Department of Ethics
Vol 373 January 31, 2009
misleadingly claim that sick people with a small but clearchance of beneﬁt do not have a medical need.
Sickrecipients’ prognoses are wrongly assumed to be normal,even though many interventions—such as livertransplants—are less eﬀective for the sickest people.
If the failure to take account of prognosis were its onlyproblem, sickest-ﬁrst allocation would merely beinsuﬃ cient. However, it myopically bases allocation onhow sick someone is at the current time—a morallyarbitrary factor in genuine scarcity.
Preferentialallocation of a scarce liver to an acutely ill personunjustly ignores a currently
healthier person withprogressive liver disease, who might be worse oﬀ whenhe or she later suﬀers liver failure.
Favouring thosewho are currently sickest seems to assume that resourcescarcity is temporary: that we can save the person who isnow sickest and then save the progressively ill personlater.
However, even temporary scarcity does notguarantee another chance to save the progressively illperson. Furthermore, when interventions are per-sistently scarce, saving the progressively ill person laterwill always involve depriving others. When we cannotsave everyone, saving the sickest ﬁrst is inherentlyﬂawed and inconsistent with the core idea of priority tothe worst-oﬀ.
Although not always recognised as such, youngest-ﬁrstallocation directs resources to those who have had lessof something supremely valuable—life-years.
Dialysismachines and scarce organs have been allocated to youngerrecipients ﬁrst,
and proposals for allocation in pandemicinﬂuenza prioritise infants and children.
has suggested strict age cut-oﬀs for scarce life-savinginterventions, whereas Alan Williams
has suggested asystem that allocates interventions based on individuals’distance from a normal life-span if left unaided.Prioritising the youngest gives priority to theworst-oﬀ—those who would otherwise die having hadthe fewest life-years—and is thus fundamentally diﬀerentfrom favouritism towards adults or people who arewell-oﬀ.
Also, allocating preferentially to the young hasan appeal that favouring other worst-oﬀ individuals suchas women, poor people, or minorities lacks: “Because [allpeople] age, treating people of diﬀerent ages diﬀerentlydoes not mean that we are treating persons unequally.”
Prudent planners would allocate life-saving interventionsto themselves earlier in life to improve their chances of living to old age.
These justiﬁcations explain much of thepublic preference for allocating scarce life-savinginterventions to younger people.
Strict youngest-ﬁrst allocation directs scarce resourcespredominantly to infants. This approach seems incorrect.
The death of a 20-year-old young woman is intuitivelyworse than that of a 2-month-old girl, even though thebaby has had less life.
The 20-year-old has a much moredeveloped personality than the infant, and has drawn uponthe investment of others to begin as-yet-unfulﬁlled projects.Youngest-ﬁrst allocation also ignores prognosis,
andcategorically excludes older people.
Thus, youngest-ﬁrstallocation seems insuﬃ cient on its own, but it could becombined with prognosis and lottery principles in amultiprinciple allocation system.
Maximising total beneﬁts: utilitarianism
Maximising beneﬁts is a utilitarian value, althoughprinciples diﬀer about which beneﬁts to maximise.
Save the most lives
One maximising strategy involves saving the mostindividual lives, and it has motivated policies on allocationof inﬂuenza vaccine
and responses to bioterrorism.
Sinceeach life is valuable, this principle seems to need no specialjustiﬁcation. It also avoids comparing individual lives.Other things being equal, we should always save ﬁve livesrather than one.
However, other things are rarely equal. Some lives havebeen shorter than others; 20-year-olds have lived less than70-year-olds.
Similarly, some lives can be extended longerthan others. How to weigh these other relevantconsiderations against saving more lives—whether to saveone 20-year-old, who might live another 60 years if saved,or three 70-year-olds who could only live for 10 yearseach—is unclear.
Although insuﬃ cient on its own, savingmore lives should be part of a multiprinciple allocationsystem.
Prognosis or life-years
Rather than saving the most lives, prognosis allocationaims to save the most life-years. This strategy has beenused in disaster triage and penicillin allocation, andmotivates the exclusion of people with poor prognosesfrom organ transplantation waiting lists.
Maximisinglife-years has intuitive appeal. Living more years is valuable,so saving more years also seems valuable.
However, even supporters of prognosis-based allocationacknowledge its inability to consider distribution as well asquantity.
Making a well-oﬀ person slightly better oﬀ ratherthan slightly improving a worse-oﬀ person’s life would beunjust; likewise, why give an extra year to a person whohas lived for many when it could be given to someone whowould otherwise die having had few?
Similarly, giving afew life-years to many diﬀers from giving many life-yearsto a few.
As with the principle of saving the most lives,prognosis is undeniably relevant but insuﬃ cient alone.
Promoting and rewarding social usefulness
Unlike the previous values, social value cannot directallocation on its own.
Rather, social value allocationprioritises speciﬁc individuals to enable them to promoteother important values, or rewards them for havingpromoted these values.In view of the multiplicity of reasonable values in societyand in view of what is at stake, social value allocation must