Abstract

Given the inevitability of scarcity, should public institutions ration healthcare resources so as to prioritize those who contribute more to society? Intuitively, we may feel that this would be somehow inegalitarian. I argue that the egalitarian objection to prioritizing treatment on the basis of patients’ usefulness to others is best thought of as semiotic: i.e. as having to do with what this practice would mean, convey, or express about a person’s standing. I explore the implications of this conclusion when taken in conjunction with the observation that semiotic objections are generally flimsy, failing to identify anything wrong with a practice as such and having limited capacity to generalize beyond particular contexts.

Introduction

Given the inevitability of scarcity, how should public institutions ration healthcare resources? Who should receive priority of treatment when waiting-lists are drawn up? Which treatments should we subsidize, and for which ailments?

Two criteria are unavoidable: need and cost. Those whose medical needs are more urgent should be treated ahead of others, all else being equal. Cost is also an important factor, not because we value thrift for its own sake, but because sensitivity to cost ensures that we can help more people as opposed to fewer. Setting aside the use of tie-breaking criteria such as queue order^[1] or a fair lottery,^[2] what else, if anything, should we take into account when rationing healthcare?

One possibility would be to take into account the social utility of the potential beneficiaries: i.e. their instrumental value to others. When all else is equal, is there a case for prioritizing those who will ‘contribute more to society,’ so to speak? These contributions might take many forms, whether intended or unintended. A gifted surgeon may be uniquely skilled in performing difficult, life-saving operations. Higher earners may contribute more to the state’s tax revenues. Entrepreneurs may generate social benefits in the form of consumer surplus.^[3] Some people care for others who will suffer greatly without them. Some people are simply more altruistic or public-spirited, contributing more to the general good through volunteering, charitable giving, or activism. Giving such individuals priority could allow them to return to health sooner rather than later, ensuring that less of their valuable social contributions are lost. Obviously, no one would propose making this the unique deciding factor in allocating scarce medical resources. But might it be one factor to be weighed alongside whatever other criteria should be taken into account, capable of tipping the balance when all else is equal?

Surveys of public attitudes indicate widespread resistance to this idea. Skitka and Tetlock found that subjects on average rated prioritizing people on the basis of their contributions to the community as inappropriate, scoring this at -2.18 on a scale ranging from -8 (extremely inappropriate) to +8 (extremely appropriate).^[4] McKie and Richardson found that 87% of respondents strongly disagreed with giving people who contribute more to society higher priority for medical care via public health services.^[5]

What could be a defensible objection to rationing healthcare in this way? My aim in this paper is to help answer this question. I’ll argue that, insofar as there is a principled objection to prioritising people on the basis of their social utility, that objection is semiotic: i.e. it has to do with what this practice would mean or express. The objection derives in part from the significance we invest in healthcare provision in countries with comprehensive public health care systems, such as the United Kingdom, whose National Health Service (NHS) I treat as focal in my discussion. (I focus on the NHS partly because it is closest to home for me, but also because it is the archetype: the first public healthcare system in the Western world providing comprehensive coverage to everyone, free at the point of use.) As well as the social significance invested in healthcare, the semiotic objection that I discuss depends on the salience of meritocratic ideals in post-industrial societies, including their salient incompatibility with the ideal of communal caring underlying public health care provision in systems like the NHS.

I think this semiotic objection is the most plausible interpretation of the widely shared intuition that prioritizing treatment on the basis of patients’ usefulness to others is objectionable from the point of view of equality. Because semiotic properties are contingent and socially constructed, I also consider what my argument implies for how we should think about the ethics of prioritization considered more generally. To that end, I explore the implications of my argument for evaluating rationing decisions concerning life and health in the sphere of private philanthropy, where donors may wish to give preference to beneficiaries with greater instrumental value to others.

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