Equity, justice and resource allocation

Let’s see if I can state the prob­lem cor­rect­ly. A typ­i­cal guide­line for med­ical staff when faced with the need to eth­i­cal­ly allo­cate scarce resources is

  1. Jus­tice, which is the pri­ma­ry eth­i­cal con­sid­er­a­tion in the area of health care is con­cerned with ‘fair­ness’ or the equi­ty of dis­tri­b­u­tion of resources

  2. There is no nec­es­sary con­nec­tion between jus­tice and effi­cien­cy. A pro­gram that is effi­cient in achiev­ing a giv­en health out­come (low cost) may nev­er­the­less be unjust or inequitable

  3. An eth­i­cal deci­sion should, there­fore, sub­or­di­nate con­sid­er­a­tions of cost-effi­cien­cy to con­sid­er­a­tions of jus­tice and equi­ty

    • A deci­sion in which cost-effec­tive­ness out­weighs con­sid­er­a­tions of jus­tice and fair­ness is not eth­i­cal­ly sound

But is this a prac­ti­cal guide­line? Or does it just avoid the dilem­ma fac­ing the med­ical deci­sion-mak­er?
The deci­sion-mak­er prob­a­bly does not ques­tion that jus­tice-as-fair­ness is impor­tant or has pri­ma­ry weight. But, in the absence of uni­ver­sal rules-of-thumb about (the­o­ries of) jus­tice, a rea­son­able per­son may first try to find a triv­ial solu­tion to conun­drums of jus­tice where equi­ty is reduced to actu­al­ly equal—or near­ly equal—proportionment of resources or goods that are pro­por­tion­able. Of course, not all goods/resources are proportionable—as the sto­ry of the judg­ment of Solomon illus­trates. In health care, deci­sions must be tak­en about the allo­ca­tion of resources where cost, which is the index of scarci­ty, is the prin­ci­pal bar­ri­er to an actu­al­ly equal dis­tri­b­u­tion. Say­ing that a resource has a high cost means that the deci­sion-mak­er must allo­cate the resource unequal­ly among the needy because each por­tion of the good is scarce (cost­ly). The high­er the cost of each por­tion of resources, the less like­ly that the deci­sion-mak­er will be able to meet all needs with­in a giv­en bud­get and must there­fore choose to dis­trib­ute few­er por­tions to some than to oth­ers. Con­verse­ly, the low­er the cost of meet­ing the sum of needs, the near­er the deci­sion-mak­er can come to mak­ing a dis­tri­b­u­tion among needs that is equi­table in the sense of equal. I sus­pect that it does not help the deci­sion-mak­er, there­fore, to warn them that (apart from avoid­ing waste), eco­nom­ic con­sid­er­a­tions are not to be a pri­ma­ry con­cern. It will be appar­ent to any deci­sion-mak­er that greater cost effi­cien­cy would be one means of approach­ing the triv­ial solu­tion to the prob­lem of a fair dis­tri­b­u­tion. But many deci­sion-mak­ers must also real­ize that they don’t have an oppor­tu­ni­ty to achieve more effi­cient use of resources because, in the short-run, costs are like­ly to be fixed. This is what the short run means: the sum of pro­por­tion­able resources and the sum of needs stand in a fixed rela­tion­ship to each oth­er. There’s not the time to devise cost-sav­ing strate­gies or to devel­op cost-sav­ing tech­nolo­gies. In the short-run, they have to have a the­o­ry of just but unequal dis­tri­b­u­tion in order to get on with it. The degree of inqual­i­ty they need to accept is actu­al­ly a reflec­tion of cost in the first instance (although it may ulti­mate­ly also reflect oth­er opti­miz­ing dis­tri­b­u­tion strate­gies)

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