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This is a repository copy of Public health care resource allocation and the rule of rescue. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/11029/ Monograph: Cookson, R., Tsuchiya, A. and McCabe, C. (2008) Public health care resource allocation and the rule of rescue. Discussion Paper. Journal of Medical Ethics [email protected] https://eprints.whiterose.ac.uk/ Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing [email protected] including the URL of the record and the reason for the withdrawal request.

Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online [email protected] - 2 - Health Economics

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Page 1: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

This is a repository copy of Public health care resource allocation and the rule of rescue.

White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/11029/

Monograph:Cookson, R., Tsuchiya, A. and McCabe, C. (2008) Public health care resource allocation and the rule of rescue. Discussion Paper. Journal of Medical Ethics

[email protected]://eprints.whiterose.ac.uk/

Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website.

Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing [email protected] including the URL of the record and the reason for the withdrawal request.

Page 2: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

- 1 -

HEDS Discussion Paper 07/04

Disclaimer:

This is a Discussion Paper produced and published by the Health Economics and Decision Science (HEDS) Section at the School of Health and Related Research (ScHARR), University of Sheffield. HEDS Discussion Papers are intended to provide information and encourage discussion on a topic in advance of formal publication. They represent only the views of the authors, and do not necessarily reflect the views or approval of the sponsors. White Rose Repository URL for this paper: http://eprints.whiterose.ac.uk/11029/ Once a version of Discussion Paper content is published in a peer-reviewed journal, this typically supersedes the Discussion Paper and readers are invited to cite the published version in preference to the original version. Published paper

Cookson R, McCabe C, Tsuchiya A. Public health care resource allocation and therule of rescue. Journal of Medical Ethics 2008;34(7):540-4.

White Rose Research Online

[email protected]

Page 3: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

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Page 4: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

HHeeaalltthh EEccoonnoommiiccss aanndd DDeecciissiioonn SScciieennccee

DDiissccuussssiioonn PPaappeerr SSeerriieess

No. 07/04

PUBLIC HEALTH CARE RESOURCE

ALLOCATION AND THE RULE OF RESCUE

Richard Cookson1, Christopher McCabe2, Aki Tsuchiya3

1. Department of Social Policy and Social Work, University of York.

2. Academic Unit of Health Economics, Institute of Health Sciences, University

of Leeds.

3. Department of Economics, and School of Health and Related Research,

University of Sheffield.

Corresponding author:

Dr Richard Cookson

Department of Social Policy and Social Work,

University of York, York

YO10 5DD

Tel: 01904 321248, Fax: 01904 321270, email: [email protected]

ScHARR

Page 5: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

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Page 6: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

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Page 7: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

←÷≈ ⊄ ←÷≈ ↵←• ↵× ″↑←•← ←≈ ≡±→ ¬≈ ←÷ ″… ⇑ ″• ⇔ ≈ ×≈″ ≈ ⇑ ↑± ≈←•≥ ↑ ≈↑ ×≈

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Page 8: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

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Page 9: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

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″…• •± ⊂ •↑ •↑ °≈↔ו↵→ °± • ±∂≈ •♠≈ •←÷ • °×•↵ •±″↑ ←÷↵← ↑≈≈ ↔″←≈→• ←↔• •♠≈ ″…

↔″≡↵•→ ±→ ♦ °×≈ •≥↵≠•″≈ ←÷≈→≈ →≈ ← ° ←•≈ ←↑ • ÷ ← ± …•≡≡≈→≈″← ±″ •←• ″↑ ÷± →≈ ←

↑↔≡≡≈→•″≠ ≈↓ � ←÷≈ ≡•→↑ •≈″← →≈ •♠•″≠ ≈ ← ↔° →←• ≈ →≈� ↵ ←÷≈ ≈ … °↵←•≈

→≈ •♠•″≠ …•↑≈↵↑≈⌠≥ •≡ •″ ←→≈ ← ≈″← •←÷ • •←≈ ≈≡≡≈←•♠≈″≈↑ ↑≈ ≈→≈ ↑•…≈⌠≈≡≡≈ ←↑

≥ •″≈ ← ← ″≈ ←→ ←≥ ← ± ≈↑ × ←÷↵← •↑ ≈≡≡≈ ←• ≈ ≡ ±←÷ ″…• • ← ″±← ↑←

≈≡≡≈ ←•♠ ↑ •← ≡ •→ ← ≡•→↑← °↵ •≈″← ÷ … →≈ •♠≈ ← •↑ ←→≈↵←≥≈ ← ← ″± ←÷≈ ≈ ″…⟨

≈ ↑≈±″ →≈↓↔•→≈≥≈″← ≡±↔↑≈↑ ↵←←≈″←• ″ ±″ ↑ ♠≈→•← ±≡ •× ″≈↑↑ ↵ ≥± ≈ ↑°≈ •≡ ↵ × ±″ ↑≈♠≈→≈

… → ≠→≈↑ •♠≈ ±″… ←•±″ ≈ ≈←≈… ← ≈ … ←± °→≈ ↵← → ⇑ ″ → ≡ → ↑≈♠≈→•← ±≡ •× ″≈↑↑

≈ ≠→±↔″… •″ ≠≈″≈→ •↑↵ ≈ ° •× ↑±°÷• °→•″ ° ≈↑ ≡ ∂↔ ←•≈ ≡•→↑← ↵ �° • →•← •↵″

°→•″•° ≈↑ ≡ °→•±→ ← ← ←÷≈ →↑← ≡ •″ ←≈→≥ ±≡ ↑≈♠ •← ±≡ •× ″≈↑↑ ≈ ←→≈ ← ≈″← ↑≈± ″

�≈ •← →• ″ °→ ≈ ≡ ≈↓↔ ← •″ ≈→≥↑ ±≡ ↑ → ← ±≡ • ×″≈↑ ≡←≈→ ←→≈ ← ≈″← ↵″… ←÷•→ ↵

�″≈≈… °→ •° ≈ …•↑←→• ↔←• ″ •″ °→±°±→←• ″ ←± ″≈≈… ÷≈→≈ ″≈≈… •↑ ↵ ≡ ← ±≡ ≈♠≈→•← ≡

Page 10: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

• ×″≈↑ ≈× ↵°↵•← ← ≈″≈≡•← ≡ ±≥ ←→≈ ← ≈″← ←÷≈•→ ≠≈″≈→↵ ≡±→ ↑ �°→•±→•←↵→•↵″�

�≈ •←↵ • ″� ↵″… � ≈ � → ″ ≈↑ ♠≈ ↵ × ≈≈•♠≈… ≈ ←≈″↑•♠≈ …≈→↵←• ″ •″ ≈ °÷• ±↑ °÷•↵×

•←≈→ ←↔→≈ ð

″… ″↔ ≈→±↔↑ ÷≈↵× ÷⌠↑°≈•≡• →•↵″ ↑ ÷ ≈ →≈≈•♠≈… ↵←←≈″←• ″ ″ ←÷≈ ÷≈ ←÷

•←≈→ ←↔→≈

∧ → •↑ ≈ °→•″• × ↑ ≡ ←÷•↑ ∝• ↑± ≡ ≡• ÷≈ ≥°±→ ↵″← …≈↑ ↵ ±≡

≈•″≠ • °→• °×≈ ↓↔↵″ • • ≈ • ↵ ≡± ≥ ←÷↵← × ↑ ←÷≈≥ ←± ≈•≠÷≈… ° ≠↵•″↑ ±↑←⌠

≈≡≡≈ ←•♠ ≈ ↑ ±″≈→″↑ ±→ ≥° ≈ ±→… ÷ …≈ ±°≈… ↵ ±→∝ ≈ ↑← ±≡ ↑≈♠ •←

♥≈• ← ″≠ ←÷↵← ↵× ±♥ ″ ≈→″↑ ≡ → ↑≈ ≈→•← ← ≈ ↓ ″←•≡• … ″ ←÷≈ ≡±→≥ ±≡ ↵ ≠ ↵ •↑≈… ≈→↑•±″

