PRINCIPLE OF AUTONOMY

INDIVIDUAL AUTONOMY - (self-rule)

Definition:
1. The capacity to think, decide, and act freely and
independently.
2. The moral right to choose and follow ones own plan of
life.

* Based on the Concept of respect for persons

* Denotes having the freedom to make choices about issues
that affect our life.
* implies freedom to choose whether to seek health care, and
whether to accept it and may refuse treatment if seen that
treatment is life-saving. (Western Secular Ethics)
 PRINCIPLE OF AUTONOMY
* Related to beneficence (doing good) and non-
maleficence (not doing harm); respect persons
autonomy - doesnt cause harm to others.
* outweighed by beneficence when patients welfare is
involved;
* The patient can act independently without controlling
influences from others;
* The basis for the practice of informed consent.
 Aspects of Autonomy:
* non-interference with the autonomy of others;
* respect for judgment of others as we have to our
own.
* should be maintained throughout treatment ;
* active participation of patients in their own
treatment should be facilitated by means of open
and sensitive communication.
* cannot thrive in a climate that does not allow for
either the independent planning of personal goals
or the privilege of examining and choosing
options to meet goals.
 PRINCIPLE OF AUTONOMY
Patient Autonomy refers to the :
* right of the patient to be a fully informed participant in all
aspects of medical decision making; and
* right to refuse unwanted, even recommended and life-
saving medical care.

Autonomy is based on respect for persons.

observed through free and informed consent
For both patients or research subjects.
 PRINCIPLE OF AUTONOMY

Importance:

* enhances a persons personal worth;

* protects a person from being used by others;
* in health care, helps develop a mature
therapeutic alliance between health
professionals and patients.
 Autonomy:
(Kant) - Principle of Respect for Persons
certain attitudes of respect be framed about:
* the personhood and beliefs of others.
* important in cultures where all
individuals are considered to be unique
and valuable members of society.
 Autonomy:
Situations:
Patients have to be fitted into the institution and
its routines rather than the institution bending to
fit the patient.
* Increase patients dependence
* Decrease patients autonomy
(is it necessary for patient to change into hospital
clothes?)
 Essential Factors in the practice of Autonomy:

1. The relationship of physician and patient is governed

by a mutual contract based on trust;
2. The doctor promises to treat his patient according to
his best judgment;
a. the expertise of the health provider, as a general
practitioner or specialist;
b. the capability of the health facility where the
health provider works;
c. the standard of care practiced in the locale
where the health provider practices.
 Essential Factors in the practice of Autonomy:
3. The doctor, although he believes he knows best,
should fully inform his patient and defer to the
latters option to accept or reject the proposed
plans of management.
The following are the physicians basis for making
decisions for or against any therapeutic options:
a. Diagnosis
b. Therapeutic management
c. Prognosis
d. Financial implications
 Essential Factors in the practice of Autonomy
4. When the patient is incompetent, proxy consent should
be sought;
5. The patient has the right to decide is and this should be
respected unless his actions constitute an evil act.
6. Autonomy is applied when there is a conflict between:
a. cultural belief and dignity of life;
b. religious belief and dignity of life;
c. legalities and dignity of life, it is always the dignity of
life that prevails as life is of the greatest value.
 INTRINSIC FACTORS THAT MAY THREATEN PATIENT
AUTONOMY:

* The patients role is a dependent one on the

health care provider.
* The role of the health care professional, on
the other hand, is one of power.
 Four Factors Relating to Failure to Recognize
Patient Autonomy:
1. Doctors may falsely assume that patients have the
same values and goals as themselves.
2. Our failure to recognize that individuals thought
processes are different.
3. Our assumptions about patients knowledge base.
4. The unfortunate fact that in some instances the
work becomes the major focus.
 Patient Autonomy:

Patient autonomy is frequently discussed with:

