This article contributes to the discourse on global justice as it pertains to resources and the just distribution of resources. The focus is on the concept of scarcity. In examining different understandings of scarcity through the use of analogies and examples, a distinction is made between absolute scarcity and relative scarcity. I examine the conceptual understanding of scarcity of resources in the context of distributive justice. Conceptual clarity is necessary to ensure that (...) scarcity is properly referred to in the discourse so that scarcity is not erroneously used when justifications are sought for material deprivation and consequent human suffering. The field of distributive justice arguably requires a full comprehension of scarcity of resources, and this can only be achieved by properly examining the concept of scarcity. (shrink)

BackgroundLittle is known about the ethical situations which physiotherapists encounter internationally. This lack of knowledge impedes the ability of the profession to prepare and support physiotherapists in all world regions in their ethical practice. The purpose of the study was to answer the following research questions: What types of ethical issues are experienced by physiotherapists internationally? How frequently are ethical issues experienced by physiotherapists internationally? Can the frequency and type of ethical issue experienced by physiotherapists be predicted by sociodemographic, educational (...) or vocational variables?MethodsAn observational study was conducted in English using an online survey from October 2018 to May 2019. Participants were 1212 physiotherapists and physiotherapy students located internationally which represented less than 1% of estimated number of physiotherapists worldwide at that time. The survey questionnaire contained 13 items requesting demographic detail and knowledge of ethical codes and decision-making, and 46 items asking what frequency participants experienced specific ethical issues in four categories: Physiotherapist and patient interaction, Physiotherapist and other health professionals including other physiotherapists, Physiotherapists and the system and Professional and economic ethical situations.ResultsThe two most frequently experienced ethical issues were ‘Scarce resources and time affecting quality of physiotherapy treatment’ and ‘Physiotherapy not accessible to all people in society who need it’. These items were experienced, on average, more often than monthly. Interprofessional practice also presented frequent ethical issues for participants. Ethical issues related to the context of ‘Physiotherapists and the system’ were most frequently experienced for all world regions. Working longer years in physiotherapy and learning about ethics in basic physiotherapy education was associated with participants reporting lower frequencies of ethical issues across all contexts.ConclusionThis study provides the first global profile of ethical issues experienced by physiotherapists. Societal and cultural systems are key influences on physiotherapists’ ethical practice. Physiotherapists globally need support from their work organisations, academic institutions and professional associations, and robust ethical training, to assist them to be active moral agents in their practice. (shrink)

The scarcity of resources during the COVID‐19 pandemic caused ethical dilemmas in prioritizing patients for treatment. Medical and ethical guidance only emphasizes clinical procedures but does not consider the sociocultural aspect. This study explored the perception of former COVID‐19 patients and their families on the decision‐making process of the patient's selection at a time of scarcity of resources. The result will inform the development of an ethical guide for allocating scarce resources that aligns with Indonesian (...) culture. We conducted qualitative research with in‐depth interviews between May ‐ December 2022 involving sixteen participants from various cities in Indonesia. We transcribed the interviews and analyzed the results using thematic analysis. This study found that doctor's decisions often differed from patient's expectations in allocating scarce resources, and therefore, it should be communicated appropriately. Medical decisions were not sufficiently made ethically, but must also be made communicatively. In Indonesia's strong communal culture, community involvement was essential to distributing limited resources. A better approach to ethical education, including adequate communication skills, is necessary to prepare health professionals for facing unpredictable future pandemics. (shrink)

This article attempts to answer two basic questions. First, can body parts be the subject of property rights? This requires us to start with a definition of property rights, and this is set out in the first section. In the second section, it will be argued that rights in relation to body parts can come within this definition of property rights. However, as explained in the third section, the fact that body parts can be the subject of property rights does (...) not mean that they should. To answer the question of whether body parts should be the subject of property rights we need to consider policy arguments. This article will develop an argument in favour of the recognition of property rights in body parts which focuses on the notion of scarcity of resources. (shrink)

This research aims to examine access to medical treatment during the COVID-19 pandemic for people living with disabilities. During the COVID-19 pandemic, the practical and ethical problems of allocating limited medical resources such as intensive care unit beds and ventilators became critical. Although different countries have proposed different guidelines to manage this emergency, these proposed criteria do not sufficiently consider people living with disabilities. People living with disabilities are therefore at a higher risk of exclusion from medical treatments as (...) physicians tend to assume they have poor quality of life, whereas access to medical treatment should be based on several parameters, including clinical data and prognosis. However, the COVID-19 pandemic shifts the medical paradigm from person-centred medicine to community-centred medicine, challenging the main ethical theories. We reviewed the main guidelines and recommendations for resources allocation and examined their position toward persons with disabilities. Based on our findings, we propose criteria for not discriminating against people with disabilities in allocating resources. The shift from person-centred to community-centred medicine offers opportunities but also risks sacrificing the most vulnerable people. The principle of reasonable accommodation must always be considered to guarantee the rights of persons with disabilities. (shrink)

William Ophuls has argued that the sources of and solutions for present scarcity conditions are to be found in Western political philosophy. I clarify various theoretical issues raised by Ophuls’ work and offer conceptual alternatives regarding some of the more basic issues. Specifically, I critique the Lockean and Hobbesian elements in Ophuls’ treatment of the role of liberal democracy, with special attention to abundance assumptions and Lockean individualism. I also argue that he fails to deal adequately with resource distribution (...) in his treatment of resource scarcity, that he improperly removes man from nature, that he misunderstands the relationship of technology and politics, and that he encounters other difficulties in terms of the public/private distinction and in integrating micro and macro issues. Ironically, Ophuls’ admirable attempt to shed light on the critical relationship between scarcity conditions and political philosophy may have created a new and disorienting set of shadows. (shrink)

This book focuses on resource allocation in military and humanitarian medicine during times of scarcity and austerity. It is in these times that health systems bend, break, and even collapse and where resource allocation becomes a paramount concern and directly impacts clinical decision-making. Such times are challenging and this book covers this very important, yet, scarcely researched topic within the field of bioethics. This work brings together experts and practitioners in the fields of military health care, philosophy, ethics, and (...) other disciplines to provide analysis on a variety of related topics ranging from case studies and first-hand experiences to policy and philosophical analysis. It is of great interest to to academics, practitioners, policy makers and students who are looking for analyses and guidance regarding the fair provision of medical care and the use of medical rules of eligibility under adverse conditions. (shrink)

Background: While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings. Research objective: The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker. Research design and participants: (...) A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials. Ethical considerations: After receiving ethics approval, signed informed consent was obtained from participants before data collection. Results: Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage. Discussion: The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women. Conclusion: Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice. (shrink)

Humanitarian social enterprises (HSEs) are facing mounting pressure to incorporate social innovation into their practice. This study thus identifies how HSEs leverage organizational capabilities toward developing social innovation. Specifically, it considers how resource scarcity and operating circumstances affect the capabilities used by HSEs for developing social innovation, using a longitudinal case study approach with qualitative data from 12 hunger-relief HSEs operating in the United States. Based on 59 interviews with 31 managers and directors and related documents, several propositions are (...) posited. The findings suggest that resource availability (i.e., scarcity vs. abundance) leads some HSEs to focus on developing social innovation using their collaborative capabilities, while others leverage their absorptive capacity. Further, HSEs adjust their approach to developing social innovation based on whether they are operating in ordinary circumstances (i.e., before the COVID pandemic) or extraordinary ones (i.e., during the COVID pandemic). Interestingly, the findings suggest that the organizational capabilities used by HSEs are adjusted as these enterprises become more familiar with extraordinary operating circumstances. For example, at the onset of the COVID-19 pandemic, resource-scarce HSEs focused on parallel bricolage to develop social innovation. Subsequently, they focused on selective bricolage. The findings offer novel insights by relating the social innovation of social enterprises to crisis management. (shrink)

Although natural resource scarcity is a pressing issue for many organizations, it has received little attention in management research. Drawing on resource dependence theory, this article theorizes how organizations manage uncertainty from their dependence on scarce natural resources. For this end, it explains how socio-ecological processes involving anthropogenic impacts on ecosystem services cause this form of uncertainty. It then proposes that organizations develop wide-ranging responses to such uncertainty, depending on their predominant institutional logics, from protecting and restoring ecosystems (...) that provision critical natural resources to further developing those ecosystems for optimal resource yields at the risk of degrading them. The article adds to the limited existing research on the unique challenges of managing natural resource scarcity and extends resource dependence theory by accounting for socio-ecological dynamics that create uncertainty regarding natural resources. (shrink)

Application of egalitarian and prioritarian accounts of health resource allocation in low‐income countries have both been criticized for implying distribution outcomes that allow decreasing/undermining health gains and for tolerating unacceptable standards of health care and health status that result from such allocation schemes. Insufficient health care and severe deprivation of health resources are difficult to accept even when justified by aggregative efficiency or legitimized by fair deliberative process in pursuing equality and priority oriented outcomes. I affirm the sufficientarian argument (...) that, given extreme scarcity of public health resources in low‐income countries, neither health status equality between populations nor priority for the worse off is normatively adequate. Nevertheless, the threshold norm alone need not be the sole consideration when a country's total health budget is extremely scarce. Threshold considerations are necessary in developing a theory of fair distribution of health resources that is sensitive to the lexically prior norm of sufficiency. Based on the intuition that shares must not be taken away from those who barely achieve a minimal level of health, I argue that assessments based on standards of minimal physical/mental health must be developed to evaluate the sufficiency of the total resources of health systems in low‐income countries prior to pursuing equality, priority, and efficiency based resource allocation. I also begin to examine how threshold sensitive health resource assessment could be used in the Philippines. (shrink)

Occasionally, doctors and health providers have to choose whom they save from death and this is an extremely hard decision to take. Here, I work on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on (...) medical doctors, nurses and other people who are at the front of the war against COVID-19. During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often have been), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, bring other good results to society? This discussion is of course important, but it leaves aside something more fundamental: the fact that resources are not simply scarce, they have been made scarce in the last years by a series of public policies nourished by an economic view that sacrificed social welfare on behalf of neoliberal beliefs. (shrink)

As coronavirus disease 2019 made its way across the world in 2019, health systems began to develop guidelines to allocate what was expected to be a scarcity of medical resources. Considerable attention was given to triaging intensive care resources such as ventilators. While there was general agreement among bioethicists and policymakers that it may be permissible to withhold life-sustaining interventions from patients with poor prognoses in order to make them available to patients with better prognoses, there was (...) disagreement about the permissibility of withdrawing such interventions for this purpose. Some maintained that the doctrine of double effect (DDE) revealed the intrinsic wrongness of such acts of reallocation. This article argues that so long as there is transparency and effective ongoing communication, the DDE may permit the discontinuation of life-sustaining interventions from patients who may still benefit from them in order to make them available to patients with more favorable prognoses. (shrink)

This study addresses the critical shortage of parallel corpora for the Kashmiri language, a significant barrier to advancing language processing technologies for under-resourced languages. Despite Kashmiri's rich cultural heritage, the development of language technology resources, especially parallel corpora, has been notably limited. Our research involves a detailed analysis of the only available parallel corpora for Kashmiri, utilizing these datasets to develop and evaluate Neural Machine Translation (NMT) models. Through this evaluation, we categorize errors and assess the corpora's adequacy in (...) quality and quantity for supporting effective language processing tasks. Additionally, we investigate the reasons behind the scarcity of high-quality resources and identify the challenges inherent in creating robust parallel corpora for Kashmiri. By proposing solutions to these challenges, our study aims to contribute to the revitalization and global recognition of the Kashmiri language, bridging a significant gap in the field of language technology and emphasizing the importance of parallel corpora in preserving linguistic diversity and facilitating technological advancement. (shrink)

ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed (...) using thematic analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making. (shrink)

This essay historicizes cultural and psychic economies in the postwar United States under the sign of material scarcity. It situates the proliferation of plastic flowers in domestic space within a context of bureaucratic anxieties surrounding natural resource scarcity, and trends toward ‘outdoor living’ that were an offshoot of the ideology of economic growth. Interrogating repeated, if relatively unexamined, invocations of ‘anxious’ suburban subjects in descriptions of postwar society, the essay suggests that plastic flowers shored up a sense of (...) stability and permanence at a time when nuclear annihilation, Cold War paranoia, and population growth combined to render life uncertain and potentially unsustainable. The essay concludes by reflecting on how legacies of that epoch – and the fiction of permanence offered by plastic flowers – endure in contemporary fantasies of limitless progress. (shrink)

Due to the rapid advance of the pandemic caused by COVID-19, several countries perceived that human and material resources would be insufficient to meet the demand of infected patients. The aim of this study is to analyze the knowledge of health professionals working in the pandemic about the application of ethical criteria in decision-making in situations of resource scarcity. This is a cross-sectional, descriptive, and quantitative survey study, conducted from June to December 2020, with health professionals working in (...) the COVID-19 pandemic in Brazil. We applied a questionnaire to assess the professionals’ knowledge about ethical criteria in decision-making in the allocation of scarce resources during the pandemic, containing 14 questions and possible score from 0 to 70, which was developed by researchers from documents and protocols validated by organizations from various countries, available in the first months of the pandemic, a sociodemographic characterization questionnaire and a self-assessment questionnaire regarding knowledge about bioethics. A total of 197 health professionals participated in the study, 37.6% of whom were nurses and 22.8% of whom were physicians, working in the Family Health Unit (28.4%) with a degree at the level of specialization (46.2%). Moreover, (9.5%) of nurses, (18.2%) of dental surgeons and (24.4%) of physicians reported that they have no prior knowledge about bioethics. Physicians and hospital workers scored higher on the knowledge assessment questionnaire. The mean score of the participants was 45.4 (SD = 7.2). Investments in training and professional education in the field of health focused on Bioethics are necessary, considering models and ethical theories that help professionals, managers and society to better position themselves in the face of pandemic contexts. (shrink)

Scarcity sharpens the conflict between short term gains and long term sustainability. Psychological research documents that decision makers focus on immediate needs under scarcity and use available resources more effectively. However, decision makers also borrow too much from future resources and overall performance decreases as a consequence. Using an online experiment, we study how scarcity affects borrowing decisions in groups. We first document that scarcity affects groups in a similar way as individuals. Then, we (...) go on to show that the negative effect of scarcity is weaker for groups than for individuals. Even in a minimal design that excludes direct interaction or communication, the fact that participants know that their own behavior affects and can be partly observed by another participant disciplines their use of scarce resources. Our results thus highlight the benefit of groups as units of human organization. (shrink)

Distribution of sufficient health care resources to the maximum number of people in LIC is the central theme of the book. Bangladesh is taken as a representative of low income countries (LIe. In LIC, there is scarcity of health care resources like other resources but the deserving persons are numerous. Therefore, it requires an efficient distribution of resources. Considering 'Inequality to get access to health care' as the basic problem in LIC, John Rawls' principle of (...) fair equality of opportunity is proposed to apply to give people access to health care resources. In this book it is critically analyzed how the principle fails to return a good result in LIC. Instead the principle of maximizing utility is proposed for the purpose. It is argued that maximum number of people can be provided sufficient health care by applying the principle. The principle has also been justified theoretically in concerned low income country and a fruitful result has been achieved from the test. It is claimed that applying principle of utility to provide sufficient health care to the maximum number of people is the most efficient way of health care resources distribution in LIC. (shrink)

