Ethical principles

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. Start with need. They suggest that more resources should go to those with more need. But they do not explain what is meant by need, and conflicting definitions exist. Frances Kamm2 defines need as ‘how badly someone’s life will have gone if he is not helped’. But others define need-based distribution differently: for instance, distribution to those who are sickest right now or who will suffer harm without assistance3 4 or distribution that excludes consideration of non-medical factors.5 Kamm’s conception picks out an ethically compelling consideration, but one better described in terms of disadvantage rather than need.

Two other principles are easier to understand. The prognosis principle tells us that the more an intervention promotes health, the more resource investment in that intervention is warranted. The equal treatment principle is the obverse of all other relevant principles: if two claims are equal with respect …