Health care with limited resources: Ethics, epidemiology and public policy
Creators: name: Pennings, Susan
Publisher: name: The Australian National University
Year: 2020

description: All modern societies have a shortage of health care resources, which means that we need to have principles to allocate health care resources fairly when not everyone's needs can be met. In this thesis, I argue that health care prioritisation decisions should be largely made on the basis of two factors: to what extent is health care likely to improve a patient's subjective well-being, and to what extent is health care likely to improve a patient's morally relevant capabilities. I argue for my view through critically engaging with alternative theories about how to allocate health care resources fairly in conditions of scarcity. In Part 1 of this thesis, I consider luck egalitarian principles, which, as I describe in Chapter 1, provide a philosophically nuanced formulation of responsibility-sensitive principles for the allocation of health care resources. Many luck egalitarians argue that those patients who deliberately engage in reasonably avoidable, health-damaging behaviours (such as smoking) should receive lower priority for scarce health care resources than those who do not engage in these behaviours. I reject this view, arguing in Chapter 2 that luck egalitarian principles are too harsh to be a plausible moral way of regulating health care resources. In Chapter 3, I argue that to the extent that luck egalitarian principles are intended to be used in public policy as a way of regulating health care resources, they should be rejected as they would be impractical to implement. In Part 2 of this thesis, I consider other principles (which do not make use of individual responsibility for health behaviours as a rationing criterion) for allocating health care resources fairly in conditions of scarcity. In Chapter 4, I reject the view that health care rationing should be solely determined by market forces, as due to the structural features of health insurance and health care, health care rationing requires some level of government intervention. In Chapter 5, I explain the problems with two metrics, Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QALYs) arguing that they are problematic because they conflate two questions which should often be considered separately: how to evaluate interventions which improve people's quality of life, and how to evaluate interventions which extend people's lifespan. In the final two chapters of this thesis, I argue for my own view of how to fairly allocate health care resources in conditions of scarcity. In Chapter 6, I argue that much of what makes health care morally valuable is the effect that it can have on improving people's capabilities, however, focusing on improving morally valuable capabilities alone cannot provide a full account of how we can make fair health care allocation decisions. This is because capability-based accounts focus on objectively measurable effects of health care, but many effects of health care, such as relieving chronic pain have an inherently subjective component. Thus, these theories do not provide plausible priority to caring for the needs of those in chronic pain and the terminally ill. In Chapter 7, I argue for the importance of including measures of subjective well-being, in addition to capabilities, in considering which health care interventions to prioritise in situations of scarce resources.