* Informed consent
* Paternalism
* Compliance
* Self determination
 Patient Autonomy:
Informed consent - relates to a process by which patients are
informed of the possible outcomes, alternative, and risks of
treatments, and are required to give their consent freely.
Paternalism - a gender-biased term and literally means acting
in a fatherly manner.
Parentalism - a non-gender term that parallels the meaning of
paternalism while avoiding gender-bias.
Noncompliance is generally thought of as denoting an unwillingness
of the patient to participate in health care activities.
Two basic factors in non-compliance:
1. The autonomous participation of the patient is essential to successful
health care. Patient must be fully informed of the choices in therapies
and the consequences of non-treatment.
2. Patients abilities must be assessed to follow plans of care:
resources, knowledge, support from family, psychological factors,
cultural beliefs.
 CASE PRESENTATION
Non-compliance vs. Autonomy
Cora is a 45 yr. old woman who looks older than her age.
She has very limited monthly income and no health insurance.
Cora smokes 2 packs of cigarettes per day. She has severe
COPD with constant dyspnea and frequent exacerbations. The
doctor, to prevent further problems, speak to Cora about the
importance of quitting smoking, but was ignored. During a
particularly severe exacerbation, the doctor told her, You are
committing suicide by continuing to smoke. Coras reply is,
You dont understand. I live along. I have no money, no friends,
no family, and will never be able to work. I know the damage
Im doing, but smoking is the only pleasure I have in Life.
 BENEFICENCE/NONMALEFICENCE
Anything that gives pleasure is good.
Hedonism (Greek)-
* Aristupus (435-356 B.C.)
* Epicurus (Greek) - 341 270 B.C.
* Aristotle (Greek) - 384-322 B.C.
* Golden Rule

For the Good of Whom?

* For the benefit of the individual;
* For the benefit of a large proportion of mankind.
(Altruism or Altruistic utilitarianism)
(based on the Teleological theory - goal-oriented)
BENEFICENCE - For the good of the Majority:
Jeremy Bentham (1748-1832)
* Utilitarianism - the morally good act is that which
produces the greatest happiness for the greatest
number of people.
John Sturart Mill (1806-1873)
Refined the utilitarian theory into:
* Act utilitarianism - The act itself that is judged to be good
or bad according to whether it serves the principle
of greatest happiness.
* Rule utilitarianism - tries to establish rules that are
capable of producing the greatest happiness for the
greatest number.
 BENEFICENCE:
Definition:
1. The moral principle that one should help others, further
their important and legitimate interests, as those persons
understand them (respecting autonomy) or as we
conceived them (paternalism).
Under this principle, failure to increase the good of
others when one is knowingly in a position to do so is
morally wrong. Nonetheless, one is obligated to act to
benefit others when one can do so with minimal risk,
inconvenience or expense.
 BENEFICENCE:
2. The duty to actively do good for patients.
3. Healing with attention to the psychological, social, and
spiritual dimensions of disease or injury as well as the
physical problems.
(Council on Ethical and Judicial Affairs of the American Medical Association)
4. The obligation to help impose upon health practitioners
the duty to promote the health and welfare of the patient
above other considerations, while attending and honoring
their personal autonomy.
BENEFICENCE - For the benefit of the individual:
PATERNALISM -
* acting in a fatherly manner.
* Assuming that you know better what is good for your patient
because of your training and experience (denying patient
autonomy).
Paternalistic Beneficence (Hippocrates)
(Beneficent Paternalism)
* The doctor because of his or her education and experience,
knows what is best for the patient. What will be done to them is
morally justified.
* The good of one patient cannot be seen in isolation in doing
good for one, we need to be sure that it is not to the detriment of
others. The duty of beneficence needs to be tempered by justice.
 Four Major Components of Beneficence: (Frankena, 1963)

