Physician-assisted suicide laws in Oregon and Washington require the person's current competency and a prognosis of terminal illness. In The Netherlands voluntariness and unbearable suffering are required for euthanasia. Many people are more concerned about the loss of autonomy and independence in years of severe dementia than about pain and suffering in their last months. To address this concern, people could write advance directives for physician-assisted death in dementia. Should such directives be implemented even though, at the time, the person (...) is no longer competent and would not be either terminally ill or suffering unbearably? We argue that in many cases they should be, and that a sliding scale which considers both autonomy and the capacity for enjoyment provides the best justification for determining when: when written by a previously well-informed and competent person, such a directive gains in authority as the later person's capacities to generate new critical interests and to enjoy life decrease. Such an extension of legalized death assistance is grounded in the same central value of voluntariness that undergirds the current more limited legalization. (shrink)

Almost all jurisdictions where physician-assisted death is legal require that the requesting individual be competent to make medical decisions at time of assistance. The requirement of contemporary competence is intended to ensure that PAD is limited to people who really want to die and have the cognitive ability to make a final choice of such enormous import. Along with terminal illness, defined as prognosis of death within six months, contemporary competence is regarded as an important safeguard against mistake and abuse, (...) arguably the strongest objections to legalizing PAD.The insistence on contemporary competence is problematic. It means that someone who has dementia is ruled out as a candidate for PAD, even if she is terminally ill and suffering terrible and unrelievable pain. It also rules out individuals with strong and unwavering desires not to end their life in dementia. (shrink)

Competent patients have considerable legal authority to control life‐and‐death care. They may refuse medical life support, including medically delivered food and fluids. Even when they are not in need of any life‐saving care, they may expedite death by refusing food and water by mouth—voluntarily stopping eating and drinking, or VSED. Neither right is limited to terminal illness. In addition, in four U.S. states, competent patients, if terminally ill, may obtain lethal drugs for aid‐in‐dying.For people who have dementia and are no (...) longer competent, however, control over the end of life is much less extensive. They may have written a clear advance directive for refusing life‐saving care in specified circumstances yet subsequently find themselves living for years in severe dementia with no need for life‐saving care that could be refused. Chronic progressive dementia is not itself life threatening until its very final stage. Even in jurisdictions that permit active aid‐in‐dying, individuals with advanced dementia are not eligible; they lack the required current competence, and they are seldom deemed terminally ill. As for the right to VSED, its very name—voluntarily stopping eating and drinking—is seen as excluding noncompetent persons.One option for ensuring that one does not live years in severe dementia is to use advance directives to withhold food and water by mouth. The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment. Thus, if incompetent people do not lose their rights to refuse life‐saving treatment, and if people when competent have just as strong a right to VSED as they do to refuse life‐saving treatment, then people do not lose their right to VSED when incompetent either. They only have to exercise it by AD. (shrink)

In the United States, amid the fractious politics of attempting to achieve something close to universal access to basic health care, two impressions are likely to feed skepticism about the status of a right to universal access: the moral principles that underlie any right to universal access may seem incredibly "ideal," not well rooted in the society's actual fabric, and the necessary practical and political attempts to limit the scope of universally accessible care to make its achievement realistic may seem (...) marked less by moral rhyme and reason than by the pull of conflicting interests. I try to directly dispel the first of these impressions and to obliquely question the second. The immense political barriers to .. (shrink)

The case of Mrs A is a provocative example of euthanasia by advance directