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Paul T Menzel

Pacific Lutheran University, Philosophy, Emeritus

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Paul T. Menzel, PhD, is Professor of Philosophy emeritus, Pacific Lutheran University. He has published widely on moral questions in health economics and health policy, including Strong Medicine:The Ethical Rationing of Health Care, and (as co-editor) Prevention vs. Treatment: What's the Right Balance? Most recently he has written on end-of-life issues, including advance directives for dementia and voluntarily stopping eating and drinking. He has been a visiting scholar at Kennedy Institute of Ethics, Rockefeller Center-Bellagio, Brocher Foundation, and Chinese University of Hong Kong. He resides now in Oakland, CA
Phone: 1-360-969-2760
Address: 373 50th Street, Oakland, CA 94609

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Papers by Paul T Menzel

Medical Costs, Moral Choices: A Philosophy of Health Care Economics in America

Journal of Policy Analysis and Management, 1984

Challenging the brain to think better and faster can be undergone by some ways. Experiencing, lis... more Challenging the brain to think better and faster can be undergone by some ways. Experiencing, listening to the other experience, adventuring, studying, training, and more practical activities may help you to improve. But here, if you don't have enough time to get the thing directly, you can take a very easy way. Reading is the easiest activity that can be done everywhere you want.

Cash or In-Kind Aid?

Prevention vs. TreatmentWhat's the Right Balance?

An inquiry into the different perspectives that can be used when eliciting preferences in health

Health Economics, 2003

There are a number of perspectives that an individual could be asked to adopt in studies designed... more There are a number of perspectives that an individual could be asked to adopt in studies designed to elicit preferences for use in informing resource allocation decisions in health care. This paper develops a conceptual framework that clearly distinguishes between six different perspectives. It is argued that the appropriate perspective to use depends on normative considerations and the particular policy context to which it will be applied. We suggest a future research agenda that explicitly addresses these considerations and which involves direct empirical investigation into the effect of perspective on preferences.

A Conservative Case for Universal Access to Health Care

Hastings Center Report, 2006

Incorporating societal concerns for fairness in numerical valuations of health programmes

Health Economics, Feb 1, 1999

The paper addresses some limitations of the QALY approach and outlines a valuation procedure that... more The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.

The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis

Social Science & Medicine, Dec 1, 2002

Chronically ill and disabled patients generally rate the value of their lives in a given health s... more Chronically ill and disabled patients generally rate the value of their lives in a given health state more highly than do hypothetical patients imagining themselves to be in such states. Much of this difference may be due to actual patients' adaptation to their health states, a phenomenon that would not typically affect the ratings of persons who only hypothetically imagine themselves to be patients. This article pursues a non-empirical, normative question: does such adaptation render actual patients' ratings of quality of life morally questionable for purposes of resource allocation? Distinguishing the different basic elements in patient adaptation reveals why, and in what respects, people are pulled strongly in opposite directions in responding to this question. Several more explicit moral arguments against using adapted patients' ratings have been articulated by economists and philosophers, and others are developed by the authors. While most of these arguments do not survive careful analysis, several do. Given the subsequent complexity of the matter, it is argued that: (1) Neither solely actual nor solely hypothetical patient perspectives should be used for rating quality of life. (2) Even if representatives of the general public acting as hypothetical patients provide ultimately the best perspective from which to discern societal values about health states, patients' values that are often influenced by adaptation must still be conveyed to and clearly understood by public representatives as a critically important fact about health-related quality of life. The article also points to the need for much additional work on adaptation, both empirical research and normative analysis.

Talking to each other about universal health care: Do values belong in the discussion? reply

Hastings Center Report, 2006

Societal value, the person trade-off, and the dilemma of whose values to measure for cost-effectiveness analysis

Health Economics, Mar 1, 2000

In a previous paper, it was argued that Societal Value measurement through person trade-off (PTO)... more In a previous paper, it was argued that Societal Value measurement through person trade-off (PTO) elicitation offers a way to include the values of both general public and patients into cost-effectiveness analysis (CEA). It was said that patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; values could be used to estimate the effect that various health care dimensions have on health-related utility and that public values could be used to estimate the Societal Value of these changes in utility. However, this previous proposal still creates opportunities for the public to misvalue the benefit of health care interventions because of bias or misunderstanding about what the health-related utility really is of various illnesses or disabilities. A procedure that combines patient and public values into CEA to partially correct for this bias is suggested in this paper. In addition, it is pointed out that, although Societal Value measurement offers a role for distinctly public preferences in CEA, it still does not answer the question of whose utilities ought to be included in CEA.

Towards a broader conception of values in measuring health care cost-effectiveness

Toward a Broader View of Values in Cost-Effectiveness Analysis of Health

Hastings Center Report, May 1, 1999

By registering different health benefits on a common scale, CEA allows us to assess the relative ... more By registering different health benefits on a common scale, CEA allows us to assess the relative social importance of different health care interventions and opens the way for the allocation decisions of health care policy. If it is really to be effective, however, CEA must be recalibrated so that it better reflects some of our widely held beliefs about the merits of different kinds of treatment.

Voluntarily Stopping Eating and Drinking: A Normative Comparison with Refusing Lifesaving Treatment and Advance Directives

Journal of Law, Medicine & Ethics, 2017

Refusal of lifesaving treatment, and such refusal by advance directive, are widely recognized as ... more Refusal of lifesaving treatment, and such refusal by advance directive, are widely recognized as ethically and legally permissible. Voluntarily stopping eating and drinking (VSED) is not. Ethically and legally, how does VSED compare with these two more established ways for patients to control the end of life? Is it more questionable because with VSED the patient intends to cause her death, or because those who assist it with palliative care could be assisting a suicide?In fact the ethical and legal basis for VSED is virtually as strong as for refusing lifesaving treatment and less problematic than the basis for refusing treatment by advance directive. VSED should take its proper place among the accepted, permissible ways by which people can control the time and manner of death.

Advance Directives, Dementia, and Eligibility for Physician-Assisted Death

Some Cost-Cutting Proposals

Medical Costs, Moral Choices

Brennan Troyen, Just Doctoring: Medical Ethics in the Liberal State. Berkeley, CA: University of California Press, 1991, 287 pp. with index, $34.95

American Journal of Law & Medicine, 1992

In this accurately titled book, Troyen Brennan argues that the traditional medical ethic which em... more In this accurately titled book, Troyen Brennan argues that the traditional medical ethic which emphasizes the beneficent physician's loyalty to the welfare of the individual patient must be constrained by larger societal considerations contained in "the public morality of liberalism". The liberalism that Brennan refers to is not just some particular political version of the 1990s or the United States, but the broad philosophical tradition that adds explicit consideration of equality to classic liberalism's emphasis on negative freedom, individual rights, and market economies. First, the new medical ethic should disavow all paternalism and respect the autonomy of patients. Second, it should incorporate society's economic and institutional concerns. Third, it should retain altruism, a virtue that requires more of physicians in individual patient relations than mere contractual fidelity. For example, commitment to all patients, not just those of the specific physician. In such altruism, duties of political involvement, especially for achieving universal access to medical care, are a professional responsibility and not merely a personal one.

Change of Mind: An Issue for Advance Directives

Avoid Advanced Dementia with an Advance Directive for Stopping Eating and Drinking

The American Journal of Medicine, 2021

Advance Directives for Dementia Can Survive Altered Preferences

The American Journal of Bioethics, 2020

Emily Walsh argues, correctly, that preference changes in progressive dementia attributable to “t... more Emily Walsh argues, correctly, that preference changes in progressive dementia attributable to “transformative experiences” can diminish the moral weight of advance directives (ADs). She also contends that an influential positive philosophical view about directives (to her, “the dominant view”) fails to account for transformative experiences, and that this failure explains why the view is at odds with clinicians’ typical and justified skepticism about ADs. Her analysis ends on a constructive note, suggesting important improvements to be made in ADs. Despite these notable strengths, Walsh’s analysis overplays the potential of transformative experience in dementia to constitute a relevant change of mind about a previous AD, misses a crucial element behind ADs’ moral weight, seems not to grasp what many people who write ADs about dementia are focusing on, and fails to examine carefully the subjective value of survival in precisely the dementia situations that many ADs address. After explaining these weaknesses, I, like Walsh, end on a positive note, refining one of Walsh’s important suggested improvements.