The scarcity of resources required to produce justice is manifested in the relation between the accuracy, depth, and scope of materially possible forms of justice. Ceteris paribus , increases in the accuracy of justice must come at the expense of its depth and scope, and vice versa, though they are not linearly proportioned. The accuracy of justice is the degree of agreement between the possible results of attempts to implement a theory or principles of justice and the desired (...) result according to that theory or those principles of justice. The scope of justice measures how broadly the principle or theory of justice is intended to apply. The depth of justice measures the gap between existing social norms and the theory or principles of justice we examine within the specified scope. This three-dimensional model explains public policies, laws, and regulations that increase the scope or depth of justice at the cost of a decrease in its accuracy – rough forms of justice such as measures of transitional justice, affirmative action, mandatory sentencing, simplified tax codes, collective guilt and victimhood, and general amnesties. The scarcity of resources necessary for justice can contract or expand. The normative choice between principles of justice that prefer accuracy and those that favor scope or depth usually corresponds, respectively, with rights-based deontological theories and consequentialist ethics. (shrink)

This paper stems from the current global worsening of the scarcity of resources for healthcare, which will deepen even more in future public emergencies. This justifies strengthening the reflection on the allocation of resources which, in addition to considering technical issues, should also involve ethical concerns. The two plans in which the allocation of resources develops—macro and micro—are then systematized, both requiring the identification of ethical criteria for the respective complex decision-making. Then, we describe how the (...) complexity at the macro level focuses on the joint consideration of the rectitude of the principles, the goodness of the ends, and the integrity—respectively the deontological, teleological, and procedural perspectives; and at the micro level, it focuses in prioritizing people, which can result in the exclusion of some, as happened with the elderly during peaks of COVID-19. The main objective of this article is to show that, in public health emergency situations, in which the daily criteria for prioritizing access to health care are not efficient, it is possible not only to ration the available means but also to rationalize them. We argue that rationing and rationalization are different concepts, entail different consequences, have different ethical foundations, and draw different guidelines for patient care. We apply them to the distribution of intensive care and vaccines to the elderly thus demonstrating the ethically legitimate domain of implementation of each of these two prioritization criteria. We conclude that rationalization respects more strictly the core ethical principles of our common morality. (shrink)

How are we disposed to the problem of natural resources scarcity that we face today and to the fact that certain natural sources remain unused, whereas the exploitation of others puts further strain on the already degraded biosphere? The scarcity of natural resources not only imposes a series of ecological issues on us; it also challenges democracy as organizational system and way of life, because it increases inequality, conflict, authoritarianism, and repression. One way to address this (...) predicament would be the re-appropriation of our relation with the biosphere by ceasing to see it as a limitless source of extraction and consumption. This essay suggests that a certain part of this.. (shrink)

Three metaphors appear to guide contemporary thinking about organ transplantation. Although the gift is the sanctioned metaphor for donating organs, the underlying perspective from the side of the state, authorities and the medical establishment often seems to be that the body shall rather be understood as a resource . The acute scarcity of organs, which generates a desperate demand in relation to a group of potential suppliers who are desperate to an equal extent, leads easily to the gift’s becoming, (...) in reality, not only a resource, but also a commodity . In this paper, the claim is made that a successful explication of the gift metaphor in the case of organ transplantation and a complementary defence of the ethical primacy of the giving of organs need to be grounded in a philosophical anthropology which considers the implications of embodiment in a different and more substantial way than is generally the case in contemporary bioethics. I show that Heidegger’s phenomenology offers such an alternative, with the help of which we can understand why body parts could and, indeed, under certain circumstances, should be given to others in need, but yet are neither resources nor properties to be sold. The phenomenological exploration in question is tied to fundamental questions about what kind of relationship we have to our own bodies, as well as about what kind of relationship we have to each other as human beings sharing the same being-in-the-world as embodied creatures. (shrink)

After initially emerging in China, the coronavirus (COVID-19) outbreak has advanced rapidly. The World Health Organization (WHO) has recently declared it a pandemic, with Europe becoming its new epicentre. Italy has so far been the most severely hit European country and demand for critical care in the northern region currently exceeds its supply. This raises significant ethical concerns, among which is the allocation of scarce resources. Professionals are considering the prioritisation of patients most likely to survive over those with (...) remote chances, and this news has triggered an intense debate about the right of every individual to access healthcare. The proposed analysis suggests that the national emergency framework in which prioritisation criteria are currently enforced should not lead us to perceive scarce resources allocation as something new. From an ethical perspective, the novelty of the current emergency is not grounded in the devastating effects of scarce resources allocation, which is rife in recent and present clinical practice. Rather, it has to do with the extraordinarily high number of people who find themselves personally affected by the implications of scarce resources allocation and who suddenly realise that the principle of ‘equals should be treated equally’ may no longer be applicable. Along with the need to allocate appropriate additional financial resources to support the healthcare system, and thus to mitigate the scarcity of resources, the analysis insists on the relevance of a medical ethics perspective that does not place the burden of care and choice solely on physicians. (shrink)

