Sustainability principle for the ethics of healthcare resource allocation

Abstract

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose.

Sustainability, equal treatment, and temporal neutrality

“…Munthe et al 1 imagine sustainability accompanying four other principles: need, prognosis, equal treatment and cost-effectiveness. Some are spelled out, however, in ways that are ambiguous or incomplete.…”

“…Accordingly, it is compatible with distributive principles other than mine or Munthe et al's, 1 such as strict egalitarianism (all should have an equal chance to receive treatment) (Munthe et al, p. 19) 1 15 reparation (favour beneficiaries who previously experienced injustice) 16 and desert (favour those who acted meritoriously in the past) (Munthe et al, p. 18). 1 While desert, for instance, attaches no importance to future interests, it is fully compatible with temporal neutrality between equally deserving present and future beneficiaries.…”

“…Any temporal principle-whether temporal neutrality, future relevance, or Munthe et al's 1 original principle of sustainability-faces challenges of assessment if framed in terms of health needs, rather than health outcomes. Consider the example of a programme that expands access to vaccinations (Munthe et al, p. 7).…”

“…Consider the example of a programme that expands access to vaccinations (Munthe et al, p. 7). 1 This programme likely increases future health: people will suffer less illness and death from infectious disease. However, it may not diminish future healthcare needs: those who escape death or illness due to infectious disease may live longer and develop other conditions (such as cancer, diabetes or dementia) that in turn generate demands for costlier healthcare.…”

Promoting the sustainability of healthcare resources with existing ethical principles: scarce COVID-19 medications, vaccines and principled parsimony

“…Munthe et al 1 argue for an asymmetry between positive and negative dynamics that justifies a new sustainability principle among the operational principles for ethical healthcare resource allocation. The purported asymmetry is that while positive dynamics are 'taken into account in present applications of the operational principles…, negative dynamics are not'.…”