This document discusses the ethical issues involved in healthcare resource allocation and priority setting. It examines principles of distributive justice and fair process. Priority setting involves considering clinical effectiveness, cost, need and ability to benefit. Fair allocation of resources balances equality of outcome, based on treatments being equally effective or cost-effective, with equality of persons where individuals are treated equally. A fair process of accountability for reasonableness is proposed to balance these considerations and allow for appeal of decisions. Exceptions to policies and a modified "rule of rescue" are discussed to account for identifiable individuals.

1. Ethical Issues in Priority Setting
’Making Difficult Choices’ Workshop
24th May 2011
Dr Mark Sheehan
Oxford BRC Ethics Fellow
James Martin Research Fellow
The Ethox Centre and Faculty of Philosophy
University of Oxford

2. Aims
 To consider some of the ethical issues
involved in the process and decision-making
surrounding resource allocation
 Along the way:
 Distributive justice
 Fair process
 Priority setting and IFR panels
 Rule of Rescue

3. Starting point
 Ethics and ethical considerations
 ‘Ought’ questions
 Unpacking and articulating reasons
 Distinct from legal considerations
 Examples:
 Anti-VEGFs
 IVF funding
 Cosmetic surgery: Hirsuitism

4. Anti-VEGFs

5. IVF funding

6. Cosmetic Procedures

7. Cosmetic Surgery
http://www.buckspct.nhs.uk/wp-content/uploads/2008/11/BPCT03-
Cosmetic-Procedures3.pdf

8. Just Allocation of Resources
What should be the general ethical principles
for the allocation of healthcare resources?
 General answers might include:
 Cost
 Opportunity costs
 Clinical effectiveness
 Benefit
 Cost effectiveness
 Need / Ability to Benefit

9. Values in Practice
 South Central Ethical Framework
 Evidence of clinical and cost effectiveness
 Equity
 Healthcare need and capacity to benefit
 Cost of treatment and opportunity costs
 Needs of the community
 Policy drivers
 Exceptional need

10. Just Allocation of Resources
Broadly fall into two categories ...
 Equality of Outcome
 Funding is based on treatments being
equally effective or cost-effective
 Best use of resources
 Equality of Persons
 Individuals are treated equally as individuals
 Required resources do not count against an
individual

11. Just Allocation of Resources
Importantly,
i. These categories very often pull in
different directions
ii. Need to be balanced or judged (we have
intuitions in both directions)
iii. This can be difficult
iv. Reasonable people (disposed to make a
decision) can disagree

12. 1. Accountability for Reasonableness
 A fair process in a context of reasonable
disagreement (satisfies equality of persons)
Four principles (Daniels and Sabin, 1997)
1. Publicity: “Decisions must be made publicly
accessible”
2. Relevance: “The rationales for decisions should…
provide a reasonable explanation”
3. Revision and Appeal: Mechanisms for challenge and
dispute resolution regarding decisions
4. Regulation: Voluntary/public regulation of the
process to ensure 1-3 are met

13. 1. Accountability for Reasonableness
What does this mean for the decision-making
structures?
 The key for this process is ‘Relevance’
 “A rationale will be reasonable if it appeals to
evidence, reasons, and principles that are
accepted as relevant by fair-minded people who
are disposed to finding mutually justifiable terms
of cooperation.”
 Need to ensure that the right people are
involved in the right way
 Representation, practical buy-in, opportunity
costs

14. 2. Policies and IFR panels
a. Policies and exceptions to policies
 We grant the possibility that a policy may
fail (unjustly) to satisfy equality of
persons
b. Appeal/Revision
 Process hasn’t been followed
 Exception to the policy (see (a))

15. 3. The Rule of Rescue
 It seems reasonable to understand the Rule
of Rescue as a general empirical tendency
 However, what makes it interesting for us is
its normative (‘ought’) component
 The (Interesting) Rule of Rescue:
People tend to be prepared to spend large sums
of money rescuing seriously endangered,
identifiable individuals and this ought to be the
case

16. 3. The Rule of Rescue
How are we to understand identifiability?
 Identifiability does not seem to be a morally
relevant property
 Lobbying, public campaigns ...
 Sliding Scale: being identified (identifiable) looks
to be a matter of degree
 Identifiability looks to be a vague, catch-all term
 Range of terms: acquaintance, proximity,
relationship, statistical likelihood

17. 3. The Rule of Rescue
However:
 Is it enough for us to withhold rescue that
someone is ‘wrongly’ identifiable?
 Applicability in context of a settled process
 Identification/attention process is more robust
 Extended idea – preserves the central intuition
 Emphasis should be on the response to need (i.e.
on the rescue)
 Notice here the parallel with the idea of equality
of persons

18. Justifying Equality of Persons
... along with considerations of fair process and the
broadened rule of rescue
Examples: family, scout troop, regiment,
constituency, ...
Different kinds of obligations at work here:
 Obligations to the population as a whole
 Obligations to individuals
The examples show the existence of these
obligations not their force

19. Conclusions?
 Equality of persons and equality of outcome
are competing conceptions of justice
 Both are relevant in resource allocation
 The justification of equality of persons
supports fair processes, policies which allow
for exceptionality and a modified version of
the rule of rescue
 This position allows scope for considerations
other than cost-effectiveness and clinical
effectiveness to matter more

20. Thank You
Please do not hesitate to get in touch if you
have any further questions:
mark.sheehan@philosophy.ox.ac.uk