Physician-Assisted Death: What Everyone Needs to Know

Journal of the Medical Library Association, 2018

Physician-Assisted Death is recommended for academic medical centers and hospital libraries. It c... more

Justifying a Surrogate’s Request to Forego Oral Feeding

The American Journal of Bioethics, 2019

Medical Costs, Moral Choices: A Philosophy of Health Care Economics in America

Journal of Policy Analysis and Management, 1984

Challenging the brain to think better and faster can be undergone by some ways. Experiencing, lis... more Challenging the brain to think better and faster can be undergone by some ways. Experiencing, listening to the other experience, adventuring, studying, training, and more practical activities may help you to improve. But here, if you don't have enough time to get the thing directly, you can take a very easy way. Reading is the easiest activity that can be done everywhere you want.

Cash or In-Kind Aid?

Prevention vs. TreatmentWhat's the Right Balance?

An inquiry into the different perspectives that can be used when eliciting preferences in health

Health Economics, 2003

There are a number of perspectives that an individual could be asked to adopt in studies designed... more There are a number of perspectives that an individual could be asked to adopt in studies designed to elicit preferences for use in informing resource allocation decisions in health care. This paper develops a conceptual framework that clearly distinguishes between six different perspectives. It is argued that the appropriate perspective to use depends on normative considerations and the particular policy context to which it will be applied. We suggest a future research agenda that explicitly addresses these considerations and which involves direct empirical investigation into the effect of perspective on preferences.

A Conservative Case for Universal Access to Health Care

Hastings Center Report, 2006

Incorporating societal concerns for fairness in numerical valuations of health programmes

Health Economics, Feb 1, 1999

The paper addresses some limitations of the QALY approach and outlines a valuation procedure that... more The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.

The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis

Social Science & Medicine, Dec 1, 2002

Chronically ill and disabled patients generally rate the value of their lives in a given health s... more Chronically ill and disabled patients generally rate the value of their lives in a given health state more highly than do hypothetical patients imagining themselves to be in such states. Much of this difference may be due to actual patients' adaptation to their health states, a phenomenon that would not typically affect the ratings of persons who only hypothetically imagine themselves to be patients. This article pursues a non-empirical, normative question: does such adaptation render actual patients' ratings of quality of life morally questionable for purposes of resource allocation? Distinguishing the different basic elements in patient adaptation reveals why, and in what respects, people are pulled strongly in opposite directions in responding to this question. Several more explicit moral arguments against using adapted patients' ratings have been articulated by economists and philosophers, and others are developed by the authors. While most of these arguments do not survive careful analysis, several do. Given the subsequent complexity of the matter, it is argued that: (1) Neither solely actual nor solely hypothetical patient perspectives should be used for rating quality of life. (2) Even if representatives of the general public acting as hypothetical patients provide ultimately the best perspective from which to discern societal values about health states, patients' values that are often influenced by adaptation must still be conveyed to and clearly understood by public representatives as a critically important fact about health-related quality of life. The article also points to the need for much additional work on adaptation, both empirical research and normative analysis.

Talking to each other about universal health care: Do values belong in the discussion? reply

Hastings Center Report, 2006

Societal value, the person trade-off, and the dilemma of whose values to measure for cost-effectiveness analysis

Health Economics, Mar 1, 2000

In a previous paper, it was argued that Societal Value measurement through person trade-off (PTO)... more In a previous paper, it was argued that Societal Value measurement through person trade-off (PTO) elicitation offers a way to include the values of both general public and patients into cost-effectiveness analysis (CEA). It was said that patients&amp;amp;amp;amp;amp;amp;amp;amp;#39; values could be used to estimate the effect that various health care dimensions have on health-related utility and that public values could be used to estimate the Societal Value of these changes in utility. However, this previous proposal still creates opportunities for the public to misvalue the benefit of health care interventions because of bias or misunderstanding about what the health-related utility really is of various illnesses or disabilities. A procedure that combines patient and public values into CEA to partially correct for this bias is suggested in this paper. In addition, it is pointed out that, although Societal Value measurement offers a role for distinctly public preferences in CEA, it still does not answer the question of whose utilities ought to be included in CEA.

