Norman Daniels

Harvard University | Harvard · Department of Global Health and Population

In 2013 the American Psychiatric Association (APA) published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Even before publication, DSM-5 received a torrent of criticism, most prominently over removal of the "bereavement exclusion" for the diagnosis of major depression. We argue that while the APA can claim...

Expensive treatments for common conditions are unaffordable for most health system, even if they are cost effective. Julian Urrutia and colleagues examine how countries could respond to WHO making direct acting antivirals essential medicines New direct acting antiviral drugs to treat hepatitis C infection are highly effective. Sofosbuvir and velp...

There has been much discussion of resource allocation in medical systems, in the United States and elsewhere. In large part, the discussion is driven by rising costs and the resulting budget pressures felt by publicly funded systems and by both public and private components of mixed health systems. In some publicly funded systems, resource allocati...

The authors would like to correct the name of the third author in this paper to Julian Urrutia. The original article was published in Int J Health Policy Manag. 2016;5(1):1–3

Background Understanding the motivations and perspectives of providers in following guidance and evidence-based policies can contribute to the evidence on how to better implement and deliver care, particularly in resource-constrained settings. This study explored how providers’ attitudes and behaviors influenced the implementation of an interventio...

Priority setting, whether in health or investments in other goods, is required whenever a society must provide for the needs and welfare of its population and resources are limited, which is always. Since health is only one good among many that a society must provide, however important people claim it is, resources for it are always limited. Yet di...

Healthcare technology assessment (HTA) aims to support decisions as to which technologies should be used in which situations to optimize value. Because such decisions will create winners and losers, they are bound to be controversial. HTA, then, faces a dilemma: should it stay away from such controversies, remaining a source of incomplete advice an...

All societies face the need to make judgments about what interventions (both public health and personal medical) to provide to their populations under reasonable resource constraints. Their decisions should be informed by good evidence and arguments from health technology assessment (HTA). But if HTA restricts itself to evaluations of safety, effic...

A moral right to health or health care is a special instance of a right to fair equality of opportunity. Nation-states generally have the capabilities to specify the entitlements of such a right and to raise the resources needed to satisfy those entitlements. Can these functions be replicated globally, as a global right to health or health care req...

—A moral right to health or health care, given reasonable resource constraints, implies a reasonable array of services, as determined by a fair deliberative process. Such a right can be embodied in a constitution where it becomes a legal right with similar entitlements. What is the role of the courts in deciding what these entitlements are? The thr...

Given the cost constraints of the European health-care systems, criteria are needed to decide which genetic services to fund from the public budgets, if not all can be covered. To ensure that high-priority services are available equitably within and across the European countries, a shared set of prioritization criteria would be desirable. A decisio...

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision...

Since 2010, more than seventy countries have requested policy support and technical advice from the World Health Organization (WHO) for how to move toward universal health coverage (UHC). As part of the response, WHO set up a Consultative Group on Equity and Universal Health Coverage. This final report by the Consultative Group addresses the ke...

Most people are concerned about international health inequalities and find them unjust. At the same time, we lack global institutions that can effectively act to reduce these health inequalities, which have various sources. Accordingly, the concern about health inequalities does not by itself support some one of the competing theories of global jus...

Background In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing individual and population health outcomes. Methods In settings with two available ART regimens, we asses...

Supplemental methods and results.

In resource-limited settings, successful HIV treatment scale-up has been tempered by reports of funding shortfalls. We aimed to determine the priorities, including ethical considerations, of decision makers for HIV antiretroviral programs. We conducted qualitative interviews with 12 decision makers, identified using purposive sampling. Respondents...

People tend to contribute more—and think they have stronger obligations to contribute more—to rescuing an identified victim rather than a statistical one. Indeed, they are often disposed to contribute more to rescuing a single identified victim than a greater number of statistical ones. By an “identified victim,” I mean Terry Q., lying injured in t...

Without focusing on the details of specific health systems, this chapter considers what we owe each other with regard to promoting and restoring health and what this means for the balance between prevention and treatment. I argue that we have robust obligations both with regard to prevention and treatment, though the specifics of what is owed depen...

In this essay we argue that the concept of affordable health insurance is rooted in a social obligation to protect fair equality of opportunity. Specifically, health insurance plays a limited but significant role in protecting opportunity in two ways: it helps keep people functioning normally and it protects their financial security. Together these...