1. Do or promote good.
2. Prevent harm or evil.
3. Dont inflict evil or harm.
4. Remove evil or harm.

In terms of health care Frankenas principle of

Beneficence can be subsumed into two:
1. That one should always do what is best for the patient;
2. That the good of the patient should be put before ones
own needs.
 BENEFICENCE
The essence of the Principle is DOING GOOD.
* Would doing good for the patient always result in
justice?
Not, if in so doing one prohibits their autonomy:
Result - conflict between:
* what the professional should always do;
* what patient want what is good for them
* What if what the patient wants is not what the
professional judges to be good for them?
 The essence of doing Good
* Suppose it is decided that the best course of action
- in the interest of the patients health is that he
should undergo surgery,
- but the patient, having been informed of the
pros and cons of surgery, decides not to submit
to it?
* Suppose he decides instead to discharge himself?
* What, then, is the most just action?
 The essence of doing Good
The question is:
Is it more just to do what the patient wants, or what the health
professional thinks is in his best interests?
* If justice is to do with respect for persons, then to allow them
personal autonomy is just.
* On the other hand, if justice (in health care) is about that ensuring
that individuals get what will be best for them, then it could be
argued that to restrain them and give them the treatment would be
just.
The difficulty is in determining what is in the patients best
interests.
It could be argued that what is in the best interests of any individual
is allowing them autonomy, allowing them to decide for themselves
which course of action to take. It might not be the healthiest
decision, but it might be the most just.
 BENEFICENCE
Moral Rules that apply to Beneficence:
1. Protect and defend the rights of others;
2. Prevent harm from occurring to others;
3. Remove conditions that will cause harm to others;
4. Help persons with disabilities
5. Rescue persons in danger.
 NONMALEFICENCE:
Definition:
The duty to prevent or avoid doing harm, whether
intentional or unintentional.
Primum non nocere - first (above all) do no harm;
- one should refrain from harming others.
This principle requires us:
to avoid causing harm to patients, intentionally or
unintentionally.
1. deliberate harm
2. risk of harm
3. harm that occurs during the performance of
beneficial acts, in such cases, the four conditions
that apply to the principle of double effect, must be
applied here.
 NONMALEFICENCE:
Principle of beneficence and nonmaleficence
* appear to uphold a notion of justice, both of them, if
rigorously applied, can lead to injustice. The only real
justice in our dealings with individuals
* is to treat them as autonomous moral beings,
able and entitled to decide for themselves what is
in their own best interests;
* to treat them with respect, as equals with
ourselves.
* One of the criticisms of the principles of beneficence and
nonmaleficence - they can lead to paternalism, which
is closely at odds with the idea of justice.
 Difference between Maleficence and Non-Maleficence:
Rules of Beneficence:
* Present positive requirements of action;
* Need not always be followed impartially;
* Rarely provide reasons for legal punishment when agents fail to
follow the rules.
* Guided by special relationships which removes obligation from
the act. The exception is rescuing strangers under conditions of
minimal risk.
Rules of Nonmaleficence:
* Negative prohibition of actions;
* Must be followed impartially;
* Provide moral reasons for legal prohibitions of certain kinds of
conduct.
* Obligations linked to beneficence can sometimes override
obligations of nonmaleficence.
 JUSTICE
* The ethical principle that relates to fair, equitable, &
appropriate treatment in light of what is due or owed to
persons, recognizing that giving to some will deny receipt
to others who might otherwise have received these things.
For health care -
refers to distribution of resources.
* Moral virtue which comes as a fruit of constant and proper
observance of rights and duties.
 JUSTICE

Justice is related to:

* truthfulness (veracity)
* autonomy
* stewardship
* nonmaleficence
 JUSTICE
Both a principle and a virtue
relating on peoples
interaction and relationship.
* As a principle:
one should give what is ones due.
* As a virtue:
it is the constant will to render what is right.
This principle underlies:
* Distribution of Resources and
* The right to Health Care
 JUSTICE
Two Essential Attributes of Justice:
1. Universality - requires that justice be applied to all, and
not merely to a particular group or class; and that
everyone is bound to give to everyone what is his
due.
Do unto others what you want others do unto you.
2. Equality - demands that justice is for all regardless of
station or quality in life; must be applied to all without
discrimination.
 DIFFERENT LEVELS WHO DECIDE ABOUT JUSTICE
1. Government -
2. Hospitals and other organizations
3. Doctors & other health care providers

DifferentTypes Of Justice:
1. Legal Justice
2. Commutative Justice
3. Distributive Justice - duties of the state to the citizens as
clearly stated in the Constitution. Focuses on distribution of
goods and services.
 CATEGORIES OF JUSTICE
* Formal Principle of Justice:
Equals ought to be treated equally and unequals
may be treated unequally;
* Material Principle of Justice:
Identifies a relevant property, such as need,
effort or merit as the basis of which, burdens
and benefits should be distributed and excludes
other properties as irrelevant.
 THE PRINCIPLE OF JUSTICE IN THE ALLOCATION OF
HEALTH CARE RESOURCES

Concepts of Justice:
* Justice as retribution or punishment
* Justice as fairness, and in particular fair distribution.
For health care - justice refers to fair distribution of goods
and services DISTRIBUTIVE JUSTICE
Health Care resources - always limited.
whatever are available must be fairly and rationally allocated
to benefit as many people as they would as possible
Allocation - must not be discriminated as to benefit only a few,
not the rich and powerful but
the poorest of the poor.
 THE PRINCIPLE OF JUSTICE IN THE ALLOCATION OF
HEALTH CARE RESOURCES
Questions to be asked:
* Is health care a right or a privileged?
* Should all people have access to the same health
care services regardless of ability to pay?
* How should ability to pay influence access to health
care services?
* Should the Government be responsible for the health
care needs of all citizens?
* If health care is a right and health care resources are
scarce, what resources are allocated to which group
of people?
 THE PRINCIPLE OF JUSTICE IN THE ALLOCATION OF
HEALTH CARE RESOURCES

3 Basic Areas of Health Care Relevant to Distributive Justice

1. Percentage of resources to spend on health care;
2. Aspects of health care to be given priority in health
resources;
3. Which patient should have access to limited or scarce
resources.

The relevant application of the principle of justice within the

health care system focuses on the fair distribution of goods
and services. called DISTRIBUTIVE JUSTICE.
 DISTRIBUTIVE JUSTICE

To each equally;
To each according to need;
To each according to merit;
To each according to social contribution;
To each according to the persons rights;
To each according to individual effort;
To each as you would be done by;
To each according to the greatest good to
the greatest number.
 DISTRIBUTIVE JUSTICE

Subsumed intro three by Seedhouse.

1. To each according to his rights;
2. To each according to what he deserves;
3. To each according to his need.
 DISTRIBUTIVE JUSTICE
Seedhouse
1. To each according to his rights - form of contract.
Patient seeks health care, enters into a contract with the
health care professional. The doctor, having agreed to take- on
the patient, offers to treat him. In return for the promise to treat,
the doctor has a right to expect the patients compliance. The
doctor gives his services the patient is expected to pay for
those services.
Question:
(1) How about those who cannot pay?
(2) Dont they have a right to health care?
 DISTRIBUTIVE JUSTICE

2. To each according to what he deserves.

Health care has to be earned.
Questions:-
Those who have the means to enhance their health, but fail to
do so from choice?
* a smoker who contracts cancer of the lungs?
* A careless driver injured in the road?
* An attempted suicide?

Can justice be achieved?

Whether at a macro or micro level, can seldom be achieved,
unless resources are unlimited.
 DISTRIBUTIVE JUSTICE

3. To each according to his need.

- from each according to his means, to each
according to his needs. Applicable if enough resources
are available, because to have justice every one should
receive 100% of what he needs. Injustice in health care
is inevitable if resourcing is insufficient to meet all
needs.
 DISTRIBUTIVE JUSTICE

Problems of distributive Justice:

