The National Health Service operates under significant resource constraints, both financially and in terms of staffing, leading to challenges in providing comprehensive healthcare for all. This poses a problem for commissioners: how do we prioritise treatment allocation? Chris Newdick’s influential work in ethics and law has shaped discourse in this area for over three decades. However, we critique a specific aspect of Newdick’s work concerning individual funding requests (IFRs) within the healthcare resource allocation system.

The allocation problem involves balancing population-wide healthcare needs with the ethical imperative to treat individuals. Decision-making frameworks like the ‘Accountability for Reasonableness’ (A4R) framework aim to address this by fostering fair processes. In the United Kingdom, local priority forums, guided by ethical frameworks, play a crucial role in resource allocation decisions. While these processes strive to be fair, they are not flawless. These processes cannot consider every potential patient perspective, circumstance or reason for needing treatment. To address this, A4R frameworks include mechanisms for revision and appeals. IFRs form an important part of this picture by providing a recourse for patients whose cases may not have been adequately considered because they are in some sense unusual or ‘exceptional’.

However, current processes often rely on a problematic interpretation of ‘exceptionality’ which fails to align with A4R principles. This interpretation sometimes excludes those who ought to be included, and includes those who ought to be excluded. We argue for a revised understanding of exceptionality to ensure fairness and effectiveness in resource allocation processes informed by Newdick’s work. 

Recent literature has drawn attention to the complex relationship between health care and the environmental crisis. Healthcare systems are significant contributors to climate change and environmental degradation, and the environmental crisis is making our health worse and thus putting more pressure on healthcare systems; our health and the environment are intricately linked. In light of this relationship, we might think that there are no trade‐offs between health and the environment; that healthcare decision‐makers have special responsibilities to the environment; and that environmental values should be included in healthcare resource‐allocation decisions. However, we argue that these claims are mistaken. The environmental crisis involves a wider range of considerations than just health. There is a plurality of reasons to act on the environment; we might do so to protect the natural world, to prevent catastrophes in other parts of the world, or to avert climate war and displacement. Trading‐off between health care and environmental sustainability is thus unavoidable and requires sensitivity to all these reasons. Healthcare decision‐makers are not well placed to be sensitive to these reasons, nor do they have the democratic authority to make such value judgements. Therefore, decisions about environmental sustainability interventions should be made at a ‘higher level’ of resource allocation. Importantly, hospitals have environmental duties but not environmental responsibilities; their job is to provide the best healthcare possible within the constraints given to them, not to choose between health care and other goods. 

Limited aggregationists argue that when deciding between competing claims to aid we are sometimes required and sometimes forbidden from aggregating weaker claims to outweigh stronger claims. Joe Horton presents a ‘fatal dilemma’ for these views. Views that land on the First Horn of his dilemma suggest that a previously losing group strengthened by fewer and weaker claims can be more choice-worthy than the previously winning group strengthened by more and stronger claims. Views that land on the Second Horn suggest that combining two losing groups together and two winning groups together can turn the losing groups into the winning groups and the winning groups into the losing groups. This paper demonstrates that the ‘fatal dilemma’ is neither fatal nor a dilemma. The First Horn is devastating but avoidable and the Second Horn is unavoidable but not devastating. Nevertheless, Horton’s argument does help to narrow down the acceptable range of views.

Sometimes we must choose between competing claims to aid or assistance, and sometimes those competing claims differ in strength and quantity. In such cases, we must decide whether the claims on each opposing side can be aggregated. Relevance views argue that a set of claims can be aggregated only if they are sufficiently strong (compared to the claims with which they compete) to be morally relevant to the decision. Relevance views come in two flavours: Local Relevance and Global Relevance. This paper presents a trilemma for both. Namely, that neither view can capture our intuition in tie-break cases, without forfeiting our intuitions in other important cases.

I then present a way to salvage relevance views and capture all our intuitions using a Hybrid view. By distinguishing between two types of relevance we can combine the strengths of Local and Global Relevance views such that we can hold all our intuitions, consistently and in a non-ad-hoc manner. Building on this, the paper demonstrates how we might amend the strongest formulation of a Relevance view, into a Hybrid account.