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Challenges for Principles of Need in Health Care


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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  1. 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.

  2. They started this work already in Hasman et al. [20].

  3. 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) [36]. 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.

  4. Although it is sometimes argued that there are non-instrumental statements of need [36, 23, ch IV sec 2]. However, there are, I think, convincing arguments to the contrary [18, p. 237, note 7, 29, pp. 96–98].

  5. Or a minimally good health. I will return to this below.

  6. 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.

  7. 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.

  8. 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.

  9. Hope et al. [21, p. 478] seem to favour this version as well.

  10. The question of the currency of principles of health care needs will be addressed below.

  11. 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 [21].

  12. Casal [5, pp. 307–308], I think, convincingly argues that egalitarianism does not imply what Frankfurt suggests.

  13. 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.

  14. The writer that perhaps is most well-known as the advocate of prioritarianism is Arneson [1]. However, he does not focus on prioritarianism primarily as a principle for prioritizing health care, which is the focus of this article.

  15. Or QALYs, or life years, or whatever should be the currency of prioritisations (see below).

  16. 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.

  17. 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.

  18. 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).

  19. 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.

  20. Others use the term autonomy [6] or human functioning [18] with similar connotations.

  21. Perhaps, then, Crisp [9] 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.

  22. For instance, Nordenfelt [25] has argued that health is something other than merely absence of disease, while Schramme [31] disagrees.

  23. Again, Nordenfelt [25] has defended the first position and Schramme [31] the second position.

  24. For instance, Ohlsson [29], who repeatedly emphasises that we only have a right to that which is required to live a minimally acceptable life.

  25. 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.


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Correspondence to Niklas Juth.

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Juth, N. Challenges for Principles of Need in Health Care. Health Care Anal 23, 73–87 (2015).

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  • Distributive justice
  • Health
  • Health care need
  • Prioritarianism
  • Sufficientarianism
  • Well-being