1. Arise when resources is scarce.
2. Regarding benefits competing claims to it will probably
result to some suffering harm;
3. Regarding burden - only few may carry the burden;
* Can this be a rational case for determining the total
health care spending?
* Or local budget?
* Or is this left to politics and tradition?
* What principle of morality prescribe and proscribe that
we can do in the pursuit of more efficient allocation of
health care?
 HEALTH-CARE RESOURCES
Any goods or services that can reasonably be expected to have a
positive effect on health. Health care resources are referred to as the
five Ms:
1. Manpower: * human resources skills;
* knowledge;
* aptitude and attitude
2. Money * monetary capability and values
* banking
* lending and financial institutions
* investments
3. Machines * health care equipment,
* instruments and devices, like Xrays, Ultrasound, CT Scan, MRI, etc.
4. Materials * health care facilities and structures, like hospitals,
health centers, etc.
5. Methodologies * efficient and effective ways to prevent and diffuse the debilitating
effects of diseases and health problems.
 HEALTH CARE RESOURCES

ALLOCATION
To allocate is to distribute resources among
alternative uses.
Health care resources are always limited. Thus,
whatever are available must be fairly and rationally
allocated so that they can benefit as many people as
they would as possible, rather than allowing a few to
enjoy them.
PARADIGMS OR THEORIES OF JUSTICEIN THE ALLOCATION
OF HEALTH CARE RESOURCES

1. Utilitarian Model
2. Libertarian Model
3. Commutarian Model
4. Egalitarian Model
5. Distributive Model
6. Social Justice Model
7. Pragmatic or Popular Model
8. Natural Law Model
PARADIGMS OF JUSTICE or THEORIES OF JUSTICE IN THE ALLOCATION OF HEALTH
CARE RESOURCES

1. Utilitarian Model - what is due is determined by utility

consequences.
* Greatest good for the greatest number;
* Favors social programs that protect public health and
distribute basic health equally to all citizens;
Problem:
* Places aggregate social good before individual
rights.
* Social utility might be maximized by denying
access to health care for some of societys sickest
and vulnerable populations.
(Beauchamp & Childress, 1994)
 Utilitarian Model
a. Act Utilitarianism -
* defines rightness with respect to particular acts;
* an act is right if and only if it maximizes utility.
b. Rule Utilitarianism
* defines rightness with respect to rules of action
and makes the rightness of particular acts depend
upon the rules under which those acts fall;
* A rule is right if and only if general compliance with
that rule maximizes utility; and
* an act is right if and only if it falls under such rule.
 PARADIGMS OF JUSTICE
2. Libertarian Model (entrepreneurial model) - for as long as
there are no restraints on individual liberty, justice is served.
* Protects the rights of property and liberty of each person;
* Health care depends on free market: - supports private
citizen or group to own and manage health care business;
* Health care is not a right but a commodity that operates on
the ability to pay principle: - risks the rich in buying too
much and leaves nothing to the poor.
* Except for the fact that professionals can choose to provide
services free of charge, this model makes little allowance for
children and the very poor.
(Bandman and Bandman, 1978; Beauchamp & Childress,
1994)
 PARADIGMS OF JUSTICE
3. Commutarian Model:
* what is valued by the community determines what is just -
places the community, rather than the individual, at the
center of the value center;
* emphasizes social meaning, community membership,
shared values;
* holds that community tradition includes commitments of
equal access to health care, and suggests that as long as
communal funds are spent, services must be equally
available (Beauchamp & Childress, 1994)
 PARADIGMS OF JUSTICE