Disease simulation models of the health and economic consequences of different prevention and treatment strategies can guide policy decisions about cancer control. However, models that also consider health disparities can identify strategies that improve both population health and its equitable distribution. We devised a typology of cancer disparit...

A range of policies in the US and abroad attempt to assign individual responsibility for health, sometimes sanctioning failure to take individual responsibility, sometimes assigning accountability for responsibility in other ways. This chapter argues that the primary responsibility for health and health care is social, but that health promotion req...

Purpose: In resource-limited settings, increasing numbers of HIV-infected individuals are initiating ART and remaining in care longer. Many HIV budgets, however, are flattening or decreasing. By modeling a policy of discontinuing ART after treatment failure, we aimed to highlight trade-offs among competing policy goals of optimizing individual heal...

Is There a Right to Health Care?What Does a Right to Health Care Include?Choice or Consent and the Exercise of our Right to Health CareReferences

History Of A Controversy Should we focus on human capabilities, as Sen (1980, 1999) and Nussbaum and Sen (1993, 2000) propose, albeit with differences in their views, or on Rawls's (1971, 1993) account of primary social goods, when we think about health and health policy? In this paper I argue that there is more convergence than difference between...

Three key ethical issues should inform the broader debate about health reform: (1) Why pursue universal coverage? (2) Why is cost containment an ethical issue? (3) What is fairness in financing? After examining these issues, we conclude that the core ethical values underlying each of these goals-including expanding opportunity, sharing burdens equa...

Socioeconomic inequality has been associated with higher levels of morbidity and mortality. This study explores the role of absolute and relative deprivation in predicting late-life depression on both individual and country levels. Country- and individual-level inequality indicators were used in multivariate logistic regression and in relative inde...

In the preceding article, Weinstein et al. [1] explain the QALYconcept, its methods, and their underlying assumptions. Anumber of interesting themes for discussion arise from thisfactual presentation. We restrict ourselves to addressing fourissues that we deem particularly challenging.As a general background for our selection of issues, we reit-era...

This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and...

Commentators on Uwe Reinhardt's Tanner Lecture. The Tanner Lectures are a collection of educational and scientific discussions relating to human values. Conducted by leaders in their fields, the lectures are presented at prestigious educational facilities around the world. Tanner Lectures are funded through the generosity of the late Professor of P...

Most people responsible for setting priorities in health have considerable expertise relevant to deciding how to use resources effectively and the kinds of improvements that should be emphasized. Most are also concerned with distributing improvements equitably. Accordingly, they often invoke human rights or principles of distributive justice to leg...

This paper is based on research funded by the National Center for Health Services Research, Grant Number HS 03097, OASH. I am indebted to May Anne Bailey, Hugo Bedau, Christine Bishop, Dan Brock, Allen Buchanan, Leslie Burckholder, Joshua Cohen, Daniel Dennett, David Gauthier, Allan Gibbard, and Daniel Wikler for helpful discussion. This version wa...

The Panel on Integrating Cost-Effectiveness Considerations into Health Policy Decisions, composed of medical and pharmacy directors at public and private health plans, was convened to (1) explore the views of health plan purchasers about cost-effectiveness analysis (CEA) and (2) to develop a strategic plan for policymakers to address obstacles and...

Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists, and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into pra...

When are international inequalities in health unjust? This discussion falls short of providing an answer because we remain unclear just what kinds of obligations states and international institutions and rule-making bodies have regarding health inequalities across countries. To arrive at a real answer, we must carry out the task of explaining the s...

The central idea behind this book is that we lack consensus on principles for allocating medical resources, and in the absence of such a consensus we must develop and rely on a fair decision-making process for setting limits on health care. The authors provide an analysis of the current situation, reviewing typical solutions, before describing thei...

In the United States, deficiencies in health care quality, value, and access are well documented.1- 5 Recent trends such as pay-for-performance, increased patient cost-sharing, and state health insurance expansion programs may represent important reforms and even a “tipping point” for the US health care system.6,7 Nevertheless, experts have caution...

HASTINGS CENTER REPORT 3March-April 2007 Bioethics, I argued nearly a decade ago, has been veryslow to respond to the profound insights into popula-tion health and its distribution that have emerged from the social epidemiology literature of the last several decades.1 Strikingly, that literature shows that universal coverage medical systems do not...

In this new book by the award-winning author of Just Healthcare, Norman Daniels develops a comprehensive theory of justice for health that answers three key questions: What is the special moral importance of health? When are health inequalities unjust? How can we meet health needs fairly when we cannot meet them all? Daniels’ theory has implication...