Professor Hall is to be congratulated on his thoughtful analysis of an issue that, as he rightly suggests, “is one of the most important issues that will confront health care tort law throughout the remainder of the century.”’ He argues that malpractice law currently can accommodate considerable latitude both for a conservative streamlining of medical practices in general and for a cost-sensitivity in individual treatment decisions. And he further argues that existing tort principles, such as the locality rule, can comfortably (...) be stretched to embrace still greater room for economics in the medical standard of care. I quite agree.Unfortunately, Hall's arguments do not go nearly far enough, for they are framed around a seriously oversimplified picture of the economic changes that are revolutionizing medicine in the United States. He envisions a fairly uniform, global set of resource constraints that generally pressure physicians to conserve on care—pressures that tort law can then encompass equally globally as it accepts more cost-efficient standards of care. However, neither the changing economics of medicine nor the resulting jurisprudential challenges are anywhere near this generalized. (shrink)

Summary Background The principle of maximization, which roughly means that we should save more lives and more years of life, is usually taken for granted by the health community. This principle is even more forceful in crises like the COVID-19 pandemic, where we have scarce resources which can be allocated only to some patients. However, the standard consequentialist version of this principle can be challenging particularly when we have to reallocate a resource that has already been given to a (...) patient. -/- Methodology Engaging in thought experiments, conceptual analysis, providing counterexamples, and appealing to moral intuitions, we challenge the standard consequentialist version of the maximization principle and make a case for adopting an alternative deontological version. -/- Discussion In certain cases, the standard consequentialist version of the maximization principle is shown to yield intuitively immoral results. The deontological version of this principle is preferable because it can retain the merits of the standard consequentialist version without falling prey to its problems. -/- Conclusion Compared to the standard consequentialist version, the deontological version of the maximization principle can better guide the ethical decisions of the health community, even in cases where we face a scarcity of resources. (shrink)

In this article we investigate the value and utility of Machiavelli’s work for Community-Based Natural Resource Management. We made a selection of five topics derived from literature on NRM and CBNRM: Law and Policy, Justice, Participation, Transparency, and Leadership and management. We use Machiavelli’s work to analyze these topics and embed the results in a narrative intended to lead into the final conclusions, where the overarching theme of natural resource management for the common good is considered. Machiavelli’s focus on practical (...) realities produces new, sometimes unsettling, insights. We conclude that this focus helps to understand the development and performance of management regimes and their consequences and that institutional design should be seen as an ongoing process, which requires a constant adaptation of these institutions. (shrink)

This article makes a contribution to the on-going debates about universalism and cultural relativism from the perspective of sociology. We argue that bioethics has a universal range because it relates to three shared human characteristics,—human vulnerability, institutional precariousness and scarcity of resources. These three components of our argument provide support for a related notion of ‘weak foundationalism’ that emphasizes the universality and interrelatedness of human experience, rather than their cultural differences. After presenting a theoretical position on vulnerability and (...) human rights, we draw on recent criticism of this approach in order to paint a more nuanced picture. We conclude that the dichotomy between universalism and cultural relativism has some conceptual merit, but it also has obvious limitations when we consider the political economy of health and its impact on social inequality. (shrink)

In the street life of the Mission District in San Francisco, two opposite ways of understanding the female ownership of the body circulate among women who are drug-using sex workers: sexual slavery and women's liberation. This article analyzes how both models obfuscate the manner in which lack and scarcity govern the economy of needs and desires when drug abuse intersects with sex work. Lack and scarcity are shown to pervade not only economic resources but also drug-related gratification, (...) bodily well-being, sexual desire and body commitment during sexual practices. Even though both women and men are involved in this economy, there is an `artificial scarcity' of drug-related gratification for women. Controlling women's ability to close this circuit, men reinstate and reproduce the gender stereotypes that dominate in the street culture. (shrink)

Practical deliberation consists in thinking about what to do. Such deliberation is deemed rational when it conforms to certain normative requirements. What is often ignored is the role that an agent's context can play in so-called ‘failures’ of rationality. In this paper, I use recent cognitive science research investigating the effects of resource-scarcity on decision-making and cognitive function to argue that context plays an important role in determining which norms should structure an agent's deliberation. This evidence undermines the view (...) that the norms of ‘ideal’ rationality are necessary and universal requirements on deliberation. They are a solution to the problems faced by cognitively limited agents in a context of moderate scarcity. In a context of severe scarcity, the problems faced by cognitively limited agents are different and require deliberation structured by different norms. Agents reason rationally when they use the norms best suited to their context and cognitive capacities. (shrink)

Abstract Normative criteria for evaluations of economic and social outcomes are often formulated in terms of social welfare functions which are essentially and importantly non-satiable. However, there are good reasons to consider certain normative criteria and many policy objectives to be capped, i.e. bounded, and thus satiable provided sufficient resources are made available for their satisfaction. Inspired by the Foster–Greer–Thorbecke class of indicators, this paper uses an interdisciplinary approach to develop a model for assessing outcomes in terms of capped (...) objectives based on an understanding of individual shortfalls from the objective, denoted needs. We present an indicator to measure need satisfaction in a population of individuals with heterogeneous needs and highlight an aggregation problem under scarcity. For such situations, we develop three ways in which the indicator can be weighted that reflect respectively concerns over the frequency, depth and severity of the need shortfalls and show that normative evaluations based on these weighting schemes can conflict, yielding mutually inconsistent outcome rankings. The indicator can be adapted to measure a wide variety of phenomena, e.g. health needs, education shortfalls, deprivation, etc., and it is suited for targeting exercises and other policy implementations. In particular, it allows for exogenous weighting schemes, i.e. weights that can incorporate non-shortfall characteristics relevant for the evaluation, e.g. age, gender, ethnicity, etc. The indicator thus enables new ways for researchers to promote and study satiable objectives in a wide variety of contexts relevant to economic and social policy, e.g. human development programs, poverty reduction, healthcare policies, etc. (shrink)

I argue that, because of scarcity, the right to life cannot imply an obligation on others to save the life of the right-holder, and that collectivising resources for health care not only ensures that resources are used inefficiently and inappropriately but also removes from people the authority to make decisions for themselves about matters of health, life and death.

It often appears that the most appropriate form of addressing disadvantage related to disability is through policies that can be called “status enhancements”: changes to the social, cultural and material environment so that the difficulties experienced by those with impairments are reduced, even eradicated. However, status enhancements can also have their limitations. This paper compares the relative merits of policies of status enhancement and “personal enhancement”: changes to the disabled person. It then takes up the question of how to assess (...) the priority of the claims of disabled people in the face of scarcity of resources for which there can be many competing social claims, arguing for the theory of “declustering disadvantage”. (shrink)

When the COVID-19 surge hit New York City hospitals, the Division of Medical Ethics at Weill Cornell Medical College, and our affiliated ethics consultation services, faced waves of ethical issues sweeping forward with intensity and urgency. In this article, we describe our experience over an eight-week period (16 March through 10 May 2020), and describe three types of services: clinical ethics consultation (CEC); service practice communications/interventions (SPCI); and organizational ethics advisement (OEA). We tell this narrative through the prism of time, (...) describing the evolution of ethical issues and trends as the pandemic unfolded. We delineate three phases: anticipation and preparation, crisis management, and reflection and adjustment. The first phase focused predominantly on ways to address impending resource shortages and to plan for remote ethics consultation, and CECs focused on code status discussions with surrogates. The second phase was characterized by the dramatic convergence of a rapid increase in the number of critically ill patients, a growing scarcity of resources, and the reassignment/ redeployment of staff outside their specialty areas. The third phase was characterized by the recognition that while the worst of the crisis was waning, its medium- and long-term consequences continued to pose immense challenges. We note that there were times during the crisis that serving in the role of clinical ethics consultant created a sense of dis-ease as novel as the coronavirus itself. In retrospect we learned that our activities far exceeded the familiar terrain of clinical ethics consultation and extended into other spheres of organizational life in novel ways that were unanticipated before this pandemic. To that end, we defined and categorized a middle level of ethics consultation, which we have termed service practice communication intervention (SPCI). This is an underappreciated dimension of the work that ethics consult services are capable of in times of crisis. We believe that the pandemic has revealed the many enduring ways that ethics consultation services can more robustly contribute to the ethical life of their institutions moving forward. (shrink)

This article examines some of the ethical challenges of prioritizing intensive care resources during the Covid-19 pandemic by comparing the Italian and United States contexts. After presenting an overview to the clinical, ethical, and public debates in Italy, the article will discuss the development of triage allocation protocols in United States hospitals. Resource allocation criteria underwent increased scrutiny and critique in both countries, which resulted in modified professional and expert guidance regarding healthcare ethics during times of emergency and resource (...) scarcity. (shrink)

The rule of rescue describes the moral impulse to save identifiable lives in immediate danger at any expense. Think of the extremes taken to rescue a small child who has fallen down a well, a woman pinned beneath the rubble of an earthquake, or a submarine crew trapped on the ocean floor. No effort is deemed too great. Yet should this same moral instinct to rescue, regardless of cost, be applied in the emergency room, the hospital, or the community clinic? (...) -/- In health care, the desire to save lives at any cost must be reconciled with the reality of resource scarcity. As one example, the estimated cost for prophylactic Factor VIII to treat one patient with hemophilia for one year is $300,000. Costs of this magnitude have been accepted by public and private insurers in the developed world, even though, in principle, these sums could provide greater overall health benefit if allocated to pay for the unmet health care needs of many other patients. Looking forward, however, broad application of the rule of rescue will be increasingly untenable. But the moral instinct will remain: the desire to help those weakest among us, especially when their small numbers allow us to see them as unique individuals. What, then, is the ethical framework that can guide coverage and reimbursement decisions for orphan drugs into the future? (shrink)

This paper presents a case for allocating health care resources so as to maximise Quality Adjusted Life Years (QALYs). Throughout parallels are drawn with the grounds for adopting utilitarianism. QALYs are desirable because they are essential for human flourishing and goal-attainment. In conditions of scarcity the principle of QALY maximisation may involve unequal treatment of different groups of people; and it is argued that this is not objectionable. Doctors in their dealings with patients should not be continually consulting (...) the principle (though it can sometimes be useful); instead by following existing ethical codes more QALYs will be produced overall. In the formulation of policy, however, the principle should be applied in a thoroughgoing way and, if it is, it will not have some of the counterintuitive consequences it may have in interpersonal situations. (shrink)

Park and Davies have laid out an illuminating map of major arguments bearing on whether vaccination status should affect access to scarce healthcare resources during a pandemic. Notably, they sugge...

