing so. I examine three arguments for affirmative (...) action—the compensation, equality-of-opportunity, and antidiscrimination arguments—and argue that both the equality-of-opportunity and antidiscrimination arguments have the potential to provide well-founded justification for race-based affirmative action for the allocation of scarce medical resources. I also consider further moral requirements that instances of affirmative action based on both or either of the two arguments should comply with for them to be justified. (shrink)

One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and (...) explain how these principles will often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity. (shrink)

The COVID-19 pandemic has placed an enormous burden on health systems, and guidelines have been developed to help healthcare practitioners when resource shortage imposes the choice on who to treat. However, little is known on the public perception of these guidelines and the underlying moral principles. Here, we assess on a sample of 1033 American citizens’ moral views and agreement with proposed guidelines. We find substantial heterogeneity in citizens’ moral principles, often not in line with the guidelines recommendations. As the (...) guidelines are likely to directly affect a considerable number of citizens, our results call for policy interventions to inform people on the ethical rationale behind physicians or triage committees decisions to avoid resentment and feelings of unfairness. (shrink)

The aim of this article is to consider whether, when, and why it is morally right to treat members of socially disadvantaged racial or ethnic groups favorably when allocating scarce medical resources. Since the COVID 2019 pandemic has had different impacts on racial and ethnic groups, some U.S. states have given racial and ethnic minorities preferential access to COVID-19 vaccines, leading to controversy over the moral and legal permissibility of doing so. I examine three arguments for affirmative (...) action—the compensation, equality-of-opportunity, and antidiscrimination arguments—and argue that both the equality-of-opportunity and antidiscrimination arguments have the potential to provide well-founded justification for race-based affirmative action for the allocation of scarce medical resources. I also consider further moral requirements that instances of affirmative action based on both or either of the two arguments should comply with for them to be justified. (shrink)

In an article titled, "Who Shall Live When Not All Can?", James Childress proposes a system for allocating scarce lifesaving medical resources based on random selection procedures. Childress writes of random selection procedures, [They] "cannot be dismissed as a ‘non-rational’ and ‘non-human’... without an inquiry into the reasons, including human values which might justify it." My thesis is that once we concentrate on determining the rationality of random selection procedures, we will see that Childress's claim that we (...) cannot dismiss such procedures as ‘non-rational’ is open to question. My claim will be that while both random selection and social worth procedures are rationally defensible systems, random selection procedures easily lead to specific choices that are objectively irrational, apart from the limited perspective of the random selection process itself. Keywords: allocation, random selection, rationality, rational decision-making, scarce resources, social worth CiteULike Connotea Del.icio.us What's this? (shrink)

ABSTRACT This study examined how lifestyle factors and gender affect kidney allocation to transplant patients by 99 British and Singaporean participants. Thirty hypothetical patients were generated from a combination of six factors and randomly paired four times. Participants saw 60 patient pairings and, in each pair, chose which patient would receive treatment priority. A Bradley-Terry model was used to derive coefficients for each factor per participant. A mean factor score was then calculated across all participants for each factor. Participants gave (...) lower priority to patients who drank more, were overweight, smoked more and exercised less. A patient’s diet and gender had no significant effect on allocation. There were no significant cross-cultural differences. There were moderate correlations between participants’ self-reported pre- and post-experiment ordering of decision criteria, and these measures and factor coefficients, suggesting a modest level of decision-making consistency. Between participants, moderate levels of concordance with respect to factor importance were observed for self-reported orderings of factors, and weaker agreement for model-derived coefficients. Very similar results were obtained for both British and Singaporean participants, and the implications of the findings are discussed. (shrink)

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)

The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising (...) benefits and minimising harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while (...) others disagree. We offer a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and (...) discuss the major ethical challenges encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. (...) Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change. (shrink)

In this paper I proceed on the assumption that moral philosophers can and should contribute to the resolution of perplexing moral problems. The ones considered here relate to decisions concerning the distribution of scarce medical resources as between those in need of treatment. I draw on considerations of egalitarianism and concern for the maximization of the use of scarce resources in the task of satisfying basic human needs (such as for good health). I propose certain (...) principles and offer some supporting suggestions as guidelines or rules for medical decisions with a view to providing a helpful decision procedure for the various persons (doctors, community panels and so on) whose task it is to make the life-or-death decisions involved in allocating certain scarce medical resources. -/- . (shrink)

Ruth Macklin argued that dignity is nothing more than respect for persons or their autonomy. During the COVID-19 pandemic, difficult decisions are being made about the allocation of scarce resources. Respect for autonomy cannot justify rationing decisions. Justice can be invoked to justify rationing. However, this leaves an uncomfortable tension between the principles. Dignity is not a useless concept because it is able to account for why we respect autonomy and for why it can be legitimate to override (...) autonomy in times of critical care resource shortages. Dignity affirms the worth of the human individual as a meaning-making embodied subject, who is always in relationship to others, the world, time, and transcendence, and who realizes their dignity through their moral behaviour. Such an understanding means people should be helped to make morally right decisions about their own treatment, which may include forgoing potentially beneficial treatment for the good of others. Respect for dignity does not require fulfilling the morally wrong choices of one who insists on treatment at the expense of others. Dignity also protects the discretion of clinicians to make decisions appropriate to their competence by prohibiting the application of broad-based criteria such as age. (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)

In this essay it will be argued that if preferential treatment for individuals who have suffered from past discrimination is permissible in any context, it should be extended to the allocation of scarce medical resources. This contention will be based on two facts: one, that health care, in particular certain life-saving operations, constitutes a scarce social good similar to but more important than other social goods such as desirable jobs and positions in desirable professional schools; secondly, (...) that a claim can plausibly be made that the greater incidence of death due to heart disease among blacks is a result of the effect of past discrimination. In addition, an argument to the effect that preferential treatment is indeed permissible will be sketched that is based upon a critique of the decision in the Bakke case. (shrink)

A common difficulty with the application of theories of justice to the allocation of medical resources is the assumption that one perspective is primary, whether that privileged perspective be that of the practitioner, on the one hand, or policy analyst on the other. By a discussion of three theories — those of Ramsey, Childress, and Joseph Fletcher — I attempt to show that these perspectives must be treated as related. As a result, values and ethics expressed in micro-allocation (...) should be uniform with those of macro-allocation. This point has implications for such issues as substance and procedure in just decision, the role of the political process in medical allocation, and the definition of health and health services. (shrink)

The health care system in Poland is undergoing major change and it is possible that these changes could affect clinical research. Therefore, the situation of funding of health care is important for the future of medical research in this country. Some questions relevant in this field will be addressed. Since funds for health care and scientific research remain inadequate, their allocation raises moral, economic, legal and organisational dilemmas. The clinical aspects of resource allocation also include physicians’ responsibilities towards their (...) patients. Scientific research, clinical medicine, and clinical research have a common denominator: they rely on trust. The physician should be a fiduciary of the patient as well as being a researcher for the benefit of the patient and for society. Some physicians and researchers, despite unethical conduct, escape disclosure and punishment, but decision-makers who wrongly allocate funds for health care and research are never held accountable for their actions. (shrink)

Resumen En este trabajo se exponen veintiuna tesis sobre la asignación de recursos escasos en tiempos de pandemia o crisis sanitaria. El autor parte de la base de que nunca se justifica tratar a una persona como un mero medio. A partir de este principio fundamental, y de otras exigencias de justicia, procura determinar cuáles son los límites a las consideraciones, por lo demás legítimas, de eficiencia o de utilidad. Esto le permite discernir qué criterios de distribución son moral mente (...) aceptables y cuáles no lo son. -/- This work presents twenty one theses on the allocation of scarce resources in times ofpandemic or health crisis. The author assumes that treating a person as a mere means is never justified. On the basis of this fundamental principle, and other requirements of justice, he seeks to determine what are the limits to considerations, otherwise legitímate, of efficiency or utility. This allows him to discern which distribution criteria are morally acceptable and which are not. (shrink)

Arising from four conferences held in Europe and the United States, this volume contains eighteen essays written mostly by Roman Catholics with the exception of select contributions from Jewish, Protestant, and Orthodox perspectives. Most essays pay particular attention to the distribution of scarce medical resources in terms of intensive care units (ICUs) which use some 38% of all medical expenditures in the U.S. each year, one percent of the GNP. The essays often make reference to one (...) another and a wide variety of Catholic perspectives are represented. The essays offer a good reflection of the contemporary state of Catholic moral thought with its strengths and diversity and are nicely framed by the ‘outside voices’ of the non-Catholics represented. Philosophers will find some essays almost exclusively theological. (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)

