What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold.
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According to this study, responsibility was considered relevant by some, but explicitly controversial, and although other factors were considered important for how priorities actually are made, such as patient flow during different periods in time and how vocal patients are when demanding health care, these other factors were considered unfortunate side-effects.
They started this work already in Hasman et al. .
On this point I wholly agree with Hope, Østerdal and Hasman, although I prefer another terminology. They rest on Wiggins’ terminology, which makes a distinction between instrumental and categorical needs (and denies that categorical needs are instrumental) . I would say that the concept of need is always instrumental, but that some needs (according to principles of needs) have special moral force or give rise to legitimate claims. It should thus be made explicit that “categorical needs” is not a linguistic category, but a moral one. This said, I do not think there are any substantial differences between my account of needs and Hope, Østerdal and Hasman’s.
Or a minimally good health. I will return to this below.
Culyer and Wagstaff [10, p. 453] argue that principles of only answer the first of these questions and that we need an independent principle of distribution in order to (plausibly) answer the second. However, the task in this context is to see if it is possible to formulate a principle of need capable of answering both questions.
Although Hasman et al. [20, pp. 151–152] are careful to point out that the interpretations can be combined; a combination may be able to provide such an answer.
Everyone seems to agree on this point, see e.g. Culyer and Wagstaff [10, p. 434] and Hasman et al. [20, p. 146]. However, even if there agreement to this point put generally, it remains unclear what is to count as a benefit more specifically. In order to clarify this, a theory of good must be provided. More about this below.
Hope et al. [21, p. 478] seem to favour this version as well.
The question of the currency of principles of health care needs will be addressed below.
It should be “could be” rather than “is” because it is perfectly intelligible to talk about needing a health care intervention that runs a risk of not succeeding, which is a main point in .
Casal [5, pp. 307–308], I think, convincingly argues that egalitarianism does not imply what Frankfurt suggests.
Although Frankfurt cannot speak for all need theorists, he is one of the most influential (if not the most influential) and I know of no need theorist who has disputed his claims in this regard.
The writer that perhaps is most well-known as the advocate of prioritarianism is Arneson . However, he does not focus on prioritarianism primarily as a principle for prioritizing health care, which is the focus of this article.
Or QALYs, or life years, or whatever should be the currency of prioritisations (see below).
While still being at odds with traditional cost-benefit analysis, ascribing all improvements the same weight, since needs have absolute priority over non-needs and greater over lesser in the way adumbrated.
How much weightier the entitlements are still needs to be specified, of course. The less weight attached to improvements of the worse off, the more similar the suggestion becomes to utilitarianism or traditional cost-benefit analysis, the more weight the more similar the suggestion becomes to egalitarianism and the sickest first principle.
Besides that, the answer is very much in line with the suggested rule of prioritisation favoured by Hope et al. [21, pp. 476–477] themselves, i.e. rule (3).
Perhaps, so does Hope et al. [21, p. 479], since their main point is that principles of need must deal with the question of multiple intervention, rather than to argue for a specific solution.
Perhaps, then, Crisp  can be considered a pure hedonist, since he has argued that hedonism as a theory on human well-being should at least be taken more seriously.
For instance, Ohlsson , who repeatedly emphasises that we only have a right to that which is required to live a minimally acceptable life.
Of course, this would also require that much more needs to be said in defence of prioritarianism in general and as a defensible theory of prioritisation in health care in particular.
Arneson, R. (1999). Egalitarianism and responsibility. Journal of Ethics, 3, 225–247.
Braybrooke, D. (1998). The concept of needs, with a heartwarming offer of aid to utilitarianism. In G. Brock (Ed.), Necessary goods. Our responsibility to meet others’ needs (pp. 57–72). Lanham: Rowman & Littlefield Publishers, Inc.
Brock, D. W. (2002). Priority to the worse off in health-care resource prioritization. In R. Rosamond, M. P. Battin, & M. Silvers (Eds.), Medicine and social justice. Essays on the distribution of health care (pp. 362–372). New York: Oxford University Press.
Brock, G. (Ed.). (1998). Necessary goods: Our responsibility to meet others’ needs. Lanham: Rowman & Littlefield Publishers, Inc.
Casal, P. (2007). Why sufficiency is not enough. Ethics, 117, 296–326.
Copp, D. (1998). Equality, justice, and the basic needs. In G. Brock (Ed.), Necessary goods. Our responsibility to meet others’ needs (pp. 113–134). Lanham: Rowman & Littlefield Publishers, Inc.
Crisp, R. (2002). Treatment according to need: Justice and the British National Health Service. In R. Rosamond, M. P. Battin, & M. Silvers (Eds.), Medicine and social justice. Essays on the distribution of health care (pp. 134–143). New York: Oxford University Press.