±≡ ←÷≈ ↑ ↵→… ±↑← °≈→ ⇓∩ °°→±↵÷ ←÷↵← ÷≈ →≈≡≈→↑ ←± ↑ �±↑ ↔≈ ↵″↵ ↑•↑�

±→…�↑

°→±°±↑↵ • ← ♠↵×↔≈ ↵× •″≈ •≡≈ ←• ≈ ≈↓↔ × � ← •″ ÷≈ ←÷ → ≈♠≈→≈ •× ⌠÷≈ ←÷ ±

±″≠ ↑ ←÷≈ °≈→ ±″ •↑÷≈↑ ←± ″← ″↔≈ ו • ↵″… ← • ≈ ←→↵″↑≡± ≥↵←• ≡↔ •±″ ←±

↓↔↵ו← ±≡ •≡≈ ↑ →≈↑ ←÷ •♠≈ ≠→≈↵←≈→ ≈•≠÷← ← × ↑↑≈ ÷≈ ↑ ♠ →≈× •× ≈″… ←÷≈

↓↔↵ו← ±≡ ו≡≈ ↑ ↵×≈ ⊂÷•↑ °→± •↑ →≈ ≥ ≈″…≈… ↵ ° ≈≥≈″←↵→ ↵× ↑•↑ •″ ↔ •↑↑• ″↑

←± ←÷≈ ±→♥≈ • ″ ≈ ••″≈↑ ⇑ ″←→± ≠≈″ • ≥↵∝ ″≠ °÷↵→≥ • ↵× →≈ ≥↔ ≈≥≈″

…≈ • • ↑∫

∇″≈ °→± ≈≥ •← …≈≡• •″ ≠≈″≈→↵× ↑ ≈ °→ ″•° ≈ ≡ ∂↔↑ • ≈ •″ ←≈→≥ ±≡ ≈♠≈ •← ±≡ •× ″≈↑↑ •↑

←÷↵← • ↑≈≈ ↑ ±°• ≡± ↔ ±″ ÷±← ±≡ • ⌠ ←÷ ↵ ↵ →← ↔ ±•″ ←• ≈ →↵←÷≈→

←÷↵″ °≈→↑ �↑ ×≈ • ≈←•≥≈ ≈♦°≈→•≈ ≈ ≡ • ×⌠÷≈↵×←÷⟨ ð

¬± ≈♠≈→ ≈″ •≡ ±″≈ ≈ ←↑ ←÷≈ ↵↑≈

≡±→ ↑≈♠≈→•← ♥≈•≠÷← ″≠ ≡ ∝• ↵… ± ←≈… → ← •↑ ≥° ↵″← ←± →≈ ≠″•↑≈ ÷↵← ″ ≈→″

≡±→ ↑≈♠≈→•← ″ ←÷≈ ÷•× ↑±° • °→ •° ≈↑ ≡ ∂ ↑←•≈ ÷↵← ↔″…≈→ ″ • •↑ ←≈ …•≡≡≈→≈″← ≡→± ←÷≈

∈↔ ≈ ∈≈↑↔≈ ÷≈→≈ • ↵″ ≥°±→ ← •≡ →≈ ≈ ≈← ≈≈ ≈→″ ≡±→ ≈♠≈→•← ↵″… ≈→″ ≡±→

•…≈″←•≡ ↵×≈ •″…•♠ ↵× • ≥≈ •↵←≈ °≈→• ⇑ ″ ″ → …≈″←•≡ ↵×≈ •″…•♠ ↵× • ≥≈ •↵←≈

°≈→• •≥° •≈↑ ≈↑↑ ″ ≈ ≡±→ ↔″•…≈″← ≡•↵ ≈ ″…•♠ …↔↵× ≡↔ →≈ →•×∑ ♥÷≈→≈↵↑ ±″ ≈→ ≡ →

Page 11: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

↑≈ →•← ° •≈↑ ←± ↵× ≈♠≈ • ×″≈↑ � ÷≈←÷≈→ ↑↔≡≡≈→≈… •…≈″ •≡•≈ ±→ ↔″ … ←•≡•≈ ″…•♠ …↔↵×↑

… ← ≈→ ↑↔≡≡≈→≈… ″± → •″ ←÷≈ ≡ ← →≈ ≡±→ ♦↵≥°×≈ …� ↑ ←≈≥ ±≡ ≈ →•← ♥ •≠÷←•″≠

±↔ ≠• ≈ ÷•≠÷ °→•±→•← ← ° ♠≈″←•♠≈ °↔× ≈↵×← °→± → ≥ ≈↑ …≈ • ± → ♠≈″← ↑ ♠≈

• ×″≈↑ •″ ←÷≈ ≡ ↔→≈∑ ÷≈→≈ ←÷≈ ↔× ±≡ ∈≈↑ ±↔ ≠• ≈ →• →•← ←± →≈ ≈″←•♠≈

°→± ↵≥ ≈↑ ≡ ←÷• ″… � •″≈ ← ← → ≈← °≈ ≈ ♥÷± →≈ ↔→→≈″←× → ←• ≈× ÷≈↵×←÷ ↵″ ″ ←

•″ ↵″ • ≥≈…•↵←≈ °≈→• • • → ←÷ ↔ ≈ ∈≈↑↔≈ • ° •≈↑ •♠•″ ± →•±→•← ←± ←→≈↵←≥≈ ←

≡ → ° •≈″← ↵← • … ←± ≥±…≈→↵←≈ ↑ ↵≠≈↑ ±≡ °→± →≈↑↑• ≈ ″ • •± ↵″… ″↑←≈↵… • •″≠ • ≈

″…• •±″ ≈ ≥≈↑ ↑↔ • • ″← ↑≈♠≈→ ←± ″↑←• ↔←≈ ≥ ≈…•↵←≈ °≈→• � •÷ •≥≈ ±≡ ↔→↑≈

←→≈↵←≥≈″ ≥↵ ≈ ×≈↑↑ ≈″≈≡• ↵″ ⟩ → ≥ →≈ ±↑←× ± ←÷≈ ↔× ±≡ ∈≈↑ ≈ •↑ ↓↔•← …•≡≡≈→≈″←

≡→± ↑≈♠≈→•← ♥≈• ← ″≠ ″… ↵″ ← ≈ ∂↔↑ •≡•≈… •← →≈≡≈→≈″ ≈ ←± ±≡ ←÷≈ ↑←↵ ↵→… °→•″•° ≈↑

±≡ ∂↔↑←•≈

•″↵×× ←÷≈ ÷•→… ↓↔•→≈≥≈″← →≈ ←→•← ←÷≈ °×•↵• •← ≡ ←÷≈ ↔↑←→ ↔ ≈ ≡ ∈≈ ↔≈ ←

″…• •±″ ÷↵← ≡≡≈← ♠≈→ ↑≥ ″↔ ≈→ ±≡ ±°× � ← ← →≥≈… � → ÷↵″� ± …•←• ″↑ • ↑←

←÷• →≈↑←→•←• ″ °→≈♠≈″←↑ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈ ≡→ ≥ ≈±≥ ″≠ → ↔← ″≈ �↵←÷⌠↵ ×� • • ÷↵→ ←

…≈≡≈″… ÷≈ ≥ → ≥°≈→↵←• ≈ ≈÷ ″… ∈↔× ±≡ ∈≈↑ →≈ ←≈↑ ←± ←÷≈ ≡ ← ≡ • ≥•″ ″← • ← •↑

″±← ×≈↵→ •← ↑÷ … ≥↵∝≈ ↵ …•≡ →≈ ≈ ≡→ ≥ ↵″ ≈← • °± ″← ±≡ ♠•≈ ≈←÷≈→ ←÷≈ ↵↔↑≈ ±≡

•≥ •″≈ ← →•× •↑ →↵→≈ ±→ ≥≥ ″

↔↑ ≈↵÷ →≈ •→≈≥ ← •↑ ≡×↵ ≈… ↵″… ≥↵ •″←→ ≈ ≠→≈↵←≈→ •″≈ ← ← ↵″ ≈↓ ← ¬ ♥≈♠≈→ ←

≥ ↑← ←→• • → ← →•↑←• ≡ ← ←→↵ו • °×≈ ≈″←↵←• ″ ±≡ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈ • ←÷↵← •← •↑

≥ ↑← ± ° ≈←≈× •″…≈°≈″… ← ±≡ ←÷≈ ″ ≈ ← ±≡ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈ ↵ …≈↑→•≈… ←÷≈

•←≈→ ←↔→≈ ⊂÷≈ •≈″ • ″± ≡↵ • ≈…•↵←≈ °≈→• ∑ ← →≈ •↑ ″ ↑≈″↑≈ ±≡ ↔→ ≈″ ←± ←÷•↑ ←±→

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≈ ↑←→↵ו↵″ ≡•″• •±″ •↑ ≥ →≈ →≈≥•″•↑≈″← ≡ ≥ ″ ↵″… ⇔ → °≈↵″ →°÷ ⇐→↔

≈≠•↑ ←• ″

⊂ ≈ ∏ ⇑ ⇑•← �↑ ⇑± × ≈≡• •← ± ↵ •♦ ↑ ↵ •±

⊂÷≈ �⇑•←•ƒ≈″�↑ • • ≠→±↔° ≡ ð ≈≥≈→↑ ±≡ ÷≈ ↔ • …→ ″ ≡→± ↵ → ↵… → ↑↑

↑≈←•± ± ←÷≈ ≠≈″≈→↵× ⊄ °±°↔×↵←• ″ •″ →…≈→ ←± ≠• ≈ ≈•→ ♠•≈ ↑ ″… ±°• • ″↑ ″ • ↑↔≈↑ ±≡ ↑±•↵×

♠↵ ≈ ∂↔…≠ ≥≈″← →≈ ← ″≠ ←± ←÷≈ ∝ ±≡ ⇑⇔ ← ÷ ← ↵ ″± ↵″…↵ ↵ ÷±→•← ← •↑ ↵

↔″• × ≈←•±″ ×↵ ≈≥≈→↑ ±≡ ←÷≈ °↔× →±↔ ← ←±≠≈←÷≈→ ←± ≥≈→↑≈ ← ≥↑≈ ♠ ↑ •″ ÷≈

↑ •↵× ♠↵×↔≈ ≈≥≈″←↑ ←÷↵← ″ ← ≈ ↵♠ • ≈… • ÷≈ →≈ →≈↑±↔→≈ ↵× ± ↵←• ∇″≈ ±≡ ÷≈•→

→≈≈ ← →≈°±→←↑ ……→≈↑↑≈ ←÷≈ •↑ ↔≈ ≡ ≈ ±≡ ∈≈↑ ≈∫

⇑⇔ ↵↑∝≈… ←÷≈ ⇑•←•ƒ �↑ ±↔″ • ←± ↵…… ↑↑ ←↑ …≈ •≈→ •±″↑ ← ≈ ≡± •″≠ ↔≈ ←•

↑ ← →≈ ↵ ° ≈→≈″ ± ↵♠ ← × ≡ ±≡ • •≥ •″≈ ← ″≠≈→ ±≡ … ≠

•″ ←≈↵… ≡ •≥° ♠ ″≠ ←÷≈ ו≡≈ ±≡ ± ≈ ×≈ × ≈ ″±← •″ •≥≥≈… ↵←

…↵ ≈

∇→

↑↵♠•″≠ ←÷≈ ו♠ ↑ ≡ ≥ ″ °≈± ×≈ ″ ÷ ≡ ←↔→≈ ←÷ ±↔≠÷ •↑≈↵↑ ° ♠≈″← ±″

°→±≠ ↵≥≥ ↔ ↑ ≈↵← ″≠ •≠÷ ±±… °→≈↑↑↔ ≈ ×±♥ • ×± ÷± ≈↑← ±

× ×↑ ⟨

Page 13: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

ð

⋅≡ ÷≈ ±↔″• •… ↑ ← ⋅⇑ ÷±↔× ≠″± ← ↔×≈ ±≡ ∈ ↔ � ÷♣⟨

⋅≡ ÷≈ ±↔″• ↑ … → ←÷ ← ←÷ ∈ × ±≡ ∈ ↔≈ ÷± ×… ↵ °×•≈… � ≈″

⇓″… ♥ ↵← ו≥• ↑ ↵→≈ ←÷ ≈⟨

← ←÷≈ ≈″ ≈•→ ≈ •≈→↵←• ÷≈ •←•ƒ≈″�↑ ⇑ ↔″• ≡≈ ← ←÷↵← ←÷≈

�≥↵ ±→ ←♣ ≠ ±↔° →≈ ↵ ←± ↑°≈•≡♣ ♥ ″ ⇑⇔ ÷± ×… °° ÷≈ ↔×≈ ±≡ ∈≈↑↔≈ ″…

…≈≡ ≈ ← ←÷≈↑≈ •≥•← ÷±↔ … �

Page 14: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⇒±♦ ⇑ ⇑•← �↑ •× ⇑ ≈ ו↑← ±≡ ∉ ↑← ± ≡ → ×≈ ←• ≠ ≈ ∈ × ±

↑ ←÷≈ • ←≈→♠≈″←•±″ ↓↔•→≈… ←± ↵♠ • ≥ ≈…•↵←≈ ± ↑ ≡ •≡≈⟨

↑ ←÷≈→≈ ± ≈ ±≡ ↵″ •″ ≈↵↑≈ •≡≈ ≈ °≈ ←↵ ⟨

•× •← →≈↑↔×← •″ ↑• ″•≡ ↵″ • °→± ≥ ← • ↵× ← ≡ •≡ ⟨ →≈ ←÷≈ ← ← ≈″←�↑ •…≈

≈≡ ←↑ ♠≈ ↑≈♠≈ ≈ ″ ±↔←♥≈•≠÷ ←÷≈ ± ←÷≈ ← ↵←≥≈″ ±↔×… ⟨

↵← • × ←÷≈ ≈↓↔≈″ ≈ ↔× ←÷≈ ←→≈↵←≥≈ ← ← ≈ →≈≈•♠≈…⟨

↵← ↵→≈ ←≈→ •♠≈ ←→≈ ← ≈ ← ↵″… ÷± …± ←÷≈ ±≥°↵ ⟨

≈ ≡ ←↔→≈ ≥≈… ↵•″ °→± ≈ ≈ ↔↑≈ ±≡ ÷≈ →≈ ≈ → ÷ ≈ ≈″ →≈… ←÷≈ ←→≈↵←≥≈″←⟨

≈ ← ≈ ↑←↑ °→± •• •♠≈ ←± ←÷≈ ¬ ⟨ ⊂ ÷ ← ≈♦← …±≈ ← ″→≈ ↑ ←÷≈ ↔→…≈ ±≡ ↑←↑ ± ≈ ¬ ↵″… ↑±•≈← ↵← → ≈⟨

± ↵← ≈ ←≈″← •↑ ↑← ≈≡≡≈←•♠≈″≈↑ …≈ ±″↑←→↵ ≈

≈ ← ≈→≈ ≠ ±… →±↔″ ↑ ≡±→ ≈ •≈ • •← ±↔ ↑≈← ↵ →≈≈…≈″← ≡±→ ± °↵←• ← ≠→±↔°

± •″≠ ≡ → ≈↑↑ ± ← ≈≡≡≈ ←• ≈ ←→≈↵←≥≈″←↑⟨

ð •× •← ♠ →← …↵ ≈→ ← ↔ו ÷≈ ≈ ≠ ←÷→≈↵← ≡ ↵″ ≈ • ≥

•× °≈ × ≡ ≈ ↑± • �↑ ±→←÷ •↑ … ≥• •↑÷≈… • ← °°≈ →↑ ←± ≈ ↵← •″ ↵″≈× •≠″ •″ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈⟨

Page 15: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⇒ ♦ →≈ → …↔≈↑ ←÷≈ ↔≈ ←• ←÷↵← ≈ ⇑• •ƒ≈″�↑ ⇑ ↔″• ± ↑ ≈→≈… ≈″←→↵× ←± ←÷≈ ° •↵←• ″