Bioethics' traditional focus on clinical relationships and exotic technologies has led the field away from population health, health disparities, and issues of justice. The result: a myopic view that misses the institutional context in which clinical relationships operate and can overlook factors that affect health more broadly than do exotic techn...

The Federal Trade Commission/Department of Justice 2004 report Improving Health Care: A Dose of Competition appeals to efficiency arguments in promoting a wide range of health care market reforms. But the market-based reforms discussed in Improving Health Care are not simply neutral with regard to equity in access to services; they are likely to ha...

Efforts to transform health systems constitute social experiments on a population. Like clinical research, they deploy measures that are unproven in the context of the reform, and they often impose significant risks on some people in order to achieve a social goal: the improvement of health delivery. The rationale for proactively evaluating clinica...

The Benchmarks of Fairness instrument is an evidence-based policy tool developed in generic form in 2000 for evaluating the effects of health-system reforms on equity, efficiency and accountability. By integrating measures of these effects on the central goal of fairness, the approach fills a gap that has hampered reform efforts for more than two d...

In this essay we examine three competing causal interpretations of racial disparities in health. The first approach views race as a biologically meaningful category and racial disparities in health as reflecting inherited susceptibility to disease. The second approach treats race as a proxy for class and views socioeconomic stratification as the re...

All health systems, whether public or private or rich or poor, limit access to medical care. Occasionally, this limit setting takes the form of a public melodrama focused on the "heartless" denial by an "evil" insurer or bureaucrat of a "last-chance" treatment for a dying patient. Such drama leaves little room for the limit setter to claim moral au...

social learning about fair limits Pharmacy benefits have become the problem child of healthcare coverage. Rising demand, increased utilization, and surging costs terrified large purchasers even when the economy was good. Limiting access to some drugs, whether through restrictive coverage policies or tiered co-pays, has often been met with patient a...

Pharmaceuticals are a crucial component of modern psychiatry. To achieve broad access to effective medications, we as a society must start by embracing what to many will seem like a paradox: no limits, no access. To promote robust pharmacy benefit programs, society must learn how to establish drug coverage policies with limits that are clinically i...

The central idea for this book is that we lack consensus on principles for allocating resources and in the absence of such a consensus we must rely on a fair decision-making process for setting limits on health care. The authors characterize key elements of this process in a variety of health care contexts where such decisions are made- decisions a...

pharmacy benefits (2). The template argues that for drugs that have comparable profiles of risk and benefit, it is ethically justifiable to favor the least costly alternative as long as individual patients are protected by a fair and efficient process for dealing with exceptions. This column, the second in a series describing strategies for managin...

The Surgeon General’s landmark 1999 Mental Health Report gives consumers and their families a prominent place in the mental health system as advocates, participants in overseeing policy, and providers of services (1). Managed care programs, when adequately funded and wisely managed, can, should, and sometimes do promote all three objectives (2). Th...

The Supreme Court, in Chevron v Echazabal, ruled that risks to a disabled worker, if established by an individualized medical assessment, can disqualify the worker from protections offered by the Americans with Disabilities Act (ADA). This decision rejected the antipaternalist position of ADA advocates that workers with disabilities should be able...

To present an ethical framework that could aid prescription drug benefit design and to propose that such a framework could be organized around a benefit allocation hierarchy. Four hierarchical levels of allocation are proposed, as follows: (1) drug categories and subcategories, (2) individual drugs within covered drug categories, (3) specific indic...

We propose an ethical template for pharmacy benefits and a fair process for using it. The template delineates four levels of decisions about pharmacy coverage, connecting ethically acceptable types of rationales for limits with decisions made at each level. It provides a framework for organizing ethically relevant reasons for coverage (or the tiere...

Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice descr...

The American Journal of Bioethics 1.1 (2001) 10-11 John Robertson argues that preconception sex selection (PSS) should remain a moral and legal prerogative of parental family planning, provided certain other conditions are met, including caveats about harms to others. If sound, his argument also applies to parental prerogatives to select offspring...

Managed behavioral health care was born in the private sector in accord with Newton’s third law of motion: an entrepreneurial, cost-expanding hospital “industry” triggered an equal and opposite entrepreneurial, cost-containing managed behavioral health care “industry” (1). The new enterprises have developed considerable expertise at reducing hospit...