4. EgalitarianModel: - what is due is what is fair,

equal distribution of benefits and burdens; equal
opportunity.
* concept of equality: - fairness in equal distribution
of benefits and burdens;
* recognizes social obligation to reduce barriers that
prevent fair equality of opportunity.
* People who are similarly situated should be treated
similarly. (Donderich, 1995)
 PARADIGMS OF JUSTICE
5. Distributive Justice Model
* both benefits and risks are equally distributed to all
members of the population
* takes into consideration that everyone must have a
right to have access to health care but that he must be
willing to make corresponding sacrifices since not
everybody can get equal benefits that health care can
offer.
 PARADIGMS OF JUSTICE
6. Social Justice Model
* promotes the belief that we give back to society what
we took from it.
* beneficiaries of this model are primarily the poor.
There must be more justice given to those who have
less in life.
 PARADIGMS OF JUSTICE
7. Pragmatic or Popular Model
* what is pragmatic or popular is the basis for the
rationalization of health care even if it breaches the
cultural, moral or religious aspects of health.
* Machiavellian in characteristic; it thrives on the
fanciful and not on the necessary.
 PARADIGMS OF JUSTICE
8. The Natural Law Model
* do what is good and avoid what is evil.
* do not do unto others what you do not want done to
yourself
 JUSTICE

Implications of the principle:

* Each individual should receive what his due by right such as:
a. life
b. information needed for decision making
c. confidentiality of private information
* Benefits should be justly distributed among individuals such as:
a. minimum health care
b. equal opportunities for a scarce resource
* Each individual should share in the burden of health and science such
as:
a. caring for his own health
b. caring for the health of others;
c. participating in the health/science progress
 VIOLATIONS:
1. To be dishonest with, deceive or withhold the truth from
the patient.
2. Withholding life-saving medications from one who
needs them;
3. Distributing a minimum health benefit unequally
providing a selected group with available safe water
supply;
4. Imposing unfair burden on an individual - using
underprivileged group as research subjects.
 JUSTICE
Role of the Health Care Professional:
1. In delivering health care give each patient what is due:
* the available care he needs, information and
confidentiality.
2. Providing health care to all patients without
discrimination;
3. Working towards just health care policies such as the
delivery of minimum health care to all according to their
needs;
4. Avoiding giving undue burdens to individuals:
* abusing the poor by using them as learning
material.
 PARADIGMS OF HEALTH CARE RESOURCE ALLOCATION
1. Giga Allocation - global or trans-global in scope.
Health care allocations must cut across national boundaries and
must reach even locales that are far flung but are equally needful of
health services and health or life saving supports. Priority must be
given to:
* countries that experience pandemics and epidemics
* war torn areas where civilians are most vulnerable.
* refugee camps

Who are supposed to help:

* rich countries
* International health organizations, like:
* WHO
* Medecins Sans Frontieres (Doctors Without Borders)
* International Red Cross
 PARADIGMS OF HEALTH CARE RESOURCE ALLOCATION

2. Macro-Allocation - National in scope.

Congress allocating budget for a national
program.
* What resources (time, energy, money, etc.)
should be put into health care and into other
social good such as education, defense,
eliminating poverty, and improving the
environment?
 Macro-Allocation
Addresses the following:
a. what kind of good is health care?
b. What kind of ends does it serve?
c. Is there a right to some kind of health care?
d. Is there a social obligation to provide it?
e. If so, what is the minimum entitlement or obligation?

a. What kind of goals would the health system be

addressing and in what order?
b. Is the present distribution of resources between
broad categories such as health promotion, cure,
rehabilitation and crisis fair and efficient?
 Resource Allocation by Departments
Dept. of budget and Management
Departments 2007 2008 2009 2010
Level Rank Level Rank Level Rank Level Rank

