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Sustainability, equal treatment, and temporal neutrality
  1. Govind Persad
  1. Sturm College of Law, University of Denver, Denver, CO 80208, USA
  1. Correspondence to Dr Govind Persad, College of Law, University of Denver, Denver, CO 80220, USA; gpersad{at}

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Addressing distributive justice issues in health policy—ranging from the allocation of health system funding to the allocation of scarce COVID-19 interventions like intensive care unit beds and vaccines—involves the application of ethical principles. Should a principle of sustainability be among them? I suggest that while the value of temporal neutrality underlying such a principle is compelling, it is already implicit in the more basic principle of equal treatment.

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 …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Some defend this tendency. See Bloche MG. The invention of health law. Calif. L. Rev. 2003;91:247, who argues that “the anguish of identified persons” should often override “population-level health maximization.” See also Goodin, op. cit. (observing that “one explanation for why too many resources are devoted to prolonging life pointlessly for terminally ill patients is that those patients are right in front of the attending physician, whereas others on whom those resources might be better spent may often not be”)

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