In lieu of an abstract, here is a brief excerpt of the content:Moral Responsibility in a Context of Scarcity:the Journey of a Haitian PhysicianPaul PierreAlmost all Haitian physicians have been involved in some sort of "social movement" at one point in their professional life. In a country characterized by a natural inclination to question authority, fighting the status quo of the ineffective, corrupt and disorganized [End Page 89] Haitian health system often appears to be the right thing to do.In (...) 2002, I played an active role in a large protest movement for better working conditions at the largest health facility in Port-au-Prince: the General Hospital (GH). Port-au-Prince is the capital and economic center of Haiti. It is home to close to a third of Haiti's ten million people. At that time, the situation at the GH facility was dire. All of the 400 beds at the GH were dirty. The staff was underpaid and unhappy. Drug and medical supply stock-outs were routine. Medical equipment was rarely maintained and only one of the six operating theatres in the surgery block was working. Unsupervised physicians in training (like me) were the main health care providers. Attending physicians were busy running their own private clinics, and most of them would come to the hospital solely to "recruit" the less poor patients for their clinics. As physicians-in-training, we had the responsibility of caring for the poor, but we had no means. We grew frustrated and angry witnessing our powerless patients losing legs, arms and their lives for lack of care. On many occasions, I had the parents of my patients buy the gloves that I would use to examine their sick relatives. I've seen patients fighting for the inheritance of medications left by others who had just passed away. There was no way for this hospital to fulfill its mission, and no way for its staff to deliver anything other than mediocre care. We could not accept that situation at such an early stage in our medical development, and so we refused to continue to work. We went on a strike, which completely paralyzed the delivery of care at the hospital for nearly two months. After intense negotiation, the strike ended with a signed agreement with the Minister of Health that addressed, more or less, the reasons of our movement. However, the implementation of the agreement was permanently delayed by other competing "state emergencies" including a general insurrection.At the time of our movement, I thought we were making history. After witnessing 11 "social movements" that similarly paralyzed the GH in the following decade for reasons identical to ours, I am now convinced that we were not. We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince. The social movement that we started ended up hurting the very same people that we were trying to help.Extending access to heath care to poor people seemed to me at that time to be too complicated and too expensive for an unorganized state like Haiti. I realized that local protests could, at best, influence the allocation of local resources. But so-called local resources are so limited in "resource-limited" countries. Haiti spends only $40 U.S. dollars per capita for health care. This is not enough for good care. The options we were provided were not real ones—since all of them would end in more suffering. The case of providing health care to poor people needed to be approached differently.I was born in Port-au-Prince at the same general hospital in which I would later work. I am the third of four children, and the first male child in my family. My father made me understand very clearly that my first responsibility was for my siblings. My sisters made me understand equally clearly that I had no authority over any of them. I ended up with a lot of responsibility but with very little authority. The few of us who completed school, entered university, studied abroad and "emerged" were considered, to some extent, responsible for the others—the ones who couldn't go to school, university, or abroad, the ones who had "sunk... (shrink)

In his Critique of Dialectical Reason , Sartre argues that it is the milieu of scarcity that generates human conflict. His account of scarcity is rather ambiguous however, and at points he seems to claim that conflict is inevitable given the context of scarcity. In this article I provide a brief account of Sartre's position, and offer a critical evaluation of that position. Finally, I argue that Sartre's claims regarding the necessity of conflict are excessive, and that (...) the resources provided in the Critique offer a means to re-evaluate our relationship to scarcity. (shrink)

Businesses interface with the natural world through rights to property. The shape of these rights and the responsibilities we assign to managers are important determinants of both patterns of resource use and pollutant levels. Consequently, conflicts have arisen between regulating bodies, indigenous groups, and corporations over the entitlements of businesses in the use of their property when that property is ecologically sensitive or significant. In this paper I develop an account of the ethical responsibilities of managers regarding their treatment of (...) the environment and their use of natural resources. This account is based on a philosophical examination of the nature of property rights. After a tour of traditional arguments employed to defend the institution of private property, I develop a new conception of property rights over objects that have a high natural resource component. I show that in today’s world, ethical concerns that motivated John Locke will yield property rights that are insufficiently strong to override a democratic say in overall use patterns and must be sensitive to factors such as need, scarcity, and the interests of stakeholders. I show a similar result for utilitarian arguments for property. On this foundation I develop a conception of property in key environmental resources that includes a stewardship element. To embody this, I suggest a set of ethical responsibilities for managers over certain natural resources that springs from it. I argue for obligations restricting harmful use patterns as a way of including the other goals (eg public participation, sustainability) that we care about, in a manner which clashes least with the liberty of owners and the efficiency of production. The outcome is a set of rights and responsibilities that take global environmental interests into account, but preserve the thrust of what is good about the institution of private property: that it rewards labour and facilitates a stable and efficient free exchange system. As a version of private property, it retains many of the advantages of global capitalism while attaching responsibilities to business decision makers. (shrink)

