Table 1

Substantive principles of justice in health care rationing

Class of principleVariants that have been proposed in the literatureRecommendation in our exercise*
*This is based on various working assumptions described in the main text of this paper, in particular (1) that Steve and Marinder have an equal degree of immediate ill-health, (2) that Steve will gain the most health from treatment (over his entire lifetime), that Joanne will gain the least, and that Daniel and Marinder will gain the same amount, (3) that treating Marinder would have a substantial indirect health benefit for others by freeing up long term care resources; and (4) that Joanne had more choice about her health predicament than Steve.
A. Need principlesDistribute in proportion to degree of immediate threat to lifeDaniel, Joanne
Distribute in proportion to degree of immediate ill-healthDaniel, Marinder & Steve equal, Joanne
Distribute in proportion to degree of lifetime ill-healthDaniel, Joanne, Steve, Marinder
Distribute in proportion to immediate capacity to benefitDaniel, Marinder & Steve equal, Joanne
Distribute in proportion to lifetime capacity to benefitSteve, Daniel & Marinder equal, Joanne
Distribute in proportion to cost of exhausting capacity to benefitEqual chance for all four patients
B. Maximising principlesMaximise healthSteve, Marinder, Daniel, Joanne
Maximise wellbeing (including non-health aspects)? Depends on non-health factors
C. Egalitarian principlesEqualise lifetime health expectancy (“fair innings” argument)Daniel, Joanne, Steve, Marinder
Equalise opportunity for lifetime health expectancyDaniel, Steve, Joanne, Marinder
D. Combination principlesCombine maximise health with equalise lifetime health expectancySteve, Daniel, Marinder, Joanne
Combine a need principle with a maximising principle? Depends on which versions of the principles and what weights