•  4570
    Principles for allocation of scarce medical interventions
    with Alan Wertheimer and Ezekiel J. Emanuel
    The Lancet 373 (9661): 423--431. 2009.
    Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. …Read more
  •  1385
    The Tarasoff rule: the implications of interstate variation and gaps in professional training
    with Rebecca Johnson and Dominic Sisti
    Journal of the American Academy of Psychiatry and the Law Online 42 (4): 469-477. 2014.
    Recent events have revived questions about the circumstances that ought to trigger therapists' duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic acr…Read more
  •  1113
    In this article, we propose the Fair Priority Model for COVID-19 vaccine distribution, and emphasize three fundamental values we believe should be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern for all individuals. The Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, s…Read more
  •  667
    This chapter examines how social- scientific research on public preferences bears on the ethical question of how those resources should in fact be allocated, and explain how social-scientific researchers might find an understanding of work in ethics useful as they design mechanisms for data collection and analysis. I proceed by first distinguishing the methodologies of social science and ethics. I then provide an overview of different approaches to the ethics of allocating scarce medical interve…Read more
  •  584
    Recent work in the behavioral sciences asserts that we are subject to a variety of cognitive biases. For example, we mourn losses more than we prize equivalently sized gains; we are more inclined to believe something if it matches our previous beliefs; and we even relate more warmly or coldly to others depending on whether the coffee cup we are holding is warm or cold. Drawing on this work, case law and legal scholarship have asserted that we have reason to select legal norms, or revise existing…Read more
  •  580
    Downward mobility and Rawlsian justice
    Philosophical Studies 175 (2): 277-300. 2018.
    Technological and societal changes have made downward social and economic mobility a pressing issue in real-world politics. This article argues that a Rawlsian society would not provide any special protection against downward mobility, and would act rightly in declining to provide such protection. Special treatment for the downwardly mobile can be grounded neither in Rawls’s core principles—the basic liberties, fair equality of opportunity, and the difference principle—nor in other aspects of Ra…Read more
  •  576
    Justice and Public Health
    In Anna Mastroianni, Jeff Kahn & Nancy Kass (eds.), Oxford Handbook of Public Health Ethics, . 2019.
    This chapter discusses how justice applies to public health. It begins by outlining three different metrics employed in discussions of justice: resources, capabilities, and welfare. It then discusses different accounts of justice in distribution, reviewing utilitarianism, egalitarianism, prioritarianism, and sufficientarianism, as well as desert-based theories, and applies these distributive approaches to public health examples. Next, it examines the interplay between distributive justice and in…Read more
  •  487
    The Current State of Medical School Education in Bioethics, Health Law, and Health Economics
    with Linden Elder, Laura Sedig, Leonardo Flores, and Ezekiel J. Emanuel
    Journal of Law, Medicine and Ethics 36 (1): 89-94. 2008.
    Current challenges in medical practice, research, and administration demand physicians who are familiar with bioethics, health law, and health economics. Curriculum directors at American Association of Medical Colleges-affiliated medical schools were sent confidential surveys requesting the number of required hours of the above subjects and the years in which they were taught, as well as instructor names. The number of relevant publications since 1990 for each named instructor was assessed by a …Read more
  •  475
    This paper takes a novel approach to the active bioethical debate over whether advance medical directives have moral authority in dementia cases. Many have assumed that advance directives would lack moral authority if dementia truly produced a complete discontinuity in personal identity, such that the predementia individual is a separate individual from the postdementia individual. I argue that even if dementia were to undermine personal identity, the continuity of the body and the predementia i…Read more
  •  434
    Are physicians willing to ration health care? Conflicting findings in a systematic review of survey research
    with Daniel Strech, Georg Marckmann, and Marion Danis
    Health Policy 90 (2): 113-124. 2009.
    Several quantitative surveys have been conducted internationally to gather empirical information about physicians’ general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician–patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?