Crisp, R. (2003). Equality, priority, and compassion. Ethics, 113, 745–763.
Crisp, R. (2006). Hedonism reconsidered. Philosophy and Phenomenological Research, 3, 619–645.
Culyer, A. J., & Wagstaff, A. (1993). Equity and equality in health and health care. Journal of Health Economics, 12, 431–457.
Daniels, N. (2008). Just health: Meeting health needs fairly. New York: Cambridge University Press.
Ekerstad, N., Löfmark, R., Andersson, D., & Carlsson, P. (2011). A tentative consensus-based model for priority setting: An example from elderly patients with myocardial infarction and multi-morbidity. Scandinavian Journal of Public Health, 39, 345–353.
Elhauge, E. (1994). Allocating health care morally. California Law Review, 82, 1449–1544.
Elmersjö, C.-Å., & Helgesson, G. (2008). Notions of just health care at three Swedish hospitals. Medicine, Health Care and Philosophy, 11, 145–151.
Frankfurt, H. G. (1987). Equality as a moral ideal. Ethics, 98, 21–43.
Frankfurt, H. G. (1998). Necessity and desire. In G. Brock (Ed.), Necessary goods. Our responsibility to meet others’ needs (pp. 19–32). Lanham: Rowman & Littlefield Publishers, Inc.
Frederick, S., & Loewenstein, G. (1999). Hedonic adaptation. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-being: The foundations of hedonic psychology (pp. 302–329). New York: Russell Sage.
Griffin, J. (1986). Well-being: Its meaning, measurement, and moral importance. New York: Oxford University Press.
Hamilton, L. A. (2003). The political philosophy of needs. New York: Cambridge University Press.
Hasman, A., Hope, T., & Østerdal, L. P. (2006). Health care need: Three interpretations. Journal of Applied Philosophy, 23, 145–156.
Hope, T., Østerdal, L. P., & Hasman, A. (2010). An inquiry into the principles of needs-based allocation of health care. Bioethics, 9, 470–480.
Howard, D. H. (2001). Hope versus efficiency in organ allocation. Transplantation, 72, 1169–1173.
Miller, D. (1976). Social justice. Oxford: Clarendon Press.
Mårtensson, J., Carlsson, P., Arvidsson, E., Frank, L., Lindström, K., & Borgquist, L. (2006). Experiences of, knowledge about and attitudes towards prioritizations—an interview study with personnel from primary care (In Swedish: Erfarenhet, kunskap och inställning till prioriteringar—en intervjustudie med personal från primärvården). CMT Rapport 2006:3. Linköping: University of Linköping. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-34033. Accessed 24 October 2012.
Nordenfelt, L. (1987). On the nature of health. Dordrecht: D. Reidel Publishing Company.
Nordenfelt, L. (2003). On the evolutionary concept of health: Health as natural function. In L. Nordenfelt & P.-E. Liss (Eds.), Dimensions of health and health promotion (pp. 37–56). Amsterdam: Rodopi Press.
Nussbaum, M. (1998). Aristotelian social democracy. In G. Brock (Ed.), Necessary goods. Our responsibility to meet others’ needs (pp. 135–156). Lanham: Rowman & Littlefield Publishers, Inc.
Nussbaum, M. (2000). Women and human development: The capabilities approach. New York: Cambridge University Press.
Ohlsson, R. (1995). Morals based on needs. New York: University Press of America Inc.
Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. Lancet, 373, 423–431.
Schramme, T. (2007). The significance of the concept of disease for justice in health care. Theoretical Medicine and Bioethics, 28, 121–135.
Swedish Health Care Act. (1982:763), 2 §.
Swedish Government Bill Prop. (1996/97:60). Prioritizations within health care (Prioriteringar inom hälso-och sjukvården). Stockholm: Department of Health and Welfare.
Wakefield, J. C. (1992). The concept of mental disorder. On the boundary between biological facts and social values. American Psychologist, 4, 373–388.
Walzer, M. (1983). Spheres of justice: A defence of pluralism and equality. New York: Basic Books.
Wiggins, D. (1985). Claims of need. In D. Wiggins (Ed.), Needs, values, truth (3rd ed., pp. 1–58). New York: Oxford University Press.
Wiggins, D. (1998). What is the force of the claim that one needs something? In G. Brock (Ed.), Necessary goods. Our responsibility to meet others’ needs (pp. 33–56). Lanham: Rowman & Littlefield Publishers, Inc.
Williams, B. (1962). The idea of equality. In P. Laslett & W. G. Runciman (Eds.), Philosophy, politics, and society (pp. 110–131). Oxford: Basil Blackwell.
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Juth, N. Challenges for Principles of Need in Health Care. Health Care Anal 23, 73–87 (2015). https://doi.org/10.1007/s10728-013-0242-7