←÷≈ ↔ ≈ ∈≈↑↔≈ ″ �↑ …≈ו≈→↵←• ″↑ ⊂÷≈ ↵∂±→•← ♠•≈♥ ↑ ← ↵ ⋅ ↑÷±↔× ←↵∝≈ •″←±

↔ ← ←÷≈ ∈↔× ±≡ ∈≈↑ ↔≈ ↔ ±″ •″ ↑°≈ •→↔ ↑←↵″ ↑ ⊂÷≈ → →← °→±°± ≈↑ ↵ ÷≈ ∝ • ←

±≡ ↑←• ″↑ ←÷≈ ↵ ↑ ≈→ ←± •÷ • • • °×•≈… ♥• ×± ⇑⇔�↑ ↵ •↑±→ •≈ ←± ↵↑↑≈ ↑

÷≈← ≈→ ← →≈ •↑ ↵↑≈ ←± ≈ …≈ ″ → ←÷≈ →±↵… ↵ ″≠ ±≡ ÷≈ ↔ ≈ ≡ ∈≈↑↔≈ ⊂÷≈ →≈°±→← •↑ ←±

≈ ± ≥≈″…≈… ≡ → ↵←←≈ °← ″≠ ← °≈•≡ ←÷≈ ″…•←• ″↑ ↔ •÷ ↔ ≈ ≡ ∈≈↑↔≈ ↑ ← ≈

°×•≈… ∇″ ± ≈ ≈ ≥•″↵←• ″ ≈→ ←÷• ↵←← ≥°← ≡≡≈→ ≡→± ←÷→≈≈ ∂ → ↑÷±→ ≥ ↑

•→↑← ÷≈→≈ •↑ ≈↵ ≠↔•… ≈ ↵ ↔← ÷± ← ≈ ↵″↑ ≈→↑ ← ←÷≈ ↓↔≈↑ •±″ ↵→≈ ←± ≈ ≈… ⇐ ≈↑

←÷≈ ↔×≈ ±≡ ∈≈↑ ≈ ↵°° •≡ ← ≈ ↵ → ← ← ±″≈ ≡ ÷≈ ↓↔≈↑ •±″ • � ⟨ ≡ ↑± •← …

°× ←± ♠•→←↔ × ←≈ ÷″± ≠•≈↑ ↑↑ ↑↑≈… ⇑⇔ ≡ ← ÷ ♥ ≥↵ ≈↑ ↵″↑ ≈→↑ ↵→≈

→≈↓↔• ↵″… ↵→≈ ↑ ≥≈ ≈ ↵″↑ ≈→↑ ≥±→≈ •≥°±→←↵″ ÷↵ ± ÷≈→↑⟨ ↔→←÷≈→≥ →≈ …± ↑ ←÷≈ ↔ ≈

±≡ ∈≈↑ ↵→ ← ↑↵≥≈ ≈•≠÷← ÷≈″≈♠ •← ↵ °×•≈ → • ← ↵ ≥↵←← → ≡ …≈ ≈≈ ←÷↵←

↵→→•≈↑ ±→≈ ♥≈•≠÷← • ≈→← •″ ≈↑ ≈ ≠ ≈″ ±→≈ ±≡ ← ≈ ↵″↑ ≈→↑ ↵→≈ ≥ ≈ ≈≥°÷↵←•

≈↑ ⟨

≈ … ← ÷≈ ∝ • ← ∝↑ ±÷≈→≈″ ≡±↔↑ → ≈ ≥° ≈ ↓ ≈ ←• ″ ↵±↔← ←≈→″↵←• ≈

←→≈↵←≥≈″←↑ ± ≈→ °↑ •←÷ ↓↔≈↑ •±″↑ ↵±↔← ≠↵•″ ← •≡≈ ≈ °≈ ←↵″ ↓ •← •

↑• ≈ ↑ ≈ ×↔ ← ↑ ″↑ • →≈ ≈″← × • ≈ ″ ≥° •↑ ÷ ←≈→″ •♠≈ ←→≈ ← ≈″←↑

″ ↓↔≈↑←• ″ ↵± ← ≈↓↔≈″ ≈ ÷±↔× ÷≈ ←→≈↵←≥≈″← ← →≈ •♠≈… ♠≈→×↵ •←÷

↓↔≈↑ •±″ •↑ ←÷≈ •″←≈→ ≈″←•±″ →≈ •→ … ← ♠ •… • ≥≈… ←≈ × ↑↑ ≡ •≡≈ ±→↑≈ ← ≈↵↑← ← ± ≡

←÷≈ ↓↔≈↑ ″↑ ≈ → ″± →≈×↵←•±″ ÷•° ← ≈ ±≡ ∈ ↑ ↔≈ ± ≈° →≈↑ ≈ ≡→± •≥ ≈…•↵←≈ °≈→•×

± •≠ ↵ × ″≈…

→ ↑ ↔↑≈↓↔≈″ × ≈ ±→↵←≈ ″ ÷≈ •←≈→ ↔→≈

↔≈↑←•± ↵±↔← ≡↔←↔→≈

Page 16: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

≥ •↵× ≠↵•″↑ →↵•↑≈↑ ″ • °±→←↵″← ≠≈″≈→↵× ↑≈← ≡ •↑ ≈ ↔← ←÷≈ ↔≈ ≡ →≈↑≈↵→ ÷ ↑↔≈↑ ≡

°±←≈″ • ≠↵• ≡→ ≥ ± ←• ↔•″≠ →≈↑≈↵→ ÷ → °±← ″←•↵× × ↑↑ ≡→± ≈↵↑ →≈ ≈ → •↑≈ ″

→≈↑±↔→≈ ↵× ± ←• ″ →≈ ≥ ≈″… • …≈ … → ← →≈↑←→ ← ← ↑°≈•↵× ↑≈↑

•″♠ × • ↔ ≈ ±≡ ∈≈↑ ← ±↔ … ↑≈ ≥ ↔″÷≈ ≡↔ ←± …≈↵× •←÷ ÷• • °±→ ← ≠ ≈→↵ •↑↑↔≈ •

←÷≈ ″ ♦← ≡ ↵ ↑ • ↵↑≈ ↔≈↑←• ″ ð ↵ …≈≥• ↵″… ± → …↵″ ≈→↑ ← °↔ • ÷≈ ←÷

→ • ≈↑ ↵″ ← ≈→ ← ≈ ← ↵× •↑↑↔≈ ↑↑↔≈ ±≡ ±″ •±↔ •↑≈ ≈ ↵″ •⌠≥ → ↵× →≈ •↑← ≈ ↵ ←÷≈→

�≈ ≈→″ •←•≈↑� →≈ ≈ ← ← ←≈… ≈°↵ ←≈× ″… ≈ ••← •″≠ ↵°°→ →•↵←≈ ±…≈ • ← ± ↑ ≡→±

≈°•…≈≥•± ≈ ″±≥ ↑ →↵←÷≈→ ÷↵″ ↔…… ≈ ← ≠ ← ≈→ ♥•←÷ ←÷≈ ↔ ≈ ≡ ∈≈↑↔≈ •″ × ←÷≈

→≈°±→← ↵ ↑± ±″↑ …≈→↑ ÷≈ ↵→≠↔≥≈ ← ←÷ ← ← •↑ ↑ ≥≈←• ≈↑ ″±← °± ↑• ≈ ← …≈≥ ″↑←→↵←≈ ↑

≈≡ ≈←•♠≈″≈↑ ≡±→ ↑°≈ •≡ ←÷≈→↵°•≈↑ ≈↵ ≈ ←÷≈ ≈ •… ≈ ≡ → ≈≡≡≈ ←• ≈″≈↑↑ ↵ × ≈ ±≥

→ ←→ → •← ←÷→≈↑÷± … • ↵•″ ↵•↑≈↑ ↵ ≈″≈→ ↑ ← ±≡ •↑↑↔≈↑ � ↵ ↔← ↑←↵″ →…↑ ±≡ ≈♠•…≈″ ≈

… ←± …≈ •←÷ ♥ ∝ ≈ •…≈ ↑ ↵ ↵← ≈↑← ←↵″≠≈ ←•↵×

←÷•→… ↑÷±→ ≥ • ÷↵← ↵ ±≡ ←÷≈ ↓↔≈↑←• ″↑ ≈ ≈ ∝ ° →↵≥≈←≈→ ↑ ♠↵≠↔≈× …≈≡•″≈… ↵←

≈•←÷≈→ ↵ � ≈↑� → ↵ �″±� ↵″↑ ≈→ ±↔ ↔↑ × ≈ ∂ ←• •≈ ″…•″ ″ ÷≈ …≈ • •±″⌠ ↵ ≈→�↑

♥″ ∂≈←• ≈ ≈ …≠≈ ≈″← ±→ •″…≈≈… ÷± ≡ → ÷≈⟩↑÷≈ •↑ ↑ ≈ ←÷≈ ± • ≡

♠≈ ←≈ •″←≈→≈ ←↑ ⊂÷≈ ♥ →↑← ≡ ≈″…≈→ •″ ÷•↑ →≈↑°≈ ← • ≈ ↵°↑ ∉↔≈↑←• ″ ∑ ÷ ← • �≠± …

≈� ⟨ … ÷ →≠≈ …± ↑ ←÷≈ �•″ ↑≈… •≡≈ ≈♦°≈←↵″ � ÷ ≈ ← �

… ≥ ÷ ≈↵ ⟨ ∇←÷≈→ ″↑←↵″≈↑ ≡ ≈″≈↑↑ •″× …≈ ∉↔≈↑ •±″ ↑± •↑

�•≥ ≈…•↵←≈ ⟨ ∉↔≈↑←• ″ →≠ •↑ ↵ �↑• ″•≡•↵″←� • → ♠≈ ≈″← ↔↵ו← ±≡ ו≡≈⟨ ↵″

∉↔≈↑←• ″ ÷± ×↵→≠≈ •↑ ↵ �°→±÷ • •♠≈� ↑←⟨

Page 17: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⊂÷≈ →≈ →← ″±←≈ ↵← � ÷≈ ≈ ″• ≠ ±≡ ← ≈ ≥≈≈←•″ ≥ ↑← ≡ ←→•≈ → ↔ ♠≈″ ≈ ×↵

±°°±→ ↔″•← ± ←� ↓ ≈ ←• ″ ÷ ♥≈♠≈→ ÷≈ •←•ƒ �↑ ⇑± •× • ••← … •← ←÷↵← ÷≈

•≥° ≈≥≈″←↵←• ″ ≡ ÷≈ ≈ ≡ ≈↑ ↔≈ ↵ ← ≈ …±″≈ • …≈″•↵× ±≡ ± → •← ↑← ←÷≈ ↑ ±

…±•″ ↑ ← ≈ ≈… ↵≠↵•″↑ ÷≈ ↔≈ ←↵ … ← •← ⊂ •↑ ″≠ ← ↑÷ ° →≈ •≈≡ ←÷≈ ≡↵←

←÷↵← ″ • ≈≥ ←↵←• ″ ±≡ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈ ÷ ↑ ← ≈ ≈ • •″ …≈≡•″ ″≠ ←÷≈ ≈♦≈ • ″↵× ↵↑≈

