Transparency Trade-Offs: Priority Setting, Scarcity, and Health Fairness

This chapter argues that rather than viewing transparency as a right, we should regard it as a finite resource whose allocation involves tradeoffs. It then argues that those tradeoffs should be resolved by using a multi-principle approach to distributive justice. The relevant principles include maximizing welfare, maximizing autonomy, and giving priority to the worst off. Finally, it examines some of the implications for law of recognizing the tradeoffs presented by transparency proposals

Justice and Public Health

This chapter discusses how justice applies to public health. It begins by outlining three different metrics employed in discussions of justice: resources, capabilities, and welfare. It then discusses different accounts of justice in distribution, reviewing utilitarianism, egalitarianism, prioritarianism, and sufficientarianism, as well as desert-based theories, and applies these distributive approaches to public health examples. Next, it examines the interplay between distributive justice and individual rights, such as religious rights, property rights, and rights against discrimination, by discussing examples such as mandatory treatment and screening. The chapter also examines the nexus between public health and debates concerning whose interests matter to justice (the “scope of justice”), including global justice, intergenerational justice, and environmental justice, as well as debates concerning whether justice applies to individual choices or only to institutional structures (the “site of justice”). The chapter closes with a discussion of strategies, including deliberative and aggregative democracy, for adjudicating disagreements about justice

Sufficiency, Comprehensiveness of Health Care Coverage, and Cost-Sharing Arrangements in the Realpolitik of Health Policy

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care

Materials Design - Towards a Functionally Graded Electrical Conductor

In this study, we discuss functionally graded (FG) materials as pulsed electrical conductors. These conductors can be designed to be more efficient and longer lasting by applying numerical modeling tools. One focus is on limiting the thermal fatigue damage in conductors caused by very high temperatures that develop during pulse heating. We have quantified the effect of various grading functions on the pulsed Joule heating generated and the peak temperature experienced in the conductors of an electromagnetic launcher by using a 1D numerical code and a state of the art 3D coupled finite element code, EMAP3D. Because FG materials incorporate applications-tailored compositions, structures, and dimensions, smoothly graded properties in lateral and longitudinal cross sections are obtainable. The Solid Freeform Fabrication (SFF) processing approach allows for architectures with a series of important features. These features include the selective use of high efficiency conducting materials in the core, preconditioned conductor/structure interfaces, and built-in features for enhanced cooling where necessary.Mechanical Engineerin

Cost-Effectiveness in Animal Health: An Ethical Analysis

This chapter evaluates the ethical issues that using cost-effectiveness considerations to set animal health priorities might present, and its conclusions are cautiously optimistic. While using cost-effectiveness calculations in animal health is not without ethical pitfalls, these calculations offer a pathway toward more rigorous priority-setting efforts that allow money spent on animal well-being to do more good. Although assessing quality of life for animals may be more challenging than in humans, implementing prioritization based on cost-effectiveness is less ethically fraught

The Medical Cost Pandemic:Why Limiting Access to Cost-Effective Treatments Hurts the Global Poor

Medical innovation in developed countries like the U.S. leads to an ever-changing medical standard of care. This innovation frequently also brings rising costs. While these costs strain even the sizeable health care budgets of developed countries, imposing them on developing countries would be much more burdensome. Yet a variety of commentators and legal actors, such as the World Health OrganiZation and UNAIDS, have argued that the same standards of care must be provided worldwide, and have enforced mandates to that effect. Interpretations of the human rght to health as a tight to the highest attainable standard of health similarly advance the idea of a uniform worldwide standard of care and threaten to produce excessive costs. This Article has two objectives: first, to identif, describe, and criticize the legal mandates and norms that threaten to produce increased medical costs and reduced access to cost-effective care in developing countries, and, second, to suggest how we can prevent these outcomes

Law, Science, and the Injured Mind

Even while we widely recognize legal liability for physical injury, we frequently discount mental, emotional, and psychological injury. We disfavor tort liability for emotional distress; we prohibit prisoners from suing for purely psychological injuries; and we tax the damages victims of emotional injury receive even while leaving damages for physical injury untaxed. This Article argues that neuroscientific, psychological, and technological advances challenge our traditional ideas about the set of injuries that are possible and that merit legal redress. The Article goes on to contend that, while these advances challenge our traditional ideas, they do not inevitably overturn traditional distinctions within tort law. Rather, they present the task of critically examining and clarifying the normative foundations of distinctions we have historically taken for granted, and considering whether those distinctions survive that searching examination. Part I defines what I call “mind-dependent” injury and presents a set of test cases that challenge current legal approaches to injury and compensation, and discusses the neuroscientific, psychological, and technical underpinnings that moved these cases from science fiction into scientific reality. Part II reviews and examines several legal contexts that distinguish different types of injury and that provide legal remedies for some but not others. Part III considers normative justifications that might be offered for this differentiation, particularly in light of the new information we have. Ultimately, I argue that while new knowledge may require us to reevaluate the distinctions we traditionally have drawn, it does not completely undermine the possibility of normative distinctions between different types of injury. However, it challenges us to better defend those distinctions and ultimately should lead us to abandon the bifurcation between “emotional” and “physical” injuries in favor of a more nuanced approach

