Access to Non-reimbursed Expensive Cancer Treatments:A Justice Perspective

When the cost-effectiveness of newly approved cancer treatments is insufficient or unclear, they may not (immediately) be eligible for reimbursement through basic health insurance in publicly funded healthcare systems. Patients may seek access to non-reimbursed treatment through other channels, including individual funding requests made to hospitals, health insurers, or pharmaceutical companies. Alternatively, they may try to pay out of pocket for non-reimbursed treatments. While currently little is known of these practices, they run counter to a deeply held egalitarian ethos that is prevalent in many publicly funded healthcare systems. In this article, we investigate to what extent this ethos can be grounded in theories of justice, notably egalitarianism and prioritarianism. We argue that allowing out-of-pocket payments by patients themselves, in principle, is not unjust from the perspective of either of these theories, provided that it does not raise in-practice justice-based concerns, for instance by displacing more cost-effective care, to the detriment of other patients, or by failing to treat patients equally. In contrast, we conclude that the practice of making exceptions for individual patients by health insurers or healthcare providers does run counter to the justice-based requirements of equal treatment.</p

Can Voluntary Health Insurance for Non-reimbursed Expensive New Treatments Be Just?

Public healthcare systems are increasingly refusing (temporarily) to reimburse newly approved medical treatments of insufficient or uncertain cost-effectiveness. As both patient demand for these treatments and their list prices increase, a market might arise for voluntary additional health insurance (VHI) that covers effective but (very) expensive medical treatments. In this paper, we evaluate such potential future practices of VHI in public healthcare systems from a justice perspective. We find that direct (telic) egalitarian objections to unequal access to expensive treatments based on different ability to afford VHI do not stand up to scrutiny. However, such unequal access might lead to loss of self-respect among individuals, or loss of fraternity within society, rendering it more difficult for citizens to interact on equal moral footing. This would be problematic from a relational egalitarian perspective. Moreover, the introduction of VHI might turn out to have negative consequences for the comprehensiveness and/or the quality of the public healthcare services that are offered to all patients equally through basic health insurance. These consequences must be weighed against potential health gains and the value of liberty. We conclude that governments should be careful when considering the introduction of VHI in public healthcare systems.</p

Employers have a Duty of Beneficence to Design for Meaningful Work:A General Argument and Logistics Warehouses as a Case Study

Artificial intelligence-driven technology increasingly shapes work practices and, accordingly, employees’ opportunities for meaningful work (MW). In our paper, we identify five dimensions of MW: pursuing a purpose, social relationships, exercising skills and self-development, autonomy, self-esteem and recognition. Because MW is an important good, lacking opportunities for MW is a serious disadvantage. Therefore, we need to know to what extent employers have a duty to provide this good to their employees. We hold that employers have a duty of beneficence to design for opportunities for MW when implementing AI-technology in the workplace. We argue that this duty of beneficence is supported by the three major ethical theories, namely, Kantian ethics, consequentialism, and virtue ethics. We defend this duty against two objections, including the view that it is incompatible with the shareholder theory of the firm. We then employ the five dimensions of MW as our analytical lens to investigate how AI-based technological innovation in logistic warehouses has an impact, both positively and negatively, on MW, and illustrate that design for MW is feasible. We further support this practical feasibility with the help of insights from organizational psychology. We end by discussing how AI-based technology has an impact both on meaningful work (often seen as an aspirational goal) and decent work (generally seen as a matter of justice). Accordingly, ethical reflection on meaningful and decent work should become more integrated to do justice to how AI-technology inevitably shapes both simultaneously.</p

Ethics of access to newly approved expensive medical treatments:multi-stakeholder dialogues in a publicly funded healthcare system

