Abstract

Maybe you only have 1000 units of some resource, but 10,000 people need the resource or would benefit from it. One question: why do you control the resource? Leave that aside for now. A second question: how should you allocate the resource? If you are a decision-maker in a health system, and if the resource has to do with medicine or public health, we are in the world of the ethics of scarce resource allocation decisions in healthcare. Munthe et al 1 note that the ‘operational norms that guide actual decision making in this area tend to be similar across health systems’ and include principles concerning need, prognosis, equal treatment and cost-effectiveness. Even with just these principles, there are hard questions of how they ought to be specified, operationalised and balanced against each other when they conflict. They do not focus on this. Instead, they identify a concern: paying attention only to these principles in making allocation decisions may lead decision-makers to miss ‘negative dynamics’ that result from their decisions. They aim to rectify this by suggesting a ‘sustainability’ principle that would sit alongside these other ethical principles, serving as a side-constraint that rules out certain allocation choices or as a distinct reason to be weighed in the decision-making calculus (or a reason to save or insure against negative dynamics). I agree that the downstream effects of our allocation decisions matter, …