Towards a broader conception of values in measuring health care cost-effectiveness

Toward a Broader View of Values in Cost-Effectiveness Analysis of Health

Hastings Center Report, May 1, 1999

By registering different health benefits on a common scale, CEA allows us to assess the relative ... more By registering different health benefits on a common scale, CEA allows us to assess the relative social importance of different health care interventions and opens the way for the allocation decisions of health care policy. If it is really to be effective, however, CEA must be recalibrated so that it better reflects some of our widely held beliefs about the merits of different kinds of treatment.

Voluntarily Stopping Eating and Drinking: A Normative Comparison with Refusing Lifesaving Treatment and Advance Directives

Journal of Law, Medicine & Ethics, 2017

Refusal of lifesaving treatment, and such refusal by advance directive, are widely recognized as ... more Refusal of lifesaving treatment, and such refusal by advance directive, are widely recognized as ethically and legally permissible. Voluntarily stopping eating and drinking (VSED) is not. Ethically and legally, how does VSED compare with these two more established ways for patients to control the end of life? Is it more questionable because with VSED the patient intends to cause her death, or because those who assist it with palliative care could be assisting a suicide?In fact the ethical and legal basis for VSED is virtually as strong as for refusing lifesaving treatment and less problematic than the basis for refusing treatment by advance directive. VSED should take its proper place among the accepted, permissible ways by which people can control the time and manner of death.

Advance Directives, Dementia, and Eligibility for Physician-Assisted Death

Some Cost-Cutting Proposals

Medical Costs, Moral Choices

Brennan Troyen, Just Doctoring: Medical Ethics in the Liberal State. Berkeley, CA: University of California Press, 1991, 287 pp. with index, $34.95

American Journal of Law & Medicine, 1992

In this accurately titled book, Troyen Brennan argues that the traditional medical ethic which em... more In this accurately titled book, Troyen Brennan argues that the traditional medical ethic which emphasizes the beneficent physician's loyalty to the welfare of the individual patient must be constrained by larger societal considerations contained in "the public morality of liberalism". The liberalism that Brennan refers to is not just some particular political version of the 1990s or the United States, but the broad philosophical tradition that adds explicit consideration of equality to classic liberalism's emphasis on negative freedom, individual rights, and market economies. First, the new medical ethic should disavow all paternalism and respect the autonomy of patients. Second, it should incorporate society's economic and institutional concerns. Third, it should retain altruism, a virtue that requires more of physicians in individual patient relations than mere contractual fidelity. For example, commitment to all patients, not just those of the specific physician. In such altruism, duties of political involvement, especially for achieving universal access to medical care, are a professional responsibility and not merely a personal one.

Change of Mind: An Issue for Advance Directives

Avoid Advanced Dementia with an Advance Directive for Stopping Eating and Drinking

The American Journal of Medicine, 2021

Advance Directives for Dementia Can Survive Altered Preferences

The American Journal of Bioethics, 2020

Emily Walsh argues, correctly, that preference changes in progressive dementia attributable to “t... more Emily Walsh argues, correctly, that preference changes in progressive dementia attributable to “transformative experiences” can diminish the moral weight of advance directives (ADs). She also contends that an influential positive philosophical view about directives (to her, “the dominant view”) fails to account for transformative experiences, and that this failure explains why the view is at odds with clinicians’ typical and justified skepticism about ADs. Her analysis ends on a constructive note, suggesting important improvements to be made in ADs. Despite these notable strengths, Walsh’s analysis overplays the potential of transformative experience in dementia to constitute a relevant change of mind about a previous AD, misses a crucial element behind ADs’ moral weight, seems not to grasp what many people who write ADs about dementia are focusing on, and fails to examine carefully the subjective value of survival in precisely the dementia situations that many ADs address. After explaining these weaknesses, I, like Walsh, end on a positive note, refining one of Walsh’s important suggested improvements.

Physician-Assisted Death: What Everyone Needs to Know

Journal of the Medical Library Association, 2018

Physician-Assisted Death is recommended for academic medical centers and hospital libraries. It c... more

Justifying a Surrogate’s Request to Forego Oral Feeding

The American Journal of Bioethics, 2019