MODULE VII: JUSTICE AND ALLOCATION OF SCARCE RESOURCES

The fair and equitable division of scarce good and services is usually considered an issue
of distributive justice. The requirement of formal justice, as attributed to Aristotle, are that is
distribution, equals must be treated equally, and unequal must be treated unequally. Formal
justice does not attempt to provide any criteria for the determination of equality and does not
state in what respect equals are to be treated, except they must be treated equally. Under the
formal justice any criteria can be used—age, sex, marital status, land ownership—provided
criteria were applied equally in all similar cases. Principle that specify relevant characteristics or
morally relevant criteria in regard to treatment are said to be material principles and from the
basis of material justice.
Society has used a wide variety of criteria for the distribution of resources. The least
ethically acceptable rationing criteria would be those that placed individuals or group
disadvantaged by poverty or incapacitated by illness in the lowest priority. Discrimination
between classes of people is morally justified only if properties of the groups are moral
responsibility of the group members or if they are sort of properties that can be overcome. The
attempt to treat all equally is formulated in the fair opportunity rule, which hold that no persons
should be granted social benefits on the basis of underserved disadvantage and no person should
be denied social benefits on the basis of underserved advantages. Under the fair opportunity rule,
sex, race, IQ, nationality origin, sexual preference, and social status would be ruled out as
relevant for material justice in the moral distribution of health care.

Common Methods for Distribution of Goods and Resources

● To each person an equal share
● To each person according to need
● To each person according to merit
● To each person according to contribution
● To each person according to effort
● To each person according to social worth

Micro- and Macro-Allocation of Health Care

Macro-allocation is usually the province of congress, state legislatures, insurance

companies, private foundations, and health organization as society attempts to determine how
much should be expended and what kind of goods and services will be made available. Macro-
allocation problems are demonstrated in such questions as: What kinds of health care would be
available? Who will get it and what basis? How will the costs be distributed? Who will deliver
the services? Who control these issues? Micro-allocation is the more personal determination of
who will receive scarce resources, such as intensive-care beds, advanced technology, or organ
transplants.
Two-Tier System and the Decent Minimum

One interesting position in regard to macro-allocation of health care goods and service is
of the two-tier system. Under this approach, everyone would be guaranteed coverage for basic
care and catastrophic health needs. This coverage of decent minimum of care would be
distributed on the basis of need, with everyone being ensured equal access. The second tier,
based on the ability to pay, would provide expanded and perhaps better care at private expense.
This blending of utilitarian and libertarian values may have real appeal as we attempt to provide
services for poor or disadvantaged citizens.

Micro-Allocation Several examples point t the difficulties encountered in micro-

allocation. In 1842, the American ship the William Brown struck an iceberg near Newfoundland
and began to sink. The crew and half of the passenger manage to leave the vessel in two
overcrowded lifeboats. After twenty-four hours, one of these vessel began to founder in the high
seas. Some of the passengers had to leave the lifeboat or all would die. The decision was to give