Background: Existing ethical guidelines recommend that, all else equal, past receipt of a medical resource (e.g. a scarce organ) should not be considered in current allocation decisions (e.g. a repeat transplantation).DiscussionOne stated reason for this ethical consensus is that formal theories of ethics and justice do not persuasively accept or reject repeated access to the same medical resources. Another is that restricting attention to past receipt of a particular medical resource seems arbitrary: why couldn't one (...) just as well, it is argued, consider receipt of other goods such as income or education? In consequence, simple allocation by lottery or first-come-first-served without consideration of any past receipt is thought to best afford equal opportunity, conditional on equal medical need. There are three issues with this view that need to be addressed. First, public views and patient preferences are less ambiguous than formal theories of ethics. Empirical work shows strong preferences for fairness in health care that have not been taken into account: repeated accessto resources has been perceived as unfair. Second, while difficult to consider receipt of many other prior resources including non-medical resources, this should not be used a motive for ignoring the receipt of any and all goods including the focal resource in question. Third, when all claimants to a scarce resource are equally deserving, then use of random allocation seems warranted. However, the converse is not true: mere use of a randomizer does not by itself make the merits of all claimants equal.SummaryMy conclusion is that not ignoring prior receipt of the same medical resource, and prioritizing those who have not previously had access to the medical resource in question, may be perceived as fairer and more equitable by society. (shrink)

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

In this paper, I claim that the doctor-patient relationship can be viewed as a vessel of trust. Nonetheless, trust within the doctor-patient relationship has been impaired by managed care. When we conceive of trust as social capital, focusing on the role that it plays in individual and social well-being, trust can be viewed as a public good and a scarce medical resource. Given this, there is a moral obligation to protect the doctor-patient relationship from the cost-containment mechanisms that (...) compromise its ability to produce trust. (shrink)

Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, (...) other things being equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. (shrink)

BackgroundRadiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant (...) principles.MethodsSemi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles.ResultsParticipants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier.ConclusionsMultiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views. (shrink)

We wholeheartedly agree with Schmidt and colleagues’ efforts to promote equity in intensive care unit triage. We also take issue with their characterisation of the New Jersey allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim—without evidence—that it will ‘compound disadvantage for black patients’. However, the NJ triage framework—like the model allocation policy we developed—actually contains four allocation criteria: (...) the two criteria that the authors mentioned and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage. (shrink)

The allocation of vaccines and therapeutics for Covid‐19 obviously raises ethical questions, and physicians and ethicists have begun to address them. Writers have identified various criteria that should guide allocation decisions, but the criteria often conflict and need to be balanced against one another. This article proposes a model for thinking about how different considerations that are relevant to the distribution of vaccines and scarce treatments for Covid‐19 could be integrated into an allocation procedure. The model employs the construct (...) of a weighted lottery, which is a construct that has been employed in other contexts that involve the distribution of scarce resources. The article highlights the advantages of applying a weighted lottery to the Covid‐19 context and offers an illustration for how it might work in practice. The primary aim of the article is to articulate the structural features of a weighted lottery for this context and to bring out its advantages over other methods for allocating Covid‐19 medications. (shrink)

There is a growing feeling in many Western countries that every human being has a right to health, or a right to health care. This feeling is reflected in a declaration of the World Health Organization (WHO) from 1976, which states: The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. Our intention in the following is to use the WHO (...) declaration as a basis for considering the allocation of resources in health care. We shall first argue that most of the criteria suggested as grounds for fair allocation of scarce medical resources have their difficulties if one tries to apply them one by one to medical practices. We shall then go on to claim that, if we take the right of all human beings to health or health care even moderately seriously, increasing the resources would in most cases be more ethical than attempting to allocate them ‘fairly’. (shrink)

How are we to decide where our scarce medical resources are most effectively spent? The notion of a quality-adjusted-life-year has been proposed as a way of doing this. Some economists appear to think that this can be done without making ethical assumptions. We examine the application of this notion to the treatment of premature newborns, and especially to comparisons between the value of medical care for newborns, and the value of medical care for older people. (...) We find that some highly questionable ethical assumptions are inovled in such comparisons. (shrink)

In this essay, I survey egalitarian and utilitarian approaches to the distribution of scarce life-saving medical resources. In my view, the major criterion for the distribution of scarce life-saving medical resources should be life expectancy: we should distribute life so as to maximize life-years. In Section II, I discuss the life-year maximization approach and situate it within utilitarian theory.

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one’s younger self for lifesaving treatments is prudent from an (...) individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age. (shrink)