� ←• → ←÷≈ ≈ °×••← •…≈ ←•≡•↵←• ″ ±≡ � ≠ ±… °→±↵ • ← ≡ •″ →≈↵↑≈ •≡≈ ≈♦°≈← ″ � …

�↑• •≡ ↵″ • °→± ≈≥ ← •″ ↵ו← ±≡ •≡≈� ⊄″ •× ←÷≈ ≈ …≈≡•″• •±″↑ ÷↵♠≈ ≈ ≈↑←↵ •↑÷≈… •← ♥•

″±← ≈ ° ↑ ≈ ← ↵↑↑≈↑↑ ←÷≈ ±↑← ±≡ ≥° ≈≥ ← ″≠ ÷• ↔×≈ ±≡ ∈≈↑ ≈ ±→ ↵↑↑≈↑↑ ÷≈←÷≈→

↑ •≈← ♠ ↔≈↑ •←↑ ≥° ≈≥≈″←↵←• ″ ± ≈ ÷• ←÷↵″ •← ±↑

•♠• ↵× ± × • ↵←•♠≈↑ ↵ ו ±× • � ← ≈ →≈× � ♦ ←•±

⊂÷≈ ⇑•←• ≈ � ⇑ ↔″• →≈°±→← …≈≥ ″↑←→↵←≈↑ ÷≈ ±″≡ •← ←♥≈≈″ ″← ←± °→ ≥ ←≈ ÷ ← ↑ ←÷≈

•″ ←•″←• ≈× →•≠÷← ← •″≠ ←± …± ← ← ÷≈ ↑↵≥≈ ←• ≈ ″± ↵″←•″≠ ← ± ↑≈ •≠÷← ±≡ ←÷≈ ° →← •←

