Efrat Ram Tiktin

The paper compares three accounts of distributive justice in health (and more specifically healthcare). I discuss two egalitarian accounts—Daniels's fair equality of opportunity for health and Segall's luck-egalitarian equity in health—and contrast them with a sufficientarian account based on sufficiency of capabilities. The discussion highlights some important theoretical differences and similarities among the three accounts. The focus, however, is on the practical implications of each account regarding four hypothetical cases (synthesized growth hormone for short children, non-therapeutic abortion, forms of compensation for paraplegics, and reconstructive breast surgery versus plastic surgery). My aim is to show that by replacing egalitarian concerns with sufficiency, and by focusing on capabilities (versus opportunities), it is possible to provide a more plausible account of justice in healthcare.

A just social arrangement must guarantee a right to health care for all. This right should be understood as a positive right to basic human functional capabilities. The present article aims to delineate the right to health care as part of an account of distributive justice in health care in terms of the sufficiency of basic human functional capabilities. According to the proposed account, every individual currently living beneath the sufficiency threshold or in jeopardy of falling beneath the threshold has a legitimate claim to justice. People's entitlements to health care should not be determined on the basis of brute luck and their efforts to maintain healthy lifestyles. The prioritization of competing claim-rights of individuals is guided by two allocation principles: number and benefit-size weighted sufficiency (among people beneath the threshold) and need-weighted utilitarianism (among people above the threshold)

Natural disasters in populated areas may result in massive casualties and extensive destruction of infrastructure. Humanitarian aid delegations may have to cope with the complicated issue of patient prioritization under conditions of severe resource scarcity. A triage model, consisting of five principles, is proposed for the prioritization of patients, and it is argued that rational and reasonable agents would agree upon them. The Israel Defense Force's humanitarian mission to Haiti following the 2010 earthquake serves as a case study for the various considerations taken into account when designing the ethical-clinical policy of field hospitals. The discussion focuses on three applications: the decision to include an intensive care unit, the decision to include obstetrics and neonatal units, and the treatment policy for compound fractures.

The posthumous retrieval and use of gametes is socially, ethically, and legally controversial. In the countries that do not prohibit the practice, posthumous assisted reproduction is usually permitted only at the request of the surviving spouse and only when the deceased left written consent. This paper presents the recommendations of an ethics committee established by the Israeli Fertility Association. In its discussions, the committee addressed the ethical considerations of posthumous use of sperm—even in the absence of written consent from the deceased—at the request of either the spouse or the deceased’s parents who wish to become the offspring’s parents or grandparents. It is concluded that under certain conditions, a request by the deceased’s parents to posthumously use the deceased’s sperm is justified and should be granted.

Bioethicists, medical professionals and lawyers who support Posthumous Assisted Reproduction as an ethical procedure in the case of the deceased’s spouse often oppose it in the case of the deceased’s parents. In addition, supporters of PAR usually rely on an individualistic version of liberalism, thus focusing on a personal rather than relational approach to autonomy. This article proposes an alternative and comprehensive theoretical framework for the practice of PAR, based on the concepts of solidarity and relational autonomy. By analyzing empirical data on people’s attitudes towards PAR, we reveal an important distinction between the deceased’s wish and the deceased’s consent. In addition, we show that in the majority of cases individuals report that the well-being of their relatives is paramount once they are dead. This finding, as will be demonstrated in the article, is not fully in line with Tremellen and Savulescu’s position who allow PAR in the case of the deceased’s spouse but not in the case of his parents. We also suggest that a relational autonomy perspective can be used to evaluate the choices and actions of the deceased, and to justify the requests for PAR by his spouse or parents. Furthermore, the discussion leads us to analyze both Sandel’s account of solidarity and the more recent account of Prainsack and Buyx. We conclude that PAR can be considered as a solidarity-based practice, both at the familial and societal level, an aspect that should be given more emphasis in the discourse surrounding PAR.

Should a theory of justice that yields universal principles for the allocation of goods be sensitive to cultural differences, and should there be a limit to the respect for cultural and religious diversity? I address this question from a liberal point of view and more specifically based on the Sen-Nussbaum capability approach. Three possible arguments within this approach are analyzed: dignity, internalist essentialism, and positive freedom. The interplay between a universal principle of distribution and respect for cultural and religious diversity is demonstrated by using a particular version of the capability approach that is applicable to the health care sphere, namely the Sufficiency of Basic Human Functional Capabilities. I discuss the account’s commitment to a universal allocation principle and its respect for cultural and religious diversity, and demonstrate the possible tension between them using two examples: treatment of congenital strabismus and the definition of death as a prerequisite for organ removal. It is shown that liberals can present and defend universal principles of justice if they can clearly define what the universal principles for justice require and if they can provide strong justification for these universal claims. I argue that by means of the same argument in favor of respecting cultural diversity, liberals can justify not respecting it under certain circumstances. It is shown why these circumstances apply to the case of congenital strabismus and why in the case of the definition of death respect for religious and cultural pluralism is compatible with universal principles of justice.

The discussion of public health ethics usually focuses on public health and relates it to the notion of a public good. In this paper, I explains why we need to focus on population health and why it corresponds to a common good and hence is prone to depletion in the absence of appropriate state regulation. Using the capability approach perspective and Sen’s focus on the value of the opportunity and process aspects of freedom, I show why the state commitment to guarantee each individual the prerequisites for her positive freedom in fact justifies limiting an individual’s freedom of action in order to protect the freedom of others. However, even such infringements might not suffice to maintain population health as a common good. Hence, in the third section I look at an additional course of intervention by the state, namely the use of nudges which are intended to influence an individual’s choices and to steer her to more health-enhancing behavior. In light of the possible violation of the opportunity and process aspects of individual freedom, I show why and under what circumstances the use of nudges is not only ethical, but actually preserves the two aspects of freedom and at the same time maintains the common good.