Background: Due to rising healthcare expenditures, countries with publicly funded healthcare systems face challenges when providing newly approved expensive anti-cancer treatments to all eligible patients. In the Netherlands in 2015, the so-called Coverage Lock (CL), was introduced to help safeguard the sustainability of the healthcare system. Since then, newly approved treatments are no longer automatically reimbursed. Previous work has shown that as policies for access to CL treatments are lacking, patient access to non-reimbursed treatments is limited and variable, which raises ethical issues. The ethics of access were discussed in a series of multi-stakeholder dialogues in the Netherlands. Methods: Three dialogues were held in early 2023 and included physicians, health insurers, hospital executives, policymakers, patients, citizens, and representatives of pharmaceutical companies, patient and professional organizations. In advance, participants had received an ‘argument scheme’ featuring three models: 1) access based on third-party payment (e.g., by pharmaceutical companies, health insurers or hospitals) 2) access based on out-of-pocket payments by patients 3) no access to CL treatments. During the dialogues, participants were asked to discuss the merits of the ethical arguments for and against these models together, and ultimately to weigh them. The discussions were audio-taped, transcribed, coded, and thematically analyzed. Results: Generally, most stakeholders were in favour of allowing access–at least when treatments are clearly beneficial–to treatments in the CL. When discussing third-party payment, stakeholders favoured payment by pharmaceutical companies over payment by health insurers or hospitals, not wanting to usurp collective funds while cost-effectiveness assessments are still pending. Largely, stakeholders were not in favour of out-of-pocket payments, emphasizing solidarity and equal access as important pillars of the Dutch healthcare system. Recurrent themes included the conflict between individual and collective interests, shifting attitudes, withholding access as a means to put pressure on the system, and the importance of transparency about access to CL-treatments. Conclusion: Policies for access to non-reimbursed treatments should address stakeholders’ concerns regarding transparency, equal access and solidarity, and loss of potential health benefits for patients. Multi-stakeholder dialogues are an important tool to help inform policy-making on access to newly approved (too) expensive treatments in countries facing challenges to the sustainability of healthcare systems.</p

Remedial educationalists can do a lot for gender-diverse young people

Dit artikel bespreekt cruciale aspecten die ten onrechte niet besproken worden in ‘Uitdagingen in de zorg voor kinderen en jongeren met genderdiversiteit’ (Vrouenraets et al., 2022a). Namelijk, de mogelijkheid dat behandeling met puberteitsremmers en cross-sekse hormonen zorgt voor een belemmerde breinontwikkeling en verminderd seksueel functioneren, en de zorg dat puberteitsremmers juist zorgen voor het aanhouden van de genderdysforie doordat zij de ontwikkeling pauzeren. Ook bespreekt deze reactie het feit dat de grote stijging van het aantal jongeren met genderproblematiek vooral geboren tienermeisjes betreft. Verder een kritische bespreking van het gebruik van de begrippen ‘geboortegeslacht’ en ‘genderidentiteit’ door Vrouenraets et al. Dit alles mondt uit in een oproep aan orthopedagogen om zich te verdiepen in genderproblematiek zodat zij betreffende jongeren adequaat kunnen helpen zonder meteen te hoeven doorverwijzen

The moral case for intelligent speed adaptation

Speeding is a major problem in road safety. Intelligent Speed Adaptation (ISA) is a potential solution, but the moral acceptability of ISA has been called into question both in the popular media and in academic discussions. In this article, a moral case is made for making warning and limiting versions of ISA obligatory in all cars.The practice of car driving involves frequent speeding, which imposes unacceptable risks of harm on other road users. In this article, I argue that ISA can therefore be justified on the basis of the harm it prevents, as is the current criminalisation of speeding. I defend obligatory ISA against three objections. First, ISA is likely to introduce some additional risk for drivers.However, drivers should accept these risks to reduce the risks from driving for other parties to an acceptable level. Second, although limiting ISA reduces drivers’ options for moral agency and exercising self-restraint to some extent, this consequence is defensible.Third, accepting ISA does not commit us to accepting an entire range of other behaviour-regulating technologies