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Justice and the Conflict Among Principles. Robert M. Veatch The Kennedy Institute of Ethics. The Shortage of Kidneys for Transplant. OPTN database, 2012. Waiting List. OPTN/SRTR database, 2004. Opening Case: Kidney Allocation. 1980s: HLA tissue-typing (efficiency)

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justice and the conflict among principles

Justice and the Conflict Among Principles

Robert M. Veatch

The Kennedy Institute of Ethics

waiting list
Waiting List

OPTN/SRTR database, 2004

opening case kidney allocation
Opening Case: Kidney Allocation
  • 1980s: HLA tissue-typing (efficiency)
  • 1990s: Time on the waiting list (fairness)
  • 2011: The “20/80” Proposal (efficiency)
  • 2012: The absence of fairness
individual vs social ethics
Individual vs. Social Ethics

The Hippocratic Ethic:

  • Benefit the patient and protect the patient from harm
  • Beneficence and nonmaleficence

Autonomy or respect for persons

  • Nonconsequentialist
  • Duty-based
  • Deontological
ethical principles at the social level
Ethical Principles at the Social Level
  • Social Utility
    • Maximizing the aggregate net good from available resources
      • General units of social utility (utiles)
      • General units of health utility (QALYs)

(Quality-adjusted life years)

ethical principles at the social level1
Ethical Principles at the Social Level
  • Justice
    • Creating an end-state pattern of distribution of the good
meanings of the term justice
Meanings of the Term “Justice”
  • Aristotle distinguishes:
    • Broad sense
    • Narrow sense
  • Aristotle’s three end-state patterns
    • Free birth
    • Noble birth
    • Excellence
modern egalitarian end state patterns
Modern Egalitarian End-State Patterns
  • Equality of well-being
  • Issues in measuring equality of well-being
    • Subjective vs. objective theories of the good
      • Preferences
      • Satisfaction of desires
      • Objective theories
    • Equality of well-being and equality of opportunity for well-being
    • Dworkin: Equality of resources
john rawls relatively egalitarian view
John Rawls “Relatively Egalitarian” View
  • Theory of Justice, 1971
  • Two principles of justice:
    • Equal right to basic liberties
    • Social and economic inequalities are to be arranged so that they provide the greatest benefit to the least advantaged and are consistent with fair equality of opportunity [“the maximin”]
egalitarian alternnatives to the maximin
Egalitarian Alternnatives to the Maximin
  • Prioritarianism
    • Gives priority to the poorly off
    • Not necessarily absolute priority
  • True or “radical” egalitarianism
three objections to egalitarianism
Three Objections to Egalitarianism
  • Leveling down
  • Bottomless pit
  • Extravagant tastes
two final problems
Two Final Problems

1. Reconciling the Conflict Among Competing Principles

a. Single-principle theories

b. Multiple principle theories

  • Balancing theories
  • Ranking (lexically ordering)
    • Primum non nocere
    • Rawls ‘s two principles
    • Judaism
  • Combining balancing and ranking
two final problems1
Two Final Problems

2. The Clinician’s Role in Dealing with the Principle of Justice

(Two Options)

  • Let clinicians abandon their patients at the margin


    • Difficulty in calculating
    • Requires abandoning patient-centered ethic
two final problems2
Two Final Problems

b. Give clinicians an exemption from the principles of social ethics

  • Permits them to remain loyal to their patients
  • Requires that other parties do the rationing