Fair allocation of scarce healthcare resources has been much studied within philosophy and bioethics, but analysis has focused on a narrow range of cases. The Covid-19 pandemic provided significant new challenges, making powerfully visible the extent to which health systems can be fragile, and how scarcities within crucial elements of interlinked care pathways can lead to cascading failures. Health system resilience, while previously a key topic in global health, can now be seen to be a vital concern in high-income countries too. Unfortunately, mainstream philosophical approaches to the ethics of rationing and prioritisation provide little guidance for these new problems of scarcity. Indeed, the cascading failures were arguably exacerbated by earlier attempts to make health systems leaner and more efficient. This paper argues that health systems should move from simple and atomistic approaches to measuring effectiveness to approaches that are holistic both in focusing on performance at the level of the health system as a whole, and also in incorporating a wider range of ethical concerns in thinking about what makes a health system good.

哲学和生物伦理学领域对稀缺医疗资源的公平分配进行了大量研究，但分析只集中在少数案例上。Covid-19 大流行带来了重大的新挑战，使人们清楚地看到卫生系统的脆弱程度，以及相互关联的护理途径关键要素的稀缺如何导致连锁故障。卫生系统的复原力虽然以前是全球卫生的一个关键话题，但现在也被视为高收入国家的一个重要问题。不幸的是，配给和优先排序伦理学的主流哲学方法对这些新的稀缺问题几乎没有提供指导。事实上，早期旨在使卫生系统更精简、更高效的尝试可以说加剧了一系列的失败。本文认为，卫生系统应从衡量有效性的简单和原子主义方法转向整体方法，既关注整个卫生系统水平的绩效，又在思考问题时纳入更广泛的伦理问题。是什么让卫生系统变得良好。