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priority to married men and all women. Under this system, fourteen single men were thrown
overboard, and two young women, sister of men in the water, chose to join them.
Upon their return to Philadelphia, all of the crew left the area—with the exception of
Seaman Holmes. Holmes was brought before the court to face trial for murder of the individuals
thrown overboard. The defense argued that the action were needed to save lives and that there
were no volunteers to enter the water. The defense justified the decision using the utilitarian
value of keeping families intact and the duty-oriented value of protecting the helpless females.
The court, using a different duty-oriented approach based on the sacred nature of life, stated that
a lottery would have been the only ethical method, and Seaman Holmes was convicted. This
view that a random selection among equals is the best approach has been forcefully restated in
the works of the ethicist Paul Ramsey:
The equal right of every human being to live, and not relative personal or social worth,
should be the ruling principle. When not, all can be saved and all need not to die, this
ruling principle can be applied best by random choice among equals
.
Lifeboat ethics, which taje their title from this episode, have often been used to describe
the situation of the industrialized Western nations and their relationship to much of the Third
World. With seemingly more of the world’s population living in conditions of famine and
pestilence, we can see analogy an analogy to lifeboat afloat on human sea of tragedy. Who shall
be saved from drowning, and what will be the criteria for our selection?
Similar in some aspect to lifeboat ethics is the process of triage. This process of
allocation scarce resources has been commonly practiced and justified in the case of war or
disaster. When used in time of war, the practice is usually to divide the wounded into three
groups. The first grounded is the walking wounded, who have received superficial wounds that
require minimal care. These soldiers are often ignored during the first few minutes or patched up
immediately if they can be sent back to the battlefield. The second group are the fatally
wounded, who are given available narcotics to ease the pain but are not treated for the injuries.
The third group is the seriously wounded. These are treated immediately, as their care will bring
about the highest percentage of survivors.
Another form of triage is that used in disaster such as earthquakes. In situation such as
this, firefighter and public safety personnel may be placed at the head of the line so that they can
quickly return to duty and help others. In disaster triage, the most seriously injured may be
placed at the end of the line, id their care would compromise the work of rescue. In this case, a
form of “rule utilitarianism” would guide the decision, requiring the greater good for the greater
number, instead of the particular good of the patient at hand.
Similar principle to triage are used in the allocation of ICU beds when there is
overcrowding. One of the criterion used are very similar to those employed in the battlefield is
that of best prognosis or medical utility. Which patient is most likely to survive? It is from this
criterion that question emerge as to whether patient with DNR order truly belong to intensive, in
fact we do not intend to treat them intensively. A second common principle is social
utility—which patient has greatest social worth. However, both social utility and medical utility
have inherent problems. Medical utility or best prognosis, is often difficult to assess; and the
social utility, or social value decisions, seems to invite problems of racism, ageism, sexism, and
bias against the retarded or mentally ill. Perhaps the most neutral system is that of “first come,
first served”, or random selection that treat all patients as essentially equal.

THEORIES OF JUSTICE

Egalitarian Theories
Egalitarian theories emphasize equal access to goods and service. Egalitarian thinkers
believe that an affluent society must find way to provide universal health care to all its citizens. It
is within the egalitarian end of spectrum that the advocates of the right to health care are most
comfortable. Egalitarian proponents often point to socialistic universal access health care
systems, In most extreme form, these thinkers hold that any deviation from absolute equality in
distribution is unjust. Some take romantic view to health care problem and fail to take into
account the capacity of resources relative to human wants. When confronted with inevitable gap
of tragedy between available resources and human desires, the romantics often point out to

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human error such as waste, fraud, or a stingy political system, claiming that these are the real
barriers, thus protecting their illusion that no scarcity exists.

Utilitarian theories
These theories emphasize a mixture of criteria so that public utility is maximized. Public
utility is defined in the phrase “the greatest good for the greatest number.” Utilitarian generally
accept political planning and intervention as methods of redistributing goods and wealth to bring
about public utility.

Libertarian Theories
Libertarians emphasize personal rights to social and economic liberty. They are not as
concerned with, nor do they outline the requirements of, how the material goods are to be
distributed, only that the choice of allocation system be freely chosen. Our free market system
operates on the material principle of ability to pay usually invokes some form of libertarianism
justification.

Enabling Lesson Learning Outcome

You, as the learner, are expected to do the following:
1. contrast between formal and material justice
2. differentiate micro-allocation and macro-allocation as they relate to health
3. explain how fair opportunity rule relates to material justice
4. differentiate between the theoretical positions of utilitarianism, egalitarianism,
and libertarianism as they relate to distributive justice.
5. justify a case analysis

Read: It is a busy night at the emergency roomDesired

and theLesson Learning
ICU is down Outcome:
to two open beds. At two in
Utilize ethical
the morning, the ambulance pulls up to the emergency room door with three reasoning and
patients whodecision-making
had in
performing nursing intervention during nursing
been involved in a shoot-out. Apparently, a sting operation had gone bad during a drug deal, and ethical dile
Protect Patients
an undercover policeman and two drug dealers had been wounded. Right
All three andappear
men Obligation
to be in
critical condition and needs the services of ICU.
1. Consider how you would decide which of the three men receive the ICU beds?

1.1 Briefly answer the question using the principle of formal justice.
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KEY CONCEPT: Formal and Material Justice; micro-macro allocation of sc
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Enabling Lesson Learning Outcome I, II and V: (1) Contrast between
1.2 Briefly answer the question using
justice (2) the principle of
differentiate material justice.
micro-allocation and macro-allocation as they relate t
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case
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 _____________________________________________________________________
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Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points

Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
or ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrates ethical
responsibility to considers ethics or indicates that the that the student is and professionalism
work in an professionalism as student does not aware that he/she in his/her response/s
ethical and he/she consider fully understand have responsibility to the case study
professional the case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.

2. Given that the policeman was hurt in the line of duty, is this a time when social utility is
an appropriate method for micro-allocation resources? Briefly and ethically support your
answer.
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________

Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points

Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the the Code of Ethics the code of ethics or
or ethical aware of the Code Code of Ethics or or ethical ethical principles
principles of Ethics or ethical principles principles and use and use it routinely
ethical principles but is not making it to when faced to work in a

4
 use of it as he/she with a potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study demonstrate ethical
responsibility consider ethics or indicate that the indicates that the and professionalism
to work in an professionalism as student do not student is aware in his/her
ethical and he/she consider fully understand that he/she have response/s to the
professional the case study what it means to responsibility to case study
manner work in an ethical work in an ethical
and professional and professional
manner manner.

3. Given that the policeman was hurt in the line of duty, is this an appropriate time to use
the method for macro-allocation resources? Briefly and ethically support your answer
Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points
Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
or ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrate ethical
responsibility to consider ethics or indicate that the that the student is and professionalism
work in an professionalism as student do not aware that he/she in his/her response/s
ethical and he/she consider fully understand have responsibility to the case study
professional the case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.

Read: It is a busy night at the emergency room and the ICU is down to two open beds. At two in
the morning, the ambulance pulls up to the emergency room door with three patients who had
been involved in a shoot-out. Apparently, a sting operation had gone bad during a drug deal, and
an undercover policeman and two drug dealers had been wounded. All three men appear to be in
critical condition and needs the services of ICU.
1. Given that the policeman was hurt in the line of duty, use the principle of material justice
common method for distribution of goods and services to prioritize his care. Briefly and
ethically support your answer.
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KEY CONCEPT: Material Justice

Enabling Lesson Learning Outcome III and V. (3)Explain how fair oppo
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Rubric

Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points

Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
or ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrates ethical
responsibility to considers ethics or indicates that the that the student is and professionalism
work in an professionalism as student do not aware that he/she in his/her response/s
ethical and he/she consider fully understand have responsibility to the case study
professional the case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.

Read: You have a four-bed intensive care unit and seven patients who need a bed. The following
is a short description of the seven patients.
Patient’s description:
1. Mr. Jones, a 75-year-old pulmonary patient with chronic emphysema. He is retired and
has DNR order.
2. Ms. Cho, a 27-year-old hemophiliac patient with AIDS contracted from a transfusion of
contaminated blood.
3. Mr. Roger, a 65-year-old retired general with congestive heart failure
4. Mrs. Rankin, a 52-year-old housewife, an alcoholic with acute heart failure.
5. Me. Reubin, a 23-year old college student in a persistent coma following an
alcoholic/drug overdose at a party.
6. Carlon Child, a 12-year-old with head trauma and in a persistent vegetative state,
following a beating by stepfather.
7. Joey Scoy, a severely retarded Down syndrome teenager with a mental age of five years.
He is suffering from aspiration pneumonia.
Select four patients (using the number assign) base on the following criteria. You cannot select
KEYasCONCEPT:
on the basis of first come, first served, they showed up at your door at exactly the same time.
Enabling Lesson Learning Outcome IV and V. (4) Differentiate betw
Briefly and ethically support your answer
positions of utilitarianism, egalitarianism, and Libertarian (5) Justify a case
d lib 6 i i h l di ib i j i
 1. Base on the Principle of Egalitarian
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2. Base on the Principle of Utilitarianism
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3. Base on the Principle of Libertarian
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_____________________________________________.

Rubric:
Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points
Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
or ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem

7
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrate ethical
responsibility to consider ethics or indicate that the that the student is and professionalism
work in an professionalism as student do not aware that he/she in his/her response/s
ethical and he/she consider fully understand have responsibility to the case study
professional the case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.
Source: Ethic of Health care
A guide for Clinical Practice
Fourth Edition
Raymond S. Edge
J. Randall Groves