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Contribution to book (peer-reviewed)

Book Rationing Health Care. Hard choices and unavoidable trade-offs
Editor , Andre den Exeter; , Martin Buijsen
Publisher Maklu, Antwerpen
Page(s) 65 - 86
ISBN 9789046605257
Title of proceedings Rationing Health Care. Hard choices and unavoidable trade-offs


A prominent view in the literature on health care resource allocation is that theories of social justice will provide scant guidance for rationing scarce resources. Although there are indeed limits to how usefully broad theories of justice can shape and constrain health care allocation, if we ignore how consistent allocation is with a broader conception of justice, we could risk injustice. In this paper I will highlight how adopting a direct approach to the justice of health care, which focuses only on the justice of healthcare and its influence on health, is problematic and can indeed exacerbate injustice. In contrast to adopting such a ‘narrow’ approach to justice, I aim to demonstrate how using a broader and multifaceted theory of social justice, which considers many determinants of health and well-being, as well as distinct facets of well-being, can help us to develop significant moral guidance on health care rationing. Using a broader theory of justice will help us to unify, under one systematic ethical framework, what may seem initially to be several divergent and mutually exclusive, narrow notions of justice. I identify four ‘tests’ which can be used to assess the justice of health care rationing principles. These are the tests for 1. sufficiency, 2. multiple determinants, 3. multiple dimensions, and 4. moral urgency. These tests are derived from Madison Powers and Ruth Faden’s theory (2006) of social justice, ‘the well-being sufficiency approach’ (‘the well-being approach’, for short). To illustrate the ethical framework the well-being approach can provide for health care resource decision-making, I apply these tests to the debate on explicit age-based rationing, i.e. the debate on whether we should directly prioritise health care resources for younger people at the expense of older people. Although the first test, for sufficiency of health, could be used to justify a qualified version of age-rationing, on the whole, I will argue, the well-being approach seems to reject age-rationing on the basis of the test for moral urgency, claiming that this form of rationing is likely to threaten sufficiency of well-being more seriously than if it was not implemented.