↑←↑ ±≡ …±•″≠ ↑± ″ ←÷•↑ ↑≈ •±″ ♥≈ ±″↑ ≈→ ≈←÷≈→ ← ≈ •″ ←•″←• ≈ ↵°°≈↵ ←÷≈ ↔×≈ ±≡

∈≈↑↔≈ →≈≡ ≈ ″ ↵°°→±° •↵←≈ ±→ ↔″…↵←•± ≡±→ °↔× ×•

← ≥• ← ≈ → ≈ ÷↵← °≈±°× ÷ ≈ ↔ ↵ →• ÷←� ←± ≈ →≈↑ … ≡→ ≥ °≈→ ←÷≈ ←↵←≈

¬± ≈→ •← • ″± ×≈↵→ ÷↵← ≈ ↑ ←≈ •± ← ↑ ↵ °≈→↑±″�↑ →• ← →≈≡↔↑•″≠ ± ↑ ↔≈ ←÷≈ ←÷≈

↑↵≥≈ ♥ ← ↵← •← •≠ ← ♠• ×↵←≈ ←÷↵← → ±″�↑ →• ÷←↑ ↑ ← →← → ″≠ ÷≈≥ �÷ →• ÷←

↑↔≠ ≈↑←↑ ↵ •″ •± ≈ ↑ …≈⌠ ←→↵•″ ±″ …≈•↑• ″ ≥↵ • →↵←÷≈→ ÷↵″ ≈ ←± ≈•≠÷≈… •

←÷≈ ↵″ ≈ ↵″ ← …≈… ±≡≡ ← ≥↵→≠•″ ″↑← ± ÷≈→ °± • ≠ ↑ ↑↔ •↑ ″≠

°± • ÷≈↵×← ≈↑±↔→ ″↑←→↵ ″← ↵ • × ←± °→≈ ≈″← ″ ∈↔×≈ ±≡ ≈ ↔≈ ≡→ ≥ ↑↑↔ ″≠

Page 18: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

←÷≈ →• •… •″♠•± ↵ ≈ ÷↵ ↵←≈→ ±≡ ↵ ÷↔ ″ →•≠ ← •← •× ″≈ ≈→ ≈ °± ↑•×≈ ← ≡±→… ↵×

←≈÷″± ± • ↵×× ≡≈ ↑• ≈ ≈…• ↵× →≈↑ ≈↑

± °→±≥• •″≠ ו″≈ ±≡ ↵→≠↔≥ ″← • ← ↵°°× ←• ±≡ ∈↔ ≈ ≡ ∈≈↑↔≈ ♣ ↔ ° ו ≥↵∝≈→↑

÷↵♠≈ � • ↔≈ ±≥≈ •±″↑ ←÷≈ ↑ ←≈ ÷ ♠ •″…•→≈← ↵″…⟩±→ × ″≠⌠←≈→≥

≈″≈≡•←↑ •″ ≥↵ • ←•ƒ≈″↑ ≡ ≈× ≈←←≈→ ↔← ←÷≈ ↑ •≈← • ÷≈ •♠≈ •″ °→± ±← ″≠ ← ↔↑← ↵″…

⌠±°≈→ ←• ″ ±→ ↑• °× ↑ �←÷≈ ≡ ↵ • • •↑≈… ↵″… ÷↔ ↵″≈ ↑ •≈← �∫

•∝≈ ÷ ↵ →•≠÷←

↑ ו ↵″ ≈ ≈•≠÷≈… ″ ←÷≈ ↵″ ≈ ″… ← …≈… ±≡≡ ↵≠↵•″ ← ←÷≈→ ♠↵×↔≈↑

÷•↑ ÷↵↑ ÷≈

•≥° →←↵″← °→ ← •≥° •↵←•± ↵← ±← ≥≈…•↵× →≈↑ ≈ →≈ ≈↓↔↵× → × • ←±→ � ↵

←÷↵← ←÷≈→ ←÷•″≠ ↓↔ ± ←⌠≈≡≡≈ ←• ≈ →≈ ↔≈↑ →≈ ← ≈ °→≈≡≈→→≈… ←± ↑←⌠•″≈≡≡≈←•♠≈ ↑ ↔≈

¬± ≈→ ←÷≈→≈ →≈ °→± ≈≥ •← ←÷• •″≈ ≡ ↵→≠↔≥≈ ← •→↑← • • ÷↵→ ← ±→≥ ≈♠≈ ←÷≈ ♠↵≠↔≈↑←

≠↔≈↑ ↵ ↔← ÷≈ ≥↵≠ •← …≈ ≡ �↑ ≥± • ♠↵×↔≈� ″ ← ″× ≈ ↵ ≈ ≈≡≡≈←↑ ↵→≈ • •→≈ ← ↵″…

←≈→≥ ↔← ↵×↑ ≈↵ ≈ ↑↵≥≈ ↵ •± ≥↵ ≥± •↑≈ •≡≡≈→≈ ← ←÷ ″≠↑ ← •≡≡≈ ← •←•ƒ ↑

≈ … ←÷≈→≈ •↑ ↵″ ≈→ ↑←× ″… •→ ←• ″↵× �≠≈ ← →≈ °± •←•↑� →≈° • ≠ ↵←• ″ …≈• •

≥↵∝•″≠ ÷•→… ← • ″±← ≈ → ←÷≈→≈ •↑ ″ ו ↔≈ ″ °→±↵←•♠≈ ° • …≈ •↑• ″↑ ≈

…• ← ″≠↔• ÷ ← ↑≈ ↵→•±↑ •→ ← ≈ ± • ← •↑ ♥•× •″≠ ←± °← …•♠≈→↑• ″↑ ≡→ ≥ ÷≈

≈ ≈→↵ ↑←⌠≈≡ ≈←•♠≈″≈↑↑ →≥ •″≠ � ≈°←•± •→↔ ↑←↵″≈↑� →≈↵ •♠≈× ±″ ↵ ↵↑≈⌠

⌠ ↵↑≈ ↵↑• ≈ ÷≈ →≈ ↔≈ ←≈↵ ±•″≠ ±♠ → ↔…≠ ← ←± ↑ ≈ ÷≈ •≡≈ ≡ ←→↵°°≈ ≥ ″≈→

↑≈±″… ≈″ •± × ↑≈→ ← ÷≈ ⇑⇔ ↑≈ •↑ ♥÷≈→≈ ↑±•≈← ≈•≡•≈↑ ≈≡ →≈÷ ←÷≈ ° → •↔ →

← °≈↑ ±≡ •″ …≈″← ÷≈→≈ ←÷≈ ≈″≈→ ±↑←⌠≈≡≡≈ ←• ≈ ↑↑ ″ •↑ ← ≈ →≈ … ≠ ←± ″♠≈↑← •″

…• → °±→←• ″↵←≈ ≈♠≈ ↑ ≡ ↑°≈• •↑← ↵≡≈← °→± •↑•±″ •″ ≥ ″≈↑ ← ″ ← •″ → •× ←↔″″≈ ↑

↑±•≈← ←÷↵← … ≈↑ ″± ± ≥ …↵←≈ ← ≈ ≡±→ → ← ±≡ ♦≈°←•±″ …±≈ …≈ ↑≈≈≥ ←± ≈

Page 19: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

•″÷ ≥↵″≈ ¬ ≈ → •← • ″ ← • ←÷↵← ↑ •≈← ←÷ ← ↵ ≥ ±…↵←≈↑ ←÷≈ ←←≈→ ← °≈

≈ ≈°←•±″ •↑ ″≈≈↑↑↵→•× ÷ ↵″≈ •← •↑ ″±← ≈ → ♥ ≈→←↵•″ →±↔°↑ ≈ ≠ ≥ ″≈→↑ ↑÷±↔×… ≈←

↑°≈ •↵ →• →•← ← ←÷≈ ±↑ ≡ ≈ ≈ ±″ ≈ ↑≈ • ≈ ←→↵•″ ↑←↵≡≡ ↵ °↵↑↑≈″≠≈→↑

±→≈ ≡ … ≈″←↵× ←÷≈ ↵↑≈ ↵≠↵•″↑ °× •″≠ ← ∈↔×≈ ±≡ ∈≈↑ ≈ ← ↔ • …≈ • • • ←÷↵← ← •↑

↑≈ ↵ ″↵← →↵ ÷↔≥↵″ ≥±←• ″ ← ↵← • •→→≈ ≈ ″← ←± …≈•↑• ″ ↵″… … ≈ ∝ °←

≡•→≥× • ← ≈ →• ↵←≈ ↑ ÷≈→≈ →…•″≠ ←± ← •↑ ♠• ♥ ←÷≈ °→• → ♠•→←↔≈↑ ≡ • …≈ • •

≥↵∝•″≠ ↵→≈ • ° → • ← ↵ ↔↑←•≈ •″ ↵″•″≠ ←÷≈ • ←≈→≈↑←↑ ±≡ …•≡≡≈→≈″← °±°↔ ↵←• ≠→ °

→ ←÷≈→ ←÷↵″ °↵→←•↵ •← … ± °↵↑↑• ″ ←± ↵ …↑ ° ←•↔×↵→ • ″←• •↵×≈ •″…• •…↔↵×↑ →± ≈ ±≡ ←÷≈

°↔ • …≈•↑• ≥↵∝≈→ • ←± ↵∝≈ •≥ →← …• ° ↑ •±″↵←≈ … ≈≥≈″← ↵± →≈↑ →≈ ↵× ± ←•±″

≈← ≈″ →±↔°↑ ≡ ↔″•… •≡•≈… °≈±° ≈ ↵″… •→ �↑←↵←• ← ↵×� •♠≈

→←• •← ″…

≥° ↑ • ″ ← →…↑ ° → •↔×↵→ …≈″←• •≈… ″…• • ↵×↑ →≈ • → ° ↵←≈ ″ …≈→ ←• ↑ ← ← ÷≈

°↔ • …≈•↑• ≥↵∝≈→ ↔ … ← ← •″←≈→≡≈→≈ •← • ≈ •↑• ″ ≥ ∝•″ ↵↑ •← •↑ ↵→•←→ →

… ″ •→ ← …• •≥ ″↵←≈ ″ ≡ ±↔→ ± °≈±° ≈ ÷± ÷↵°°≈ ← ≈ •… •≡•≈… ↵″… ↵≠↵•″ ← ←÷±↑≈ ♥÷

÷ ≈ ″± ← ≈≈″ •…≈″←• •≈…

⇑ ↑• ≈ ≈↑ ±≡ ←÷≈ ∈↔ ≈ ≡ ∈≈ ↔≈ ← ↵± ← °≈ •≡ • • • ↔ ↑ …→ ″• ″ ← ≈ ←≈→ →

≈″←→ ≈ ″ ≡•→≈ ″ ≈ ≥≈…•↵× ″ ≈♦← ←÷• ± →≈↑°±″… ←± ←÷≈ •″ ↵× ≈…↑•…≈ ≈ ≈× ÷≈

°→±°→•↵←≈ ° → ≈ •″ ↵ ≈…• ″←≈ ← ←÷≈→≈≡±→≈ ÷≈← ↵″ ″…•♠ ↵× → ↵ ←≈↵≥ ≡ ≈…•↵×

↑←↵ ≡ ≈″← ≈ … ← ≈• ↔ ↔ ↵× ≡ …↔← ←± ↑ ≈ •≡ •≡≈ ↑ … °→↵•↑≈… ≡ → •″≠

↑ ⊂÷≈ ↵°°→±° •↵←≈ ° •″ ≥≈ ± ←≈ ← • ″± ÷≈←÷≈→ → ″±← ⇑⇔ ↑÷ ↔ ↔← •″ °

↑ ↑← ≥ ←• ° •±″ ≡ → ← ↑≈ ↵↑≈↑ ≈→≈ •″…• •… •♠≈ •×× ←÷→≈ ← ″≈ ≈ →≈≥•← ±≡

Page 20: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⇑⇔ … ≈↑ ″±← ± ≈→ •″…• •… ↵↑≈ •← •↑ ↵ … ≈← ↔° ←± ↵∝≈ →≈±≥ ≈″…↵←• ÷≈

″↵←•± °± • ≈ ×

⊂÷≈→≈ •↑ ↵×↑ ↵ ≡↔″ ≥≈″ ∂ ←• ″ ←± ↵ …≈≡• ←•± ≡ ÷≈ ↔×≈ ±≡ ∈≈↑↔≈ ↵↑ ↵ ≈♦≈°←• ↵

↵↑≈ ″♠ × • • • ″← …≈ ÷ ↔ ↵ ≈ ″≠↑ →≈ ±→←↵× ±″≈→ → ←≈→ ↵× •♠≈↑ •× ° ↑↑

←÷→±↔ ÷ ÷≈ ↑ ≈ ÷± ≈→ …≈≡•″≈… ↵″… ±°≈→ •±″↵ו↑ ÷≈→≈ ≈↵←÷ •↑ � ≥ •″≈″←� ± ≈

…≈ ÷↑ ↵→≈ ↔ ♦°≈ ← … ↵ … •∝ ≈ ←→ ≡≡• •…≈ ←↑ ↑ ← ←÷•↑ ♥• ÷↵°°≈″↑ ♠≈→

↑↔……≈″ ↵ • ± →→ ♥ ←÷ →≈ •↑ ≈ ≡±→ ≈…• ″←≈→♠≈″←• ″ ¬± ≈→ • ↵ → ≈

″ ≈→ ±≡ ≈↑ …≈↵← •↑ ±→≈ → ≈↑↑ °→≈…•←↵×≈ ↵″… ≈≡ →≈ …≈ ← • ≈ ↵ ↑←↵≠≈ ÷≈→≈ ←÷≈

°↵←•≈″← •× ≈ →≈ →…≈… ↵↑ ≡↵ • ≥•″≈ ← …≈ ÷ ← •↑ °→ ≈≥↵←• ←± →≈≠↵→ ≡ •″≠ ♥•← •″ ←÷•

•″ ″↑← ←↔← ″≠ ↑± ≈←÷ ″≠ ≈ ≈°←• ″ ↵″… ≈•″ ±→←÷ ≡ ↑°≈ • × ±″↑ …≈→ ←• ″ ← •

″±← ±≥ ←÷ ≈♦≈°←• ″ ↔← ↑± ≈←÷ ≈ •× ↵×× ↵↑↑ ←÷→ ↔≠÷ •″ ↑± ≈ ≡ →≥ ±→ ←÷≈→

¬↵♠•″≠ ↑≈← •…≈ ÷± ≈ ≡±→ ♥÷ ≥ ″ →≈↑ •↑ °±↑ • ≈ ″… ÷±↑≈ ≡±→ ÷±≥ ←÷≈ ↑←↵←≈ ±≡ •≥ •″≈″←

