MANCEPT: Health Thresholds

Thresholds are ubiquitous in healthcare.

1. Decision-making bodies such as the UK’s NICE set cost-effectiveness thresholds for public funding of health interventions;
2. Treatment decisions in resource-scarce systems make use of thresholds in deciding whom to treat (e.g., whether individuals with mental health conditions are “sick enough” for in-patient/home treatment) or whom not to treat (e.g. the use of a ‘grey zone’ in neonatal gestational age (Wilkinson 2017);
3. While the idea of a ‘decent minimum’ of healthcare benefitted from sustained attention some years ago, recent work on sufficientarian justice has only recently begun to be applied specifically to healthcare (Fourie and Rid 2016).

These and other thresholds raise important pragmatic and theoretical questions, which this workshop will explore. Topics to cover could include, but are not limited to:

The normative status of thresholds

Are (some) healthcare thresholds justified at a fundamentally normative level, or are they morally arbitrary constructs that must be justified (if at all) on pragmatic grounds? If thresholds have some fundamental normative significance, do they mark the point where the relevant good will no longer have (the same) value for the recipient, or a point where although recipients could still benefit, they are no longer entitled to further benefit following Nielsen (2019)? If they are arbitrary, how can they be justified to those who fall just on the wrong side of them, and are, e.g., refused access to care which might benefit them?

The role of thresholds

In sufficientarian political theory, there is disagreement about the role that one or more sufficientarian thresholds might play. Do thresholds mark a point above which there are no concerns of justice at all? Where different distributive principles come into play? Or a point below which individuals’ claims have special but not absolute priority? Should we understand healthcare thresholds in sufficientarian terms at all, or in some other terms, such as a version of ‘limitarianism’? (Robeyns 2019) Might the appropriate normative role of a threshold depend on details of the clinical or resource context?

Thresholds and disability

Some approaches to thresholds rely on the idea of flourishing or humanity which may exclude individuals with disabilities, particularly severe cognitive disabilities (Kittay and Carlson 2010). Do the claims of individuals with cognitive disabilities require a more pluralist or individualist approach? What is required for healthcare systems to function while treating such claims appropriately?

The political justification of thresholds

Healthcare decision-making must operate within a pluralist society, where different groups and individuals have competing values and priorities, both within healthcare and in trade-offs with other goods. If we are to use thresholds in healthcare, who should set them? Does it depend on the role the threshold plays? What role should (medical; economic; ethical and political) experts play? What about patient groups? Or the ‘general public’? If threshold-setting should be somewhat democratic, should majority opinion always win, or should thresholds be subject to stricter standards of public justification (Vallier 2018)?