Fairness in the distribution of scarce healthcare resources - a hybrid approach

James Hart

This research addresses how considerations of fairness can be incorporated into decision-making, specifically when deciding how to distribute scarce healthcare resources. The research outlines a hybrid approach between two major theories of fairness, with the aim of creating tools to help institutions incorporate notions of fairness consistently and coherently when deciding how to distribute resources. A reviewer wrote, ‘This is a clear, interesting, and insightful essay’ and praised the easy to follow and compelling analysis.

This thesis relates to our research direction on global priorities research.

Researcher profile

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James Hart

James is a moral philosopher by training. His prior work has sat quite centrally in the normative domain, but he has spent the last year looking at how to apply his skills and ideas to practice, in particular bioethics. He now plans to shift his focus entirely in that direction, though he also has interests in resource allocation in other domains.

Researcher profile

What was your thesis topic?

My thesis focuses on issues surrounding moral aggregation, especially as they pertain to distributing resources fairly. Questions of moral aggregation are about whether, and when, it is right to allow many small benefits to aggregate and outweigh fewer larger benefits. For instance, ought we to save many from mild impairments, such as back pain, or a few from much more serious impairments, such as paralysis? I develop and defend a version of a view called limited (or partial) aggregation. Limited aggregation uses considerations of fairness and respect for individuals’ personal perspectives, to put constraints on when aggregation is permitted.  

This paper forms a chapter of the wider thesis. It looks at two competing accounts of fairness with different implications for aggregation and resource allocation and demonstrates their compatibility. This is an important finding as it allows us to avoid a number of problems with either view taken separately and gives decision-makers more tools for analysing what we ought to do. 

In what ways do you think your topic improves the world?

Deciding how we ought to weigh benefits and harms alongside considerations of justice and fairness is absolutely vital in determining how we allocate resources and set priorities. EA has a reputation for being utility maximising but (as has become quite clear recently) we might want to maximise utility within side-constraints. Establishing a systematic way to do so enables us to make better and more transparent decisions.  

In its application to healthcare, this approach can guide commissioners and policy-makers in determining healthcare priorities. Alongside colleagues at the Ethox Centre we are already beginning to draft an “Ethical Framework” to ensure efficient, fair, and consistent decision-making in health along these lines.

In what ways have you changed your mind since you finished writing it?

Before working on my PhD I was definitely happier with utility maximising approaches to resource distribution and equated such approaches with doing more good. I always felt that other accounts seemed unable to provide appropriate constraints without losing their sensitivity to the importance of the large potential impacts. This has shifted now. I can see how constraints can be integrated into maximising accounts preventing some of the worst excesses of such approaches whilst recognising the significance of large-scale problems.

What recommendations would you make to others interested in taking a similar direction with their research?

For those interested in bioethics research in particular, or moving their work in that direction, I would advise starting early. Don’t think that you need a huge background of knowledge or that you need to wait for opportunities to come along. I’d advise engaging with others early: don’t feel afraid to message researchers and institutions whose work sounds interesting, or you think might be related to your own work. Be prepared for no responses and responses that go nowhere or take a long time to get off the ground. There is always an element of luck in whose working on what, at what time etc., so contact lots of people and don’t be disappointed if they do not get back to you.

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