…≈ ÷ →→• ≈↑ °→≈…•←↵× ← ←÷≈ ≈ ÷♥↵ ≡ •″ →≈↵↑•″ ↵″… ↵° → °→•↵←≈× ≥↵ ↵≠≈… •

÷≈ ←÷ ≈ →≈ × ← •← ≠→± ±≡ °≈ ≈ ≡ → ÷± ←÷≈ ←→ ↑ ←•± ←± ←÷≈ ← ≈ •≥ ≈…•↵←≈ °≈→•

÷≈←÷≈→ ≡ ←↵× ±→ ″ ≡ ← ↑ ↔″≈♦ ≈ ← ↵ ≡ → ≥ ←→≈ ← ≈ ↵ ← ≠÷ ″ ← ± ← ≈≡≡≈ ←• ≈

•↑ °± ↑•×≈ ↑ ≠→±↔ • …≈≡ ″≈ ↵← ← •↑ ″±← ↵″… • °×•• ″ ←÷↵← ″ ←•±″ • ÷ × ≈

±≡ …≈♠•↑•″≠ → ⌠ ←• ≈ °± • ↑←↵←≈ ≈ ← ≡±→ ←÷≈ →←÷≈→ •← •↑ ≠→± ≥ ↑← ∝≈ ←± ≈

″ ≈ ←→ ← … ÷± ≈ ÷± ←≈→ ← ≈ ÷≈↵ ← →≈ ↑ ↑←≈ ←÷→±↔≠÷ ←÷≈ ≈ ≈→≠≈ …≈° ←≥≈″ ∑

÷• ÷ •↑ …≈↑• ≈ ↵″… ≡↔ ≈… → ÷≈ ↔ ↑≈ ±≡ →≈ ↔•″ ↑≈ ÷± ≈ • ×⌠ ← • ↔″≈ ←≈

… ←≈″←•↵× ×•≡≈ ← →≈↵←≈″• ÷≈ ↵°°→±°→• ←≈ • °± • ≈♦°→≈↑↑• ″ ±≡ ← ≥ → •≥°≈→↵←• ≈

Page 21: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

←± →≈↑ ↔≈ ←÷ ↑≈ ÷± ″≈ ←≈… ≡ • ←± •≥≥ …•↵←≈ ≈→• × ≈ ←÷≈ ≈ ≈ ≈″ ÷≈↵×←÷

↵→≈ ≈→♠• ↑

± × •±

≈ ∈↔×≈ ±≡ ∈≈↑ ↔≈ • …≈ → • ″ ≡ ↵ ≥≥ ″ ″… ↑÷↵→≈… ″…• •…↔↵× →≈↑ ±″↑≈ ← °≈±° ≈ •

•≥ ≈…•↵←≈ °≈→•× ⇒ ↵↔↑≈ ≈ ↑÷ →≈ ← •↑ →≈↑° ″↑≈ ↵↵ ≥• ↵″ °± • ≥↵ →↑ ↵♠ ↑←→↔≠ ≈

←± • °×≈ ≈″← ← •″ ÷≈ ± ←≈♦← ±≡ ÷≈↵ ←÷ ↵→≈ °± • ⊂÷≈ ≈″←→↵× → ×≈ ↵↑ ≈≈″ ←

±°≈→↵←•±″↵ •↑≈ ↔″…≈→ •″≠ ±″≈°← ↵″… ← ±→≠↵ •↑↵ • ↑ ÷↵♠≈ ≈♦° • •← ↵ °←≈… ←÷≈

≈″≠≈ ≈ ↔↑←→ • °± • ±″ ≈ ±≡ ≈↑ ↔≈ ″ °÷↵→≥↵≈↔←• ♠≈ ↵≠ …≈ •↑• ″↑ •↑ •″

≡ ← ≥ ↑← ± °× ←≈× …• ±→ ≈… ≡→±≥ ←÷≈ ±→• ↵× ″ °← ≡ • ≈…•↵←≈ °≈→ ↵″… ≡ ↔ ↑

•″ ←≈ ±″ ↵ •≡ ≈→≈ ← ↑≈← ≡ • ↑↔≈↑ →±↔″… ″≠ ÷≈ °→± ≈≥ ≡ →°÷ … ⊂÷≈ ⇑⇔

⇑ ←•ƒ≈″�↑ ⇑ • →≈°±→← °→ ♠•…≈↑ ↔ ≈≡ →≈÷≈↵→↑ ≡ ←÷≈ • ↑↔≈↑ ↔← •″ ←÷≈ • ↵″ ↑• ←÷≈•→

↑ ×↔←•± •↑ ↑± ≈× …≈≡•″≈ ← ← • ↑ ←± °→± • ≈ ≈ ±°≈→↵←• ″↵× ≠↔•…↵″ ≈∫

⊂÷≈ ∈ ≈ ±≡ ≈↑ ↔≈ � • ≈ ÷≈ ±→↵× • → ←•♠ ←± →≈↑↔≈ …≈″←•≡•≈… ″…• ↔ ↑ ″ •≥ ≈…•↵←≈

°≈→•× →≈≠↵→…×≈ ↑ ≡ ↑← • ↑← ″← ≡ ±≥ ←÷≈ ≠ ≈→↵× •↑ ±≡ ±″≈→″ ≡ → ←÷ ↑≈♠≈→≈× •× ♥÷•÷

…±≈↑ ← ←↵÷ ≈ ↵ • °±→←↵ ≈ ≈•←÷≈→ ←± ÷≈ • ≥≈ •↵ ±≡ • ↑↑ → ← ←÷≈ •≡•↵•× ← ±≡

←÷≈ ″…• • ↵× ″ → ≈… ″ו∝≈ ←÷≈ ∈↔ ≈ ≡ ∈≈↑↔≈ ±″≈→″ ≡±→ ←÷≈ ↑≈♠ ≈× •×× ≈

≠→ ↔ …≈ ≠≈″≈→↵ו ↵ ≈ • ↓↔≈↑←• ″↵ ≈ ° •× ↑±°÷• °→•″•° ≈↑ ≡ ←• ↓ ″←• •≈… ″

≡±→ • ↵× ≡±→ ≈ ≥• ≈ ↵←• ″∫

∈≈≡ ≈ ←•″ ↔° ″ ÷≈ °± ↑• ≈ ±→↵× ≡±↔″…↵←• ″↑ ≡ → ÷≈ ↔↑≈ ±≡ ↔× ±≡ ∈≈↑↔≈ •″ °↔ • →≈↑ ↔→ ≈

± ←•± •← •↑ …•≡≡ ↔× ←± ≡ ″… ″ •″ ″≠ →≠↔ ≈″← → …≈♠≈× °• °→±⌠ ←•♠≈ ↑±•↵× ••≈↑

Page 22: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

±″ ÷≈ ≡ ↔″…↵←• ″ ″…•♠ …↔ ±→↵× →≈ ≈↑ ← ≈ ≈°←• ″ •→↔ ↑←↵″≈↑ ⊂÷≈ ↵° → •↵←≈

→ ×≈ ≡ → ←÷≈ • …≈ •↑• ″ ∝≈→ • ← ≈″↑↔→≈ • ° ←•↵× ← ↵″… ↔ ←• ≈ •″ ↵×↵″•″ ≈ •″←≈→≈↑←

± ↔″•…≈″←• •≈… •″…• •…↔↵× ≈ • ←± …•≡≡≈→≈″← °↔×↵ •±″ ≠→ ↔ ↑ ← • •∝≈× ← ↵← °↔× ° ו

≥↵∝≈→↑ ″ ÷↔ ↵″≈ ↑ •≈← ↑÷±↔ … ≡↵•×• ↵←≈ ≈ ≈°←• ″ …≈° → → ↑ ≡→± ↵ ± ← ≈≡≡≈ ←• ≈″≈↑↑

