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Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries., Funding Agencies|Norges Forskningsrad [303724]

It is uncontroversial to claim that the extent to which health care interventions benefit patients is a relevant consideration for health care priority setting. However, when effects accrue to the individual patient, effects of a more indirect kind may accrue to other individuals as well, such as the patient's children, friends, or partner. If, and if so how, such relational effects should be considered relevant in priority setting is contentious. In this paper, we illustrate this question by using disease-modifying drugs for Alzheimer's disease as a case in point. The ethical analysis begins by sketching the so-called prima facie case for ascribing moral weight to relational effects and then moves on to consider a number of objections to it. We argue that, whereas one set of objections may be dismissed, there is another set of arguments that poses more serious challenges for including relational effects in priority setting.

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification.

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries., Funding Agencies|Norges Forskningsrad [303724]

This thesis explores how philosophical perspectives of justice can facilitate a critical discussion and a deepened understanding of the school choice issue and how it can be related to fundamental pedagogical ends of education, such as developing children´s autonomy and educating them to become democratic citizens. The methodological approach is based on John Dewey’s view of pragmatism, which argues for an experimental process of inquiry incorporating reflection on alternative lines of action. According to this approach, analyses of Swedish school choice policy are conducted based on three philosophical perspectives of justice: John Rawls’ justice as fairness, Nancy Fraser’s understanding of justice as three-dimensional and participative, and Amartya Sen’s capability approach. These perspectives clarify the relationship and meaning of three value premises that are prominent in the concept of school choice and foundational to liberal democratic societies: individual freedom, pluralism, and equality. Thus, the explorative approach highlights three answers to how the issue of school choice might be viewed from the perspective of justice. These answers are integrated into three criteria that serve as a pragmatistbased understanding of educational matters of justice, suggesting 1) that people should be viewed as active, social, and capable of intelligent change—individual and social—through reflective action; 2) that people should be given equal rights and opportunities to participate in and access influence over how they lead their lives; and 3) that societal organization (as well as the education system) should promote both people’s individual and common potential to act, which presupposes the striving toward full, free communication within and between social groups. Although the analyses of current Swedish school choice policy reveal increased criticism toward the contemporary system of school choice, the expressed policy strategies for dealing with injustice mainly a

Preexposure prophylaxis for HIV is a drug that reduces the risk for an HIV-negative person to acquire HIV if taken prior to sex. It has been suggested that it is important for resource allocation decisions that there are alternatives (such as abstinence, masturbation, etc.) for individuals potentially benefitted by this prophylaxis. In this paper we explore this idea from an ethical perspective in relation to three notions often discussed in priority setting ethics, namely responsibility, outcomes, and severity of disease. While the relevance of alternatives may be explained in terms by responsibility-sensitive priority setting, such a view comes with several challenges. We then discuss two other ways in which this intuition could be better explained: (a) in terms of total outcome of health, and (b) in terms of severity of the condition., Funding: Swedish Research Council [2021-01266]; Severity and priority setting in health care

Current studies indicate that robotic-assisted surgery is not inferior to laparoscopic or open surgery regarding oncologic or functional outcomes. An exception may be uterine cervix cancer, where the survival after minimal invasive surgery might not be as good as after open surgery. There is less bleeding and need for blood transfusion after robotic-assisted surgery, and postoperative complications are similar to open or laparoscopic surgery. Robotic-assisted surgery offers ergonomic advantages compared to laparoscopic surgery. The effect of the surgical learning curve is not sufficiently studied. Presently robotic-assisted surgery is not cost-effective due to high costs of investments. The operation is more time consuming than laparoscopic or open surgery with risks of delaying and cancellation of other operations., Onkologiskt och funktionellt resultat vid robotassisterad kirurgi skiljer sig inte från laparoskopisk eller öppen kirurgi. Ett undantag kan vara sämre överlevnad vid cervixcancer. Robotassisterad kirurgi är inte kostnadseffektiv i dagsläget på grund av investeringskostnaderna. Robotassisterad kirurgi erbjuder ergonomiska fördelar och ger ingen ökning av postoperativa komplikationer. Operationstiderna är längre, men möjligen är blödning och transfusionsbehov mindre och vårdtiden kortare. Inlärningseffekterna är ofullständigt undersökta. Det finns etiska skäl att vara observant på undanträngningseffekter till följd av ökad användning av robotkirurgi.

Funding Agencies: Stockholm County Council

In recent years, the issue of accepting a higher cost per health improvement for orphan drugs has been the subject of discussion in health care policy agencies and the academic literature. This article aims to provide an analysis of broadly egalitarian arguments for and against accepting higher costs per health improvement. More specifically, we aim to investigate which arguments one should agree upon putting aside and where further explorations are needed. We identify three kinds of arguments in the literature: considerations of substantial equality, formal equality, and opportunity cost. We argue that considerations of substantial equality do not support higher costs per health improvement orphan drugs, even if such considerations are considered valid. On the contrary, arguments of formal equality may support accepting a higher cost per health improvement for orphan drugs. However, in order to do so, a number of both normative and empirical issues must be resolved; these issues are identified in the article. For instance, it must be settled to what extent the opportunity cost in terms of foregone health for other patients is acceptable in order to uphold formal equality. We conclude that certain arguments can be set aside, and future focus should be put on the unresolved normative and empirical issues related to formal equality and opportunity cost., Funding Agencies|Forskningsradet om Halsa, Arbetsliv och Valfard [2014-4024]; Swedish Research CouncilSwedish Research Council [2014-4024]

