Ben Sachs

In November 2008 Professor Mike Richards issued his much awaited review of the British Department of Health's policy on out-of-pocket payments for drugs not approved as cost effective by the National Institute for Health and Clinical Excellence. The policy stated, or had been construed as stating, that those who top up thereby became ineligible for further National Health Service treatment for the condition targeted by the drug. For instance, if a lung cancer sufferer bought Avastin, which is not NICE approved, she could no longer receive free treatment for her cancer on the NHS's tab. Richards, the National Cancer Director, recommended that the policy be repealed. From an ethical point of view, this change should be enthusiastically welcomed.

Norman Daniels's new book, Just Health, brings together his decades of work on the problem of justice and health. It improves on earlier writings by discussing how we can meet health needs fairly when we cannot meet them all and by attending to the implications of the socioeconomic determinants of health. In this article I return to the core idea around which the entire theory is built: that the principle of equality of opportunity grounds a societal obligation to meet health needs. I point, first, that nowhere does Daniels say just what version of that principle he accepts. I then proceed to construct a principle on his behalf, based on a faithful reading of Just Health. Once we actually nail down the principle, I argue, we will find that there are two problems: it is implausible in itself, and it fails to ground a societal obligation to meet health needs

Recent work on consequentialism has revealed it to be more flexible than previously thought. Consequentialists have shown how their theory can accommodate certain features with which it has long been considered incompatible, such as agent-centered constraints. This flexibility is usually thought to work in consequentialism’s favor. I want to cast doubt on this assumption. I begin by putting forward the strongest statement of consequentialism’s flexibility: the claim that, whatever set of intuitions the best nonconsequentialist theory accommodates, we can construct a consequentialist theory that can do the same while still retaining whatever is compelling about consequentialism. I argue that if this is true then most likely the non-consequentialist theory with which we started will turn out to have that same compelling feature. So while this extreme flexibility, if indeed consequentialism has it (a question I leave to the side), makes consequentialism more appealing, it makes non-consequentialism more appealing too.

In research ethics there is a canon regarding what ethical rules ought to be followed by investigators vis-à-vis their treatment of subjects and a canon regarding what fundamental ethical principles apply to the endeavor. What I aim to demonstrate here is that several of the rules find no support in the principles. This leaves anyone who would insist that we not abandon those rules in the difficult position of needing to establish that we are nevertheless justified in believing in the validity of the rules. I conclude by arguing that this is not likely to be accomplished.The rules I call into question are the rules requiring:– that studies be designed in a scientifically valid way– that risks to subjects be minimized– that subjects be afforded post-trial access to experimental interventions– that inducements paid to subjects not be counted as a benefit to them– that inducements paid to subjects not be ‘undue’– that subjects must remain free to withdraw from the study at any time for any reason without penaltyBoth canons, the canon on principles and the canon on rules, are found in the overlap among ethical pronouncements that are themselves canonical: the Nuremberg Code, the Declaration of Helsinki, the Belmont Report, CIOMS's International Ethical Guidelines for Biomedical Research Involving Human Subjects, and NBAC's 2001 report, Ethical Issues in International Research: Clinical Trials in Developing Countries

A universal entitlement to health care can be grounded in the liberty principle. A detailed examination of Rawls's discussion of health care in Justice as Fairness shows that Rawls himself recognized that illness is a threat to the basic liberties, yet failed to recognize the implications of this fact for health resource allocation. The problem is that one cannot know how to allocate health care dollars until one knows which basic liberties one seeks to protect, and yet one cannot know which basic liberties to protect until one knows how health care dollars will be allocated. The solution is to design the list of basic liberties and the health care system in tandem so as to fit each other, such that every citizen is guaranteed a set of basic liberties and access to the health services needed to secure them.

Several authors have worried, or anyway assumed, that confronting people with highly demanding moral requirements would be counterproductive, in the sense of causing people to turn away from morality, and thus actually decreasing (for instance) amounts donated. In this chapter, Ben Sachs notes that whether or not such behaviour would be counterproductive is a non-obvious empirical matter. After reviewing the available evidence, Sachs concludes that we should not be at all confident that “demanding the demanding” would be counterproductive. Sachs argues that more empirical studies are needed, but tentatively defends a theory of moral psychology according to which, when people are confronted with a demanding ethical theory (like act-consequentialism) they will, if they accept the theory, respond by _coming close_ to conforming to it.