Dep ED 137 1 146 1 158 1 185.5 1

DPWH 80 3 94 2 130 2 126.9 2
DND 93 2 51 4 56 4 57.7 4
DILG 72 4 54 3 63 3 65.4 3
DA 3.4 11 3.2 11 3.6 11 38 3
DOTC 20.9 5 22.8 5 25 6 16.6 5
DOH 3.5 6 16.3 6 27.9 5 30.6 6
DAR 11.3 8 2.5 7 7.9 9 20.8 8
JUDIC. 10.3 9 10.7 8 12.1 8 12 12
DFA 8.9 10 10.1 9 12.6 7 - -
COMEL 12.4 7 4.8 10 5.4 10 10.5 11
DSWD - - - - - - 15.3 10
 PARADIGMS OF HEALTH CARE RESOURCE ALLOCATION
3. Meso-Allocation: - Institutional in scope
Aspects of health care to be given priority in health resources. Deals with
decisions regarding how many of the health resources should go to which kind of
services
Questions to answer:
a. What kind of goals would the health system be addressing and in what order?
b. Is the present distribution of resources between broad categories such as health
promotion cure, rehabilitation, and crisis fair and efficient?
c. Should optometry, dentistry, ect. Be included?
d. On what basis are choices between possible types of healthcare to be made when
not all can be afforded?
e. What limits does the proper freedom of physicians, healthcare institutions insurers
and patients place on any scheme of just allocation of healthcare?
f. Is the provision of healthcare without regard for efficiency morally acceptable or
even required?
 Meso-Allocation

* Within the area of health, how much time, energy, money,

etc. should we allocate for prevention, cure, rehabilitation,
and how much for rescue and crisis medicine?
* Within either preventive or rescue medicine, who should
receive resources such as vaccines or organ transplants
when we cannot meet everyones needs?
* Can there be a rational basis for determining the total
healthcare spending? Or local budget? Or is this left to
politics and tradition?
* What principle of morality must be prescribed and
proscribed in the pursuit of more efficient allocation of
health care?
 Distributive Justice
3. Microallocation
Deals with decisions regarding how a scarce resource should be distributed among
individuals with competing claims to it. Which patients should have access to limited or
scarce resources. (distributive justice). Questions to answer are:
* Is the present distribution of healthcare resource between persons equitable and
efficient?
* What inequalities in healthcare distribution are morally acceptable?
* Who is to receive a particular treatment when it has to be rationed?
* Should factors such as religion, race, gender, age, ability to pay, regional and social
justice be important? Should we, for instance, prefer the young to the elderly?
* Should physicians try to do everything possible for their patients irrespective of the
needs of others?
* What principles of morality prescribe or proscribe what we can do in the pursuit of
more efficient micro-allocation of healthcare?
* In its starkest terms who is to be saved when not all can be?
 Distributive Justice

TRIAGE - derived from a French word, meaning

to pick or sort according to quality. Applied to
medicine, it refers to screening of patients to
determine their priority for treatment.
* It is a means of micro-allocation.
* It considers two principles:
 CRITERIA FOR EVALUATING ALLOCATION
1. Efficiency Criteria: (Formal Principle)
Dominant concept of efficiency Pareto Optimal
A change can be made that improves the condition of
some without worsening the condition of any, regardless of
who deserves the benefits conferred.
* scarce resources should not be wasted but should be
used impartially giving equal weights to the rights of all
whose lives are in jeopardy;
* it directs the triage decision maker to apply even-
handedly whatever rules are deemed right establishing.
1EVALUATING ALLOCATION 1. Efficiency Criteria
Principle of Utility:
Allocational states are to be ranked according to
how much net overall utility of a particular allocation
which can be calculated by summing up the net utility for
each individual affected. The net utility for each individual
is the sum of the benefits that allocation produces for
him/her, minus the costs to him/her. An allocation
maximizes utility if and only if the net, overall utility it
produces is at least as great as, if not greater than, the
net, overall utility produced by each of the feasible
alternative allocations.
1. Cost Benefit
2. Cost effectiveness
 EVALUATING ALLOCATION
2. Ethical Criteria - Rights to health care.
a. Principle of Justice:
1) Principle of greatest equal liberty
Each person is to have equal right to the most
expensive total system of equal basic liberties compatible
with a similar system of liberty for all.
b. Substantive or procedural principle
Social and economic inequalities are to be arranged so that they
are both:
a) To the greatest benefit of the least advantaged,
(Difference Principle) &
b) Attached to offices and positions open to all under
conditions of fair equality of opportunity.
(Principle of fair equality of opportunity)
EVALUATING ALLOCATION 2. Ethical criteria (cont.)
c. Principle of Beneficence
- the provision of at least some of the more important
forms of health care to the needy.
d. Principle of Utility: -(Rescher)
Greatest happiness principle.
- Those actions are right that produce the greatest
happiness for the greatest number of people.
Key concept Happiness
Actions are right in proportion as they tend to promote
happiness. Wrong as they tend to produce the reverse of
happiness. This principle focuses on the consequences of
actions.