Evaluating the Legality of Age-Based Criteria in Health Care: From Nondiscrimination and Discretion to Distributive Justice

Recent disputes over whether older people should pay more for health insurance, or receive lower priority for transplantable organs, highlight broader disagreements regarding the legality of using age-based criteria in health care. These debates will likely intensify given the changing age structure of the American population and the turmoil surrounding the financing of American health care. This Article provides a comprehensive examination of the legality and normative desirability of age-based criteria. In the Article, I defend a distributive justice approach to age-based criteria. Rather than viewing age as a personal characteristic akin to race or religion, the distributive justice approach regards age as relevant in two ways to the distribution of an extremely valuable and widely desirable good, namely years of life. First, age establishes how much life someone has already enjoyed. Second, age indicates (though imperfectly) how much more life a person is likely to gain from treatment. A distributive justice approach also differentiates justifications grounded in distributive considerations — such as the higher predicted costs of treating older patients — from justifications grounded in animus or false stereotypes about older patients. Distributive justice approaches are therefore aligned with emerging animus-focused approaches to antidiscrimination law. The distributive justice approach I defend contrasts with two prevailing theoretical approaches to age-based criteria, which I call nondiscrimination and discretion. On the nondiscrimination approach, age-based criteria are viewed with great skepticism, analogous to race-based criteria: they are permissible — if at all — only when they advance the interests of disadvantaged groups, and they are subject to exacting judicial scrutiny. In contrast, the discretion approach, often identified with highly deferential versions of the “rational basis” test in equal protection law, views age-based criteria as broadly permissible, and defers to medical professionals’ judgments. Part I of the Article explains that age discrimination statutes, as well as the Equal Protection Clause and similar state constitutional provisions, permit the use of age-based criteria when those criteria have a rational grounding and do not appeal to animus or bias. They therefore leave room open for the use of a distributive justice approach. Part II goes on to argue that the conceptual underpinnings of antidiscrimination law do not support the enactment of new law, or the adoption of new interpretations of existing law, that would reject the use of age-based criteria. Part III proposes a detailed normative framework for the use of age-based criteria in health care, the lifetime justice approach, that considers the future life patients can gain from treatment and the past years of life they already have experienced. The lifetime justice approach also includes a principle of nonabandonment, which supports the continued provision of supportive medical care to older people in need. It then defends this framework against objections — most prominently, the objection that it disregards the moral equality of older people. Part IV applies the analysis offered in the earlier Parts to age-based criteria employed in various areas of medical practice and health policy, including the examples of transplantation and health insurance discussed at the outset

Reforming Age Cutoffs

This Article examines the use of minimum age cutoffs to define eligibility for social insurance, public benefits, and other governmental programs. These cutoffs are frequently used but rarely examined in detail. In Part I, I examine and catalogue policies that employ minimum age cutoffs. These include not only Medicare and Social Security but also other policies such as access to pensions and retirement benefits, eligibility for favorable tax treatment, and eligibility for discounts on governmentally provided goods and services. In Part II, I examine different rationales underlying eligibility and discuss the imperfect fit between these rationales and the use of age cutoffs, as well as the likelihood that cutoffs will exacerbate disparities and disadvantage those with atypical life plans. In Part III, I consider different ways that age cutoffs might be reformed. One, the most realistic, is the option proposed for Medicare: extending eligibility downward to people earlier in life. But other options exist as well. One option, often advanced by those further to the political left, would completely eliminate age-based eligibility cutoffs in favor of universal programs such as Medicare for All. Another option would adjust age cutoffs upward or downward based on factors like geography or occupation, rather than basing eligibility on a one-size-fits-all cutoff. Yet another would replace age-based eligibility cutoffs with eligibility time periods, which are limited but can be started and ended flexibly: people could give up some eligibility time later in life in order to receive access during earlier periods

Priority Setting, Cost-Effectiveness, and the Affordable Care Act

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA is neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry