Abstract
Alternative allocations of a fixed bundle of healthcare resources often involve significantly different indirect, non-health effects. The question arises whether these effects must figure in accounts of the conditions under which a distribution of healthcare resources is morally justifiable. In this article we defend a Scanlonian, affirmative answer to this question: healthcare resource managers should sometimes select an allocation which has worse direct, health-related effects but better indirect, nonhealth effects; they should do this when the interests served by such a policy are more urgent than the healthcare interests better served by an alternative allocation. We note that there is a prima facie case for the claim that such benefits (and costs) are relevant—i.e. they are real benefits, and in other contexts our decisions can permissibly be guided by them. We then proceed to rebut three lines of argument that might be thought to defeat this prima facie case: they appeal to fairness, the Kantian Formula of Humanity as an End in Itself, and the equal moral worth of persons, respectively.
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Notes
Trappenburg (2000), Walzer (1983), and Williams (1973) all qualify as strong health exceptionalists. Trappenburg and Walzer are a strong exceptionalists not only about healthcare, but also about a number of other goods, e.g. honours and education, in the sense that they think that the justifiability of a distribution of each of these goods is justified independently of how they affect the distribution of other goods. Note, however, that our definition of health exceptionalism allows being an exceptionalist about other goods in addition to health.
It would be an exaggeration to say that strong health exceptionalists do not permit us to allocate in a way that maximizes indirect, non-health benefits. Suppose we have implemented a certain allocation, because it maximizes direct, health benefits. Later we discover that, as it happens, there is no other feasible allocation which has better indirect, non-health effects, but some have worse indirect non-health effects. If strong health exceptionalism did not permit (unintentionally) bringing about an allocation with optimal indirect, non-health benefits, it would implausibly require us to switch to one of the latter non-optimal allocations.
By this we do not mean to deny that health exceptionalists face a problem analogous to the last one. This problem comes out in cases involving the choice between a trivial health benefit, e.g. the elimination of a mild headache, to a large number of people, and, alternatively, a huge health benefit, e.g. survival, to a very small number of people. We thank an anonymous reviewer for bringing this point to our attention.
In his more recent work, Daniels addresses the impact of socio-economic factors on health (see, e.g. Daniels 2001).
http://whqlibdoc.who.int/bulletin/2002/Vol80-No12/bulletin_2002_80(12)_981-984.pdf [accessed July 5, 2007].
Kamm (1996, p. 183), believes that causal structure matters morally, e.g. her Principle of Permissible Harm implies that it matters whether a lesser harm is a cause of the production of a greater good or an aspect or a causal effect of it. However, this does not amount to ascribing moral relevance to causal proximity per se.
For a similar reason we shall ignore the pragmatic objection that strong health non-exceptionalists may direct against substantive non-health exceptionalism: namely, that the notion of urgency, which is crucial to the latter, is hard to quantify and, thus, that measurement problems may be more intractable under substantive non-health exceptionalism than under strong health non-exceptionalism. We concede this point about the notion of urgency. Specifically, we admit that there are bound to be a lot of cases where the notion of urgency is vague and, thus, cannot determine the ranking of different outcomes. However, our primary interest lies in whether one provides a principled defence of strong health non-exceptionalism setting aside pragmatic considerations about measurement etc. Also, recall that while we do not argue in favour of strong health non-exceptionalism, we do not rule out this view either. This is a further reason why our present argumentative purposes do not oblige us to address the measurement intractability problem.
We are not convinced that the concern for trust between patients and doctors aligns suitably with the cut between indirect non-health effects and direct health effects. Why should a patient trust her doctor less when she prioritizes another person over her because of an indirect non-health effect than when she does so because of a direct health effect? We owe this challenge to an anonymous referee.
We do not claim to offer support for our view that the three arguments discussed below are the most influential and promising arguments against counting indirect, non-health effects. In our experience, most readers do not disagree with this view. Readers, who do, are invited to consider our critique of the three objections below on its own merits and in isolation from the overall issue of whether, in view of all relevant arguments, an allocation of health-care resources can be morally justified partly because of its indirect, non-health effects.
‘… it would, in short, be unjust to distribute life-saving resources in a way which in effect valued the lives some sorts of citizens more highly than others’ (Harris 1988a, p. 261). Harris makes this claim to rebut what he calls ‘ageism’, but it has a much wider scope (see also Harris 1988b; Brouwer et al. 2006, pp. 343–344; Brock 2003a, p. 297).
‘Medical need’ is often used in a way that embodies substantive commitments to certain values: for a similar point in relation to ‘clinically indicated’ see Hope et al. (1993). Here we use the term as follows: something constitutes a medical need if, and only if, it is required to restore an individual to a species-normal functioning, i.e. to full health in Daniels’ (1996) and Boorse’s (1975, 1977) sense.
The same objection applies to schemes that aim to do most good in terms of direct, health benefits only. Arguably, broadening the aim to include indirect, non-health benefits adds further unfairness.
Kamm (1993, p. 148), considers the Principle of Irrelevant Utilities, which arguably extends to indirect non-health benefits in relation to the allocation of scarce healthcare resources, as one that is justified by the Kantian Injunction not to treat people solely as means but also as ends in themselves.
In one of the cases Kamm uses to illustrate the moral irrelevance of some indirect benefits in relation to the question of whom to save by means of an organ transplant, the irrelevant indirect benefit is the life-saving treatment of twenty people that a doctor can confer on them qua exercising his skills if he is given the organ transplant (see Kamm 1993, pp. 262–263). However, Kamm thinks that a variation of this case where the relevant indirect benefits reflect the doctor’s ability to distribute a resource that the person doing the organ transplant has, e.g. 20 additional organs that only the doctor can distribute if he himself receives one, ‘may undermine the validity of the mere-means principle’, http://personal.lse.ac.uk/voorhoev/03-Voorhoeve-Chap01.pdf [Accessed 29.12.2009]. Also, it shows that not all indirect benefits are irrelevant. Indeed, some such relevant indirect benefits may be the satisfaction of urgent non-health related needs.
See the distinction between criteria of justice and decision procedures in Railton (1984).
Interestingly, people are more inclined to accept healthcare priorities that favour parents of small children than they are to accept priorities favouring economically productive patients (see Olsen 2000, p. 3). The explanation for this might be that, because most people associate at times or often with small children, and because only a few of us associate at times or often with very productive people, the second priority, unlike the first, is thought to conflict with treating people as equals (see Olsen and Richardson 1999, p. 25). Alternatively, the explaining feature might be the different degrees of urgency of the needs met by the differing priorities.
Walzer stresses that once medical care becomes a socially recognized need, being deprived thereof is not just a loss to one’s health but also a loss to one’s social standing (Walzer 1983, p. 89).
One additional complication is how to understand equal moral worth in the light of situations where we must choose between a reduction in the probability of a very bad health outcome for one patient and a similar reduction in the probability of a much less bad health outcome for another patient. Treating on the basis of medical needs implies that we should deal with the first patient and ignore the latter’s medical needs, but, arguably, selecting whom to treat on the basis of the outcome of a weighted lottery that gives the latter patient some appropriately smaller chance of being treated is the right way to recognize this person’s equal moral worth.
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We thanks two anonymous reviewers of this journal for some very helpful comments.
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Lippert-Rasmussen, K., Lauridsen, S. Justice and the allocation of healthcare resources: should indirect, non-health effects count?. Med Health Care and Philos 13, 237–246 (2010). https://doi.org/10.1007/s11019-010-9240-9
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DOI: https://doi.org/10.1007/s11019-010-9240-9