  •  418
    The assumption that procuring more organs will save more lives has inspired increasingly forceful calls to increase organ procurement. This project, in contrast, directly questions the premise that more organ transplantation means more lives saved. Its argument begins with the fact that resources are limited and medical procedures have opportunity costs. Because many other lifesaving interventions are more cost‐effective than transplantation and compete with transplantation for a limited budget,…Read more
  •  399
    This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cas…Read more
  •  374
    This project considers whether and how research ethics can contribute to the provision of cost-effective medical interventions. Clinical research ethics represents an underexplored context for the promotion of cost-effectiveness. In particular, although scholars have recently argued that research on less-expensive, less-effective interventions can be ethical, there has been little or no discussion of whether ethical considerations justify curtailing research on more expensive, more effective int…Read more
  •  352
    Cass Sunstein and Richard Thaler's proposal that social and legal institutions should steer individuals toward some options and away from others-a stance they dub "libertarian paternalism"-has provoked much high-level discussion in both academic and policy settings. Sunstein and Thaler believe that steering, or "nudging," individuals is easier to justify than the bans or mandates that traditional paternalism involves. This Article considers the connection between libertarian paternalism and the …Read more
  •  351
    This Note offers a normative critique of cost-benefit analysis, one informed by deontological moral theory, in the context of the debate over whether tort litigation or a non-tort approach is the appropriate response to mass harm. The first Part argues that the difference between lay and expert intuitions about risk and harm often reflects a difference in normative judgments about the existing facts, rather than a difference in belief about what facts exist, which makes the lay intuitions more d…Read more
  •  333
    Misuse made plain: Evaluating concerns about neuroscience in national security
    with Kelly Lowenberg, Brenda M. Simon, Amy Burns, Libby Greismann, Jennifer M. Halbleib, David L. M. Preston, Harker Rhodes, and Emily R. Murphy
    American Journal of Bioethics Neuroscience 1 (2): 15-17. 2010.
    In this open peer commentary, we categorize the possible “neuroscience in national security” definitions of misuse of science and identify which, if any, are uniquely presented by advances in neuroscience. To define misuse, we first define what we would consider appropriate use: the application of reasonably safe and effective technology, based on valid and reliable scientific research, to serve a legitimate end. This definition presents distinct opportunities for assessing misuse: misuse is the…Read more
  •  324
    What Marriage Law Can Learn from Citizenship Law
    Tul. Jl and Sexuality 22 103. 2013.
    Citizenship and marriage are legal statuses that generate numerous privileges and responsibilities. Legal doctrine and argument have analogized these statuses in passing: consider, for example, Ted Olson’s statement in the Hollingsworth v. Perry oral argument that denying the label “marriage” to gay unions “is like you were to say you can vote, you can travel, but you may not be a citizen.” However, the parallel between citizenship and marriage has rarely been investigated in depth. This paper i…Read more
  •  316
    Standing by our principles: Meaningful guidance, moral foundations, and multi-principle methodology in medical scarcity
    with Alan Wertheimer and Ezekiel J. Emanuel
    American Journal of Bioethics 10 (4). 2010.
    In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity …Read more
  •  312
    Clinical research: Should patients pay to play?
    with Ezekiel J. Emanuel, Steven Joffe, Christine Grady, and David Wendler
    Science Translational Medicine 7 (298). 2015.
    We argue that charging people to participate in research is likely to undermine the fundamental ethical bases of clinical research, especially the principles of social value, scientific validity, and fair subject selection.
  •  299
    This essay examines the connection between socioeconomic mobility and equality, and argues for two conclusions. First, socioeconomic mobility is conceptually distinct from three common species of equality: (1) equality of opportunity, (2) equality of outcome, and (3) relational equality. Second, socioeconomic mobility is connected — in different ways — to each species of equality, and, if we value one or more of these species of equality, these connections endow mobility with derivative normativ…Read more
  •  295
    Offensive defensive medicine: the ethics of digoxin injections in response to the partial birth abortion ban
    with Colleen Denny and Elena Gates
    Contraception 90 (3): 304. 2014.
    Since the Supreme Court upheld the partial birth abortion ban in 2007, more U.S. abortion providers have begun performing intraamniotic digoxin injections prior to uterine dilation and evacuations. These injections can cause medical harm to abortion patients. Our objective is to perform an in-depth bioethical analysis of this procedure, which is performed mainly for the provider’s legal benefit despite potential medical consequences for the patient.
  •  287
    This article examines a fundamental question of justice in global health. Is it ethically preferable to provide a larger number of people with cheaper treatments that are less effective (or more toxic), or to restrict treatments to a smaller group to provide a more expensive but more effective or less toxic alternative? We argue that choosing to provide less effective or more toxic interventions to a larger number of people is favored by the principles of utility, equality, and priority for thos…Read more
  •  286
    We consider an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the w…Read more
  •  277
    In the United States, the Presidential Commission for the Study of Bioethical Issues has proposed deliberative democracy as an approach for dealing with ethical issues surrounding synthetic biology. Deliberative democracy might similarly help us as we update the regulation of human subjects research. This paper considers how the values that deliberative democratic engagement aims to realize can be realized in a human subjects research context. Deliberative democracy is characterized by an ongoi…Read more
  •  262
    Priority Setting, Cost-Effectiveness, and the Affordable Care Act
    American Journal of Law and Medicine 41 (1): 119-166. 2015.
    The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue …Read more
  •  226
    Distributive Justice and the Relief of Household Debt
    Journal of Political Philosophy 26 (3): 327-343. 2018.
    Household debt has been widely discussed among social scientists, policy makers, and activists. Many have questioned the levels of debt households are required to take on, and have made various proposals for assisting households in debt. Yet theorists of distributive justice have left household debt underexamined. This article offers a normative examination of the distributive justice issues presented by proposals to relieve household debt or protect households from overindebtedness. I examine t…Read more
  •  193
    Dilemmas in access to medicines: a humanitarian perspective – Authors' reply
    with Ezekiel J. Emanuel
    Lancet 387 (10073): 1008-1009. 2017.
    Our Viewpoint argues that expanding access to less effective or more toxic treatments is supported not only by utilitarian ethical reasoning but also by two other ethical frameworks: those that emphasise equality and those that emphasise giving priority to the patients who are worst off. The inadequate resources available for global health reflect not only natural constraints but also unwise social and political choices. However, pitting efforts to reduce inequality and better fund global health…Read more
  •  184
    The Case for Valuing Non-Health and Indirect Benefits
    with Jessica du Toit
    In Ole F. Norheim, Ezekiel J. Emanuel & Joseph Millum (eds.), Global Health Priority-Setting: Beyond Cost-Effectiveness. pp. 207-222. 2020.
    Health policy is only one part of social policy. Although spending administered by the health sector constitutes a sizeable fraction of total state spending in most countries, other sectors such as education and transportation also represent major portions of national budgets. Additionally, though health is one important aspect of economic and social activity, people pursue many other goals in their social and economic lives. Similarly, direct benefits—those that are immediate results of health …Read more
  •  183
    In this retrospective for Ethics, I discuss H.M. Oliver’s “Established Expectations and American Economic Policies.” This article, by a then-modestly-famous economist, has been ignored (no citations) since its 1940 publication. Yet it bears directly on a normative problem at the intersection of ethics and economics that challenges today’s policymakers but has received comparatively little philosophical attention: how should we balance potentially desirable institutional change against the disrup…Read more
  •  156
    Expanding Deliberation in Critical-Care Policy Design
    American Journal of Bioethics 16 (1): 60-63. 2016.
    In this commentary, I suggest expanding the deliberative aspects of critical care policy development in two ways. First, critical-care policy development should expand the scope of deliberation by leaving fewer issues up to expertise or private choice. For instance. it should allow deliberation about the relevance of age, disability, social position, and psychological well-being to allocation decisions. Second, it should broaden both the set of costs considered and the set of stakeholders repres…Read more