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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

The shortage of kidneys for transplant
The Shortage of Kidneys for Transplant

OPTN database, 2012

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