Medical Ethics
Michael Green
Manuel Vargas
phone, office information

11 May. Numbers don't count.
13 May. Aggregation and Kamm.
13 May. Glover
15 May. How to measure quality in a QALY
15 May. QALYs and fairness
18 May. The veil of ignorance argument
22 May. QALYs in macro and micro contexts
29 May. How great a loss is death?
3 June. Consent as a way out?

Medical Ethics: 27 May. Rakowski and Post on preferring the younger.

Here are some things I thought while listening to Manuel today. By the way, I thought the lecture was great. Thanks Manuel!

Does Rakowski need that specific view of justice?

I thought Emma had a good point: are we really unjust if we allow some people to have more good luck than others?

It made me wonder whether Rakowski really needs to elaborate that big view of justice in order to make his point about rationing health care. Of course, he wants to do that to show how comprehensive and impressive his grand theory of justice is. But we may not care: we're more interested in rationing health care than we're interested in justice in general.

What would we substitute in its place? Perhaps this principle of equal opportunity would do. We should treat patients in the medical system as equals, unless we have special reasons not to. The medical system treats patients fairly if it does what it can to provide them with equal opportunities to live good lives.

That expresses the basic principle without the very strong claims about the importance of sharing good and bad luck.

It may be the case that when we're pressed to justify this simplified principle of equal opportunity, we'll have to make the arguments Rakowski does about luck. In that case, we would not have really changed very much.

Still, I think we should prefer the more simple version of the principle in formulating our arguments.

After all, it's possible that the person we're addressing would accept this simple principle. If that's so, we would have gotten everything we wanted without adding a lot of baggage.

If someone does want to push this assumption, at least our initial formulation of the argument would have put the emphasis where we want it: on rationing health care. If it turns out that someone disagrees with my position on rationing because she rejects my underlying assumptions about justice, that suggests that she and I need to talk about justice first, not health care.

What about that phrase "excluding certain things" (in 5.))

Manuel gave a powerful argument for thinking that this would exclude much more than Rakowski thinks. Many of our health problems can be traced to choices that we make so if we only employ rationing rules for health problems that are due solely to bad luck (and not our choices) our rationing rules won't cover very much.

Could Rakowski respond like this? What we exclude is a matter of social decision, not just facts about what kinds of problems can be linked to choices. We may decide that the public health system will treat people for problems that they incur because of their voluntary behavior because we all want to be able to run some risks on our own yet be covered by the health care system. I like sky diving, you smoke. We can both agree that our voluntary behavior runs the risk of serious health problems and agree that we'll pay our taxes to ensure one another against these risks. I want you to help me in case I crash, you want me to help you in case you get cancer. We both agree to cover one another's risky behavior.

Since our society does, in fact, cover a great range of risky behavior in this way, our rationing decisions have very broad application.

Could he avoid Manuel's objection that way?

What about when the life years are different?

Post wants to ration care according to its efficacy: the more effective treatments take priority over the less effective ones (or, at least, we need not provide futile treatments -- I assume he'd extend this idea more broadly).

Rakowski wants to ration care according to the age of the patient when other things are equal.

It looks like they've got compatible views: if treatments of equivalent efficacy are in competition, choose the one that will (or is most likely to) benefit the younger patient or patients.

But that's no fun. More to the point, is Rakowski allowed to skate away like that?

I would have thought that he would take a stronger stand: even if the younger patients would not live as long or as well, we should prefer them because they haven't had as many years of life as the older ones have.

Give this some thought. When we talk about fair innings next time, that's where we'll start.

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This page was originally posted on 5/27/98; 12:08:51 PM and was last built on 6/3/98; 2:44:24 PM with BBEdit and Frontier 5 on a Macintosh running System 8.1.