″±→ ↵← •× ±≥ ←•≥≈↑ •←≈ →• ÷← ≈ …≈ ÷≈ ←÷ → ≡≈↑↑• ↵× °≈→ ← ″≠ ← ← ″•

≈…↑•…≈ ×≈ •″ ↵∝•″≠ ≈• •±″ ↵±↔← …≈ •≡•≈… •♠ …↔ ↑ ↔← •← • ← ↑± ±♠• ↔↑ ←÷↵← ←÷≈

↑÷±↔ … ≥ ←←≈→ ≡ • ו ≈♦≈ ← ↵″ ±″≈ ≠→±↔° ≡ ″•…≈″←• •≈… •″…•♠ …↔↵×↑ •←÷

↑ •≈← → ≥ ← ≈ → ≈↑ ±≡ ° →←↔ •← ±↑← ↵← ← ≈ ≈♦°≈″↑≈ ±≡ ↵ × ±←÷≈→↑

Page 23: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

ð

⇓ ♥ ≠≈ ←↑

≈ ↔ →↑ … •∝≈ ← ←÷↵″∝ ∏↵→ ⇑ ♦← ″ ⇔→ ∝ … → ÷≈ ≡↔ ≥≈″←↑ •÷ …

⇑ ±∝↑±″ •↑ ≡↔ ≈… ⇑ ¬≈ ≈→ • ≈↑ ∈≈↑≈↵→ ÷ °≈• → • ≈××± ↑÷•° ð⟩

⇑± ≈←• ⋅ ≈→≈↑←↑

∈• →… ⇑ ±∝↑± • ≈ ≈→ ←÷≈ ⇔ °→↵•↑ ⇑± ≥ ←←≈≈

⇑÷→ ↑←± ≈→ ≈ ↵↑ → • × ≡↔ …≈… ←÷≈ •± ″↑←•← ←≈ ≡ → ¬≈↵×←÷ ″… ⇑ •″•↵×

⇔♦≈×× ≈ ≈← ðð ↵″… ðð

Page 24: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

∈≈ ≈ ≈ ↑

√±″↑≈″ ∈ ⇒≈″ ↵ ″ ± ⊂≈ ÷″ ≠ ↑↑≈↑ ≥≈″← ↵″… ¬ ←÷ →≈ ↵× ←• ″ ↵♥

≈… ≈ ↵″… ≈ ←÷ ⇑ →≈∑ ∑ ⌠

¬ …±→″ ⇑ ≈←← ″≠ ÷≈↵×←÷ →≈ ° •±→• •≈↑ • ∇→≈ ±″ ±↑← ≈≡≡≈ ←• ≈ ≈ ↑ ≈≈←↑ ÷≈ →↔ ≈ ≡

→≈↑ √ ⌠

•≈ •÷ …↑±″ ÷≈ ≈ ±≡ ≈↑ ↔≈ ± • ≈… ∑ ð�

√≈″″• ⇔ ↵″… ± ≈ ←≈•″ ⇔ ° • •″≠ ←÷≈ � …≈″ • • ≈ ♠• •≥ ≈≡≡≈ ←� √ ↔→″ ≡ •↑

… ≈→←↵•″←

←• ″↵× ″↑←•←↔←≈ ≡±→ ≈ ←÷ ↵ ו • ⇔♦≈ ×≈″≈ •←•ƒ ⇑ ↔″•× ∈≈° →← ← ↔×≈ ±≡

∈≈↑↔≈ ⇑⇔ ±″…±″ ðð ÷← °⟩ ♥ ♥ •≈ →≠ ⟩°↵≠≈ ↵↑°♦⟨ ≈↑↑≈…

⟩ ð

∈ • ↔ ♣≈→ ←•±″↵× ″↑← ←↔←≈ ≡ → ⇑ •″• ⇔♦≈ ×≈ ≈ ↵″… •← ↔≈ ↔ ≈≥≈″←

⇒→• • ≈… ↵× √±↔ ↵ ðð ⌠

←• ″↵× ″↑←•←↔←≈ ≡±→ ≈ ←÷ ↵″… ו • ⇔♦≈× ≈″≈ ⇑⇔ ± •↵× ⊇ ↔≈ ↔…≠≈ ≈″← �

→• ° ≈↑ ≡±→ ÷≈ …≈ ≈× °≥≈″← ≡ ⇑⇔ ∧↔ ≈ ±″…±″ ⇑⇔

÷←←° ⟩⟩ ♥ ″• ≈ ±→ ° ≠≈ °♦⟨ ↑♠∂ ↔•…↵″ ≈ ↑≈… ð

⇐≈° →←≥ ≡ ¬≈↵×←÷ ↵″… ≈•″≠ ∧↔•…≈ •″≈↑ ≡ → ≈ ÷ → ↔← ″ ↔↑ ±″ →≈° → • ″

±≡ ↔ •↑ • ←± ÷≈ ÷ → ≈↔← ↵ ⇒≈″≈≡•←↑ …♠• ±→ ⇑ ≥ •←←≈≈ •″ •″ ≥↵∂ →

↑↔ •↑ •±″↑ ″♠± • ≈ ″±≥• ↵″ ≈ ↑← •↵ ±♠≈→″≥≈″← ≈ ↵→ ≥ ← ±≡ ¬≈ ←÷

… ≠≈•″ ⇑ ″≈→→

÷←←° ⟩⟩ ♥ ÷≈ ←÷ ≠ ♠ ↵ •″←≈ ≈←⟩ ≥↑⟩ ↔ו ÷ ″↑ ⟩⇑± ←≈″← ÷≈ ←÷⌠° ⌠≠≈″≈→ × ↔

°÷↵→≥°↵ ⌠ ÷←≥ ≈ ↑≈…

Page 25: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⇑×↵♦← ↵″… ⇑↔ ≈→ ⊃• …″≈↑↑ ±→ × ⟨ ≈←÷•↑ ±≡ …≈ • ±″↑ √±↔ ″ ±≡

≈… ←÷• ð ⌠

ð ↵→≡•← ⇐ �⇔↓ •← ≡ °→•±→•← ⟨� →≈° •″←≈… • ⇑ ← ″ ⊃• •↵≥↑ ≈…↑ ⊂÷≈

•…≈ ±≡ ↓↔ ← ⇒ • ↑← ∝≈ ↵≥• ×↵″ ↑↑ ðð

• ≈→ ⇐ → ″•°×≈ ±≡ ↑±•↵ ←•≈ ⇒ ↑←± ¬ → • ≈→↑•← →≈↑↑ ðð

∏↵≥ → •← ±→← ← ⊇ × ≈ ←÷ ⊃÷ ≥ ←± ↵♠≈ →±≥ ← ∇♦≡ →

∇ →… ⊄″•♠≈→↑• →≈↑↑

∈ ↑ √ ≈ ±≡ √ ←•≈ ↵→♠↵ ⊄″• ≈→↑•← ↑↑ ⇒≈ ∝ ↵° →≈↑↑ ¬↵→♠↵→

⇒→± ≥≈ √ �∧ ±… ≡ •→″≈↑↑ ↵″… ↓ ↑ ″ ÷• ± ♣ ↵ •↵× ⊃≈×≡↵ ≈…•←≈… ←

⇒≈ ″… ↑ ≈ …↔↑ ⇑ → …≠≈ → ≈ ⊄″•♠≈ ↑•← →≈↑ ° �

⇑↔× ″… ⊃↵≠↑←↵≡ ↓↔ ← ↵″… ↓↔↵ו← •″ ≈ ←÷ ¬≈ ⇑ →≈ √±↔ ″

¬≈↵×←÷ ⇔ ″± ∑ ⌠

⇑± ±″ ∈ … ⇐± ↵″ •″ ≈↑ ±≡ ∂ ↑ • ≈ •″ ÷≈ ←÷ ↵ →↵←• ″ ±↔ ″ ≡ ≈…

⇔←÷• ðð ⌠

±→… ⇔ ⇑± ←⌠♠ ↔≈ ↑•↑ •″ ←÷ →≈ •″≠ ↑≈″↑≈ ±≡ ⇓∩ ⇑↵ →•… ≈ ↵≥→•… ≈

⊄″•♠≈→ •← →≈↑↑

±→… ⇔ ¬≈↵× ÷ ← ←≈ ♠↵×↔≈↑ ≡→± ↔ ←•↵←←→ ↔←≈ ←• •← • ←→↔≥≈ ←↑ ″≈≈… →→≈←•±″ ″ ↵× ±

≈…• ≈ ⌠

± ≈≠• ″ ≈… ↑ ⇑ ″←→± ⇓≠≈″ ±→♥≈≠•↵ ≠↔ ≈ •″≈↑ ≡ → ↵→ ≈ ″±≥•

↑•↑ • ←• ″ •← ↵°° • ↵←• ≡±→ •≥↔→↑≈ ≈″← ⇑ ∇↑ ðð

÷←←° ⟩♥♥ ≠≈ •… × →∝≈← ″± ←≈≥ ←≈↑⟩ ″←≈→ ↵≠≈ℑℑℑℑ ↑°♦ ≈↑↑ ⟩ ð

ð ⊃• ↵≥↑ ÷≈ �≡↵• •″″ ↑� ↵→≠↔ ≈″← …≈↑≈→♠≈↑ ≡↵•→≈→ ÷≈ → ″≠ ⇑ ≥ ≈″ ×↵″

•× • ↑ ±→… … √ ÷↵″ ↑↑±″ ¬≈↵ ← ⇔ ″ ∑

Page 26: Public health care resource allocation and the rule of rescue · Journal of Medical Ethics 2008;34(7):540-4. White Rose Research Online eprints@whiterose.ac.uk - 2 - Health Economics

⇑↵≈ ⇑ ⇑ ♦← ″ ∏ ↑↔÷• ⇓ ∇→°÷↵″ ↔≠↑ ↵″… ÷≈ ¬ … ≈ ↔≈ →↵→•← ⟨

⇒→• • ≈… ↵× √±↔ ↵× ð∑ ð⌠

±±… ↵″… ⇐ ↔≠ …≥ ″• ←→ •±″ ∇→ ÷↵ … ↔≠ ↵← ↵↑ ≈″…≈… ♥♥ ≡ ↵ ± ⟩±→°÷↵″⟩ ↵ ÷←

≈≠↔×↵←• ″ ⇔⇑ ± ðð ≡ ≈ ⇔↔→ ≈↵″ ↵→ו ≥≈″ ↵″… ≡ ÷≈ ⇑ ↔″• ±≡ ⇐≈≈≥≈→

″ →°÷↵″ ≈…••″↵ °→±…↔ ↑ ∇≡≡•• √±↔→″↵× ±≡ ÷≈ ±°≈ ⇑ ≥ ←•≈↑

ð ⌠

±ƒ•∝ ∈ ⊂÷≈ ↵←↔→≈ ±≡ ∈↵ •±″↵ו← →•″≈←±″ →•″≈←±″ ⊄″• ≈→↑•← →≈↑↑ ðð

→±± ≈ √ ⊂ •″ ←± ♠↵×↔≈ ↵ ו ≈ √ ↔→″ ≡ • ⇔ ″± •↑ ∑ ⌠

∧± •″ ⊄ • •←↵→ ↑ ↵ ↔ • • ± ±°÷ ↵≥→•… ≈ ⇑↵ → …≠≈ ⊄″•♠≈→↑•← →≈ ↑