Intensive research is carried out to develop a disease-modifying drug for Alzheimers disease (AD). The development of drug candidates that reduce Ass or tau in the brain seems particularly promising. However, these drugs target people at risk for AD, who must be identified before they have any, or only moderate, symptoms associated with the disease. There are different strategies that may be used to identify these individuals (eg, population screening, cascade screening, etc). Each of these strategies raises different ethical challenges. In this paper, we analyse these challenges in relation to the risk stratification for AD necessary for using these drugs. We conclude that the new drugs must generate large health benefits for people at risk of developing AD to justify the ethical costs associated with current risk stratification methods, benefits much larger than current drug candidates have. This conclusion raises a new set of ethical questions that should be further discussed., Funding Agencies|Stockholm County CouncilStockholm County Council

Aim. The paper is part of a PhD-project which aims to explore how the Swedish school choice system can be justified from the perspective of three different philosophical theories of justice. The purpose of this paper is to present the main conclusions of the project. Theoretical framework. I examine three conceptions of justice in relation to school choice: justice as fairness by John Rawls (1971/2005), the capability approach by Amartya Sen (1992), and Nancy Fraser’s (2008) three-dimensional theory of justice. With inspiration from John Dewey’s (1917/1985) pragmatism, I view the conceptions as lines of action, i.e. as three potential ways to understand and manage the inherent value-based conflicts of school choice. The implications of each perspective are discussed in relation to the idea that schooling should promote children’s ability to lead flourishing lives (Brighouse, 2006). Methodology. I conduct philosophical text analyzes of policy texts (n=50), mainly produced at governmental level in the contemporary Swedish context. Findings. If we consider education a fundamental aspect of human life, and ultimately a prerequisite for both social cohesion and individual quality of life, school choice arrangements should be evaluated and justified with respect to children’s potential to take part in educational activities that promotes their ability to lead flourishing lives. However, what kind of circumstances and principles that needs to be met varies depending on our conception of justice (as does the empirical difficulties). Relevance to Nordic educational research. Although this paper focus on the Swedish school choice system, explorative studies concerning the principles and values on the basis of which we evaluate and think about educational goals and arrangements are relevant for other contexts as well., Ej belagd 20220204

I skrivande stund pågår det intensiv forskning för att få fram ett sjukdomsmodifierande läkemedel mot Alzheimers sjukdom (AD). Vid introduktion av sådana läkemedel kommer en rad etiskt svåra frågor kring screening och prioriteringar av vårdens resurser, att aktualiseras. Föreliggande rapport behandlar dessa frågor. Trots att de nya läkemedlens effekt sannolikt har en påverkan på närstående till personer med AD så är det vår bedömning att den svenska etiska plattformen inte lämnar något utrymme för sådan hänsyn. Det finns också skäl att vara särskilt uppmärksam på utsträckningen i vilken de surrogatmått som används i de kliniska studierna faktiskt är av klinisk relevans. När det gäller att väga samman patientnytta som tillfaller olika individer är det vår bedömning att plattformen inte tillåter aggregering av patientnytta på ett sådant sätt. Det innebär att det faktum att personer med AD utgör en stor patientgrupp utgör i sig inte ett skäl för högre prioritet då effekten skall bedömas med avseende på hur den tillfaller varje enskild individ. I ett scenario där budgetpåverkan blir så stor att man behöver prioritera inom gruppen så tycks det saknas för prioriteringar relevanta kriterier. Manifest AD är ett tillstånd med mycket stor svårighetsgrad. Men eftersom de nya läkemedlen siktar in sig på den prekliniska eller fasen i vilken patienter har en lindrig kognitiv störning så bör svårighetsgraden av tillståndet viktas ned med avseende på sannolikheten att faktiskt insjukna i AD. Tillståndets svårighetsgrad blir därmed olika för läkemedel som siktar på den prekliniska fasen, de som siktar på fasen med lindrig kognitiv störning och de som siktar på kliniska stadier av AD. Eftersom personer med AD kan ha sämre förutsättningar än andra patientgrupper att kommunicera sina behov bör de beaktas särskilt. Det innebär dock inte någon högre prioritet utan en markering att personer med AD har samma rätt till hälso- och sjukvård som andra grupper med liknande behov. Populationsscr, Intensive research is carried out by several pharmaceutical companies in order to develop a disease modifying drug for Alzheimer’s disease (AD). The development of drug candidates which reduce Aß and tau in the brain seems particularly promising. These drugs and the characteristics of AD raise a number of ethical challenges. In this report we analyze these challenges in relation to priority setting and the diagnostic measures associated with these drugs. The former analysis draws primarily on the Swedish ethical platform for health care priority setting, whereas the latter draws on the guidelines for screening developed by the National Board of Health and Welfare. Although the effect of the new drugs is likely to have an impact on relatives of people with AD, it is our interpretation that the Swedish ethical platform leaves no room for such considerations. In relation to the effect of the drugs there is also reason to pay special attention to the extent to which the surrogate measures used in the clinical studies are of clinical relevance. When it comes to aggregating benefits across individuals, it is our interpretation that the platform does not allow aggregation of patient benefits in such a way. This means that the fact that people with AD constitute a large group of patients does not in itself constitute a reason for giving this group a higher priority. The ethical platform rather seems to prescribe that the effect must be assessed with regard to how it accrues to each individual. In a scenario where the budgetary impact becomes so great that decision makers need to prioritize within the group, it seems that there are no relevant criteria for these priorities. AD is a condition with a very high degree of severity. However, as the new drugs are targeting the preclinical or Mild Cognitive Impairment (MCI) phase, the severity of the condition should be decreased with respect to the likelihood of actually developing AD. The severity of the condition thus becomes di

Background Genetic testing is moving from targeted investigations of monogenetic diseases to broader testing that may provide more information. For example, recent health economic studies of genetic testing for an increased risk of breast cancer suggest that it is associated with higher cost-effectiveness to screen for pathogenic variants in a seven gene panel rather than the usual two gene test for variants inBRCA1andBRCA2. However, irrespective of the extent to which the screening of the panel is cost-effective, there may be ethical reasons to not screen for pathogenic variants in a panel, or to revise the way in which testing and disclosing of results are carried out. Main text In this paper we discuss the ethical aspects of genetic testing for an increased risk of breast cancer with a special focus on the ethical differences between screening for pathogenic variants inBRCA1/2and a seven gene panel. The paper identifies that the panel increases the number of secondary findings as well as the number of variants of uncertain significance as two specific issues that call for ethical reflection. Conclusions We conclude that while the problem of handling secondary findings should not be overstated with regard to the panel, the fact that the panel also generate more variants of uncertain significance, give rise to a more complex set of problems that relate to the value of health as well as the value of autonomy. Therefore, it is insufficient to claim that the seven gene panel is preferable by only referring to the higher cost effectiveness of the panel., Funding Agencies|Linkoping University Library

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition-specific severity). In this paper I argue that giving priority to the worse off in terms of condition-specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).

Research Topic During the development of school choice policies in Sweden the values of pluralism, parental influence and equal education for all children where present in different ways. Since the reform in 1992, the idea of parental choice in education has reached almost a level of political consensus. However, due to declining PISA-results and increased school segregation, the political debate on school choice in Sweden nowadays has heated up after having maintained status quo since the middle of the 90s. One example is the latest report from the Swedish School Commission, which on the basis of OECD-recommendations suggests school choice-targeted solutions for balancing the values mentioned above (OECD 2015, SOU 2017:35). The aim of this paper is to characterize the value base of the school choice debate during the period 1975-2017, with the following research question: What discursive shifts and continuities can be seen in the debate on school choice and independent schools when studying political documents from the investigated period? Theoretical and methodological framework My overall understanding of the education system take departure from curriculum theory, i.e. I view the curriculum as ideologically and politically contested (Apple 2004). In this presentation, the focus is directed to how the value base of school choice is discursively constructed and changing, emphasizing the values and “truths” that obtain recognition and legitimacy over time (Schüllerqvist 1996). The analysis is based on a comprehensive reading of political documents (motion, government bills, official reports and policy texts). The searching and selection of documents was centered around some key words as well as the principle of intertextuality (Fairclough 1992). I will provide a brief summary of the values and arguments discussed in the 70s and 80s, but the presentations main focus will be on the present. Excerpts from documents will be used to highlight the characteristics of the v

Is school choice fair? The main argument is to give citizens greater influence over their lives and to promote a more pluralistic and pedagogically innovative education system through competition. At the same time, research as well as OECD-reports show that some choice and school funding arrangements tend to strengthen the segregation within and between schools (Ambrose, 2016; OECD, 2012a, 2012b; Trumberg, 2013). Ultimately, school choice concerns issues of what education pupils should have access to, where, and how this should be decided. From this point of view, school choice is to be regarded an issue of justice. Justice, however, is certainly an essentially contested concept, with Gallie’s (1956) terminology. The essence of the concept, as well as the approaches to explore it, varies greatly. One could though, with education philosopher Harry Brighouse (2004), claim that the most fundamental task of a theory of justice concerns: “assigning relative weights to different values to decide exactly which value should prevail and how in particular situations” (Brighouse, 2004, s. 4). A central aspect of exploring the justice dimensions of school choice therefore has to do with identifying the values underpinning it, then arguing how these values should be weighted in relation to each other. The subject of this paper can be described as the value base of school choice (cf. Schüllerqvist, 1996). School choice, in some form, is present in most European education systems. Sweden, however, constitutes a historically interesting case, since the education system during the past 50 years has undergone a shift from strong state control to a deregulated choice system with great freedom of establishment for independent schools. The Swedish case is also especially relevant from a policy perspective, since the reform can be described solely as a policy reform, and thus not a result of religious or historical traditions. The aim of the paper is to characterize the value base of sch