Utility or usefulness of an action is determined by the extent to

which it produces happiness.
 Substantive or Procedural principle
The substantive or procedural principle proposes the rights
according to two Principles:
1. Formal Principle:
* Scarce resources should not be wasted but should be
used impartially giving equal weights to the rights of all
whose lives are in jeopardy;
* It directs the triage decision maker to apply even-handedly
whatever rules are deemed right establishing.
2. Substantive or procedural principle:
proposing the rights according to two groups of alternative
criteria:
 Substantive or Procedural principle
1) Utilitarian alternative:
a) Maximizing strategies to achieve the greatest amount
of good (the greatest good for the greatest number);
or minimizing strategies to reduce the amount of
potential harm;
* The medical success gives priority to those for
whom treatment has the highest probability of
medical success.
Problem - success - social worth, quality of life, etc.
* The principle of immediate usefulness gives
priority to the candidate who needs the greatest
immediate service than the larger group under the
circumstances;
 Substantive or procedural principle
* The principle of conservation gives priority to those
candidates who require proportionally, smaller
amount of resources and therefore more lives
would be saved.
* The parental role principle gives priority to those who
have the largest responsibility to dependents.
* Example: Father with dependent children.
* The principle of general social value gives priority to
those who believed to have the greatest social
worth leading to the good of society.
* Ex. Leader in the society vs. non-leader
 Substantive or procedural principle
2) Egalitarian Alternative:
a) Represent maintaining or resorting to the equality of
the person in need.
* The principle of saving no one gives priority to
no one because not all can be saved.
* There are not enough resources for all who need
them, then no one should receive any.
* The principle of medical readiness gives priority
to the candidates with the most pressing medical
needs.
* the candidates with most advanced disease
would receive the available resources.
 Substantive or procedural principle
* The principle of general neediness gives
priority to the most helpless or generally
neediest in an attempt to bring them as
nearly as possible to a level of well being
equal to that enjoyed by others.
* The principle of first come first served or
principle of queuing gives priority to those
who arrive first.
* The principle of random selection gives
priority to those selected by chance or
random.
* - lottery
 Substantive or procedural principle
Distribution of burden:
* It is common to find the rich paying for others health
care and the poor being subjects for health education
and research.
* Justice demands that giving undue burden to an
individual requires his informed consent.
EVALUATING ALLOCATION

CASE EXAMPLE NO. 1

An obstetrician delivers a child and finds that the
child suffers from severe birth defects. The childs
spine is open; feet and legs are deformed; there are
indications of severe brain damage.
EVALUATING ALLOCATION

POSSIBLE ACTIONS OF THE ACT UTILITARIAN:

1. Give the child only the ordinary treatment that

would be given to a normal child.
2. Give the child special treatment for its problem.
3. Give the child no treatment and allow it to die.
4. Put the child to death in a painless way.
EVALUATING ALLOCATION

Case Example No. 2

Lifeboat situation - some have to be sacrificed - who?

Others will have a chance of surviving. Each person in
the lifeboat has an equal worth. Sacrificing one for the
goods of the others will not be morally defensible.
 CRITERIA FOR ALLOCATION Of RESOURCES:
A. Criteria for inclusion (for selection of candidates):
1. Constituency member of the community?
2. Progress of science can new knowledge be
gained from the case?
3. Success is the treatment likely to be effective?
 CRITERIA FOR ALLOCATION Of RESOURCES:
B. Criteria for comparison (for selection of recipients):
1. Likelihood of successful treatment compared with
others in the group;
2. Life-expectancy of the person;
3. Persons family role;
4. Potential of the person in making future
contributions; and
5. Persons record or services or contributions.