Symons X. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106626 1 Refective disequilibrium: a critical evaluation of the complete lives framework for healthcare rationing Xavier Symons 1,2 Original research To cite: Symons X. J Med Ethics Epub ahead of print: [please include Day Month Year]. doi:10.1136/ medethics-2020-106626 1 Plunkett Centre for Ethics, Australian Catholic University, Sydney, NSW, Australia 2 Institute for Ethics and Society, University of Notre Dame Australia, Sydney, NSW, Australia Correspondence to Mr Xavier Symons, Plunkett Centre for Ethics, Australian Catholic University, Sydney, NSW 2007, Australia; xavier.symons@acu.edu.au Received 25 June 2020 Revised 29 September 2020 Accepted 28 October 2020 © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’s complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of refective equilibrium—a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF confict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the confict between the youngest frst principle and Persad et al’s investment refnement; the confict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives. INTRODUCTION One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’s complete lives framework for the rationing of life- saving healthcare interventions. 1–4 The complete lives framework states that we should prioritise the needs of individuals who have had less oppor- tunity to experience the events that characterise a complete life. Persad et al argue that younger people should have the opportunity to pass through all the significant milestones that characterise a full-life narrative, such as pursuing a career, fostering inti- mate relationships, raising children and watching them grow up, and so on. In this regard, younger people have a stronger claim on lifesaving health- care resources than older people. i This paper, however, presents a critique of the complete lives framework for healthcare rationing i Persad, Emanuel and Wertheimer (2006; 2009), for example, have argued that young people should receive priority access to resources like organ transplants or vaccines for new and deadly forms of the influenza. More recently, the complete lives approach has even been operationalised in COVID-19 healthcare rationing protocols. The Interim Pennsylvania Crisis Standards of Care for Pandemic Guidelines, for example, propose life- cycle considerations for the rationing of crit- ical care and ventilators in the event that patients cannot be distinguished based on their health condition. See Pennsylvania Department of Health. Interim Pennsylvania Crisis Standards of Care for Pandemic Guidelines . Harrisburg, PA: Pennsylvania Department of Health, 2020:33. (hereafter CLF). Proponents of CLF argue that their system is the product of a successful process of reflective equilibrium—a philosophical meth- odology whereby theories, principles and consid- ered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. 5 Yet I will argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al fail to achieve an acceptable coherence between them. As such, CLF is an unsuccessful application of the method of reflective equilibrium. I will focus on three tensions in particular: the conflict between the youngest first principle and Persad et al’s investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives. I will begin with a discussion of CLF and its philosophical foundations, and will then discuss the tensions in the framework. THE COMPLETE LIVES FRAMEWORK In this section, I offer an overview of the complete lives framework for healthcare rationing and discuss its philosophical foundations. To be clear, Persad, Wertheimer and Emanuel propose the complete lives framework as a system for the rationing of lifesaving interventions, rather than recommending it as a framework for rationing in all healthcare settings (2009, p429). ii Indeed, they state that struc- tural inequalities and inefficiencies in healthcare would need to be addressed before implementing a complete lives framework in other areas. A statement of the framework The complete lives framework was first expounded in two papers in the mid to late 2000s, though it has received significant scholarly attention since then. The egalitarian currency of the framework is opportunity, and, specifically, the opportunities that characterise the different stages of a full-life narra- tive. The framework gives graded priority to indi- viduals based on the extent to which they have had the opportunity to live a complete life, as well as the extent to which they are invested in their own life. ii The authors do not offer a definition of life- saving resources, but presumably they have in mind resources that postpone death for a period of time that is deemed to be both morally and medically significant. For a critique of the notion of lifesaving resources, see Yetter- Chappell R. Against ‘saving lives’: equal concern and differential impact. Bioethics 2016;30(3):159–164. copyright. on January 4, 2021 at University of Notre Dame. Protected by http://jme.bmj.com/ J Med Ethics: first published as 10.1136/medethics-2020-106626 on 17 December 2020. Downloaded from