Economists since the First Industrial Revolution have been interested in the links between economic growth and resources, often pointing to resource scarcities as a hindrance to growth. Offering a counter perspective, this volume highlights the positive role that scarcities can play in inducing technical progress and economic growth. It outlines a structural framework for the political economy of scarcity and rents, and offers a novel way of organizing the evidence concerning the role of resources in industrial growth. (...) This book proposes a major shift in the treatment of scarcity issues by focusing on bottlenecks and opportunities arising within the production system, and will appeal to economists and policy makers interested in the role of resources as triggers of structural change. (shrink)

The past 15 years of exceptionally severe water scarcity in the Islamic Republic of Iran have resulted in the desertification and salinity of formerly arable lands, drying out of Iranian lakes and rivers, and quickly shrinking groundwater resources, while water demand has risen, along with the size of the Iranian population, of which over 70% lives in urban areas now. We have aimed to discover the causes of water scarcity in the IR Iran and evaluated its social (...) and economic impacts. First, we computed the Weighted Anomaly Standardized Precipitation (WASP) Index for the period of 1979-2014. To illustrate the social impact of water scarcity, we analyzed the current water risk for the twenty most populous Iranian cities, by employing the composite index approach to translate hydrological data into comprehensible indicators of water related risks, and made a projection for 2020-2030, by modeling potential changes in the future demand and supply of water. To demonstrate the economic impact of water scarcity, we evaluated the overall agricultural contribution to the IR Iran GDP. We have found that the 1999 severe drought in the IR Iran commenced a period of unusually dry conditions that is still ongoing. The rapidly growing Iranian urban populations presently experience a medium to extremely high overall water risk, with extremely high baseline water stress that, in part, is due to the lack of upstream protected lands. The relationship between baseline water stress and drought severity has been determined as weak, confirming that other factors than drought are equally or more important contributors to the existing water risk. Our projection calculations indicate that Iranian urban populations will continue to experience an extremely high water stress for the coming decade. Due to the fast growth of these populations as well as considerable rise of value added to the IR Iran GDP by other sectors of the national economy, the contribution of agricultural production to the national GDP has declined from about 25% to under 10% (although its total yield has risen considerably) during the past 30 years. This decrease has been directly proportional to the increased foreign food imports, dependency on the IR Iran oil exports and reduction in the non-oil exports. The main causes of water scarcity in the IR Iran appear to be due to climatic factors, insufficient environmental protection, and over-exploitation and mismanagement of water resources, especially by the agricultural sector. In conclusion, our study proposes anti-wasting water management action plan that recommends shifting the IR Iran government response to water scarcity from reactive survival strategies to proactive crisis prevention, with emphasis on safeguarding, monitoring, early warning, and effective step-by-step preparedness and readiness, and by laterally integrating water management between all levels of the IR Iran government, including local, regional and national, for a sustainable, resilient and prosperous economy of the Islamic Republic of Iran now and in the future. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Developing Health Care in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences of health care providers working in resource-poor settings, with stories written by those on the frontlines of global health. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of global health practitioners within the frameworks of sociology and (...) medical anthropology respectively.The burgeoning interest in global health among students, health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantial moral claims. People working in global health often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to quality health care services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among global health equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basic health services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducing health disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes of health inequity.We believe that global health must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of global health as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by global health leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of global health work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic and moral—involved in this work. The profound scarcity of resources available to health providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and other health care workers, who make difficult choices every day about what to do with the few resources they have. These are the ethical dilemmas of mortal dramas at their most dire. Global health work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of global health practitioners. They highlight the translation of the moral and programmatic challenges of health care delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-up care. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)

In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially medical (...) judgments. In contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)

Contemporary issues such as euthanasia, surrogate motherhood, organ transplantation and gene therapy, which occupy the minds of ethicists in the industrialized countries are, for the moment, irrelevant in most developing countries. There, the ethics of scarcity, sacrifice, cross-cultural research, as well as the activities of multinational companies, are germane. In this article, only the ethics of scarcity and sacrifice will be discussed. Structural adjustment programmes, designed to solve the economic problems of the developing countries, muddied the waters. The (...) dilemma confronting practitioners in developing countries is how to adhere to the basic principles of medical ethics in an atmosphere of hunger, poverty, war and ever-shrinking and often non-existent resources. Nowhere else in the world is the true meaning of scarcity portrayed as vividly as in the developing countries. Consequently, the doctor's clinical freedom may have to be sacrificed by the introduction of an essential drugs list and practice guidelines. The principle of greater good, while appealing, must be carefully interpreted and applied in the developing countries. Thus, while health promotion and disease prevention must be the primary focus, health planners should avoid pushing prevention at the expense of those currently sick. Health care reform in developing countries must not merely re-echo what is being done in the industrialized countries, but must respond to societal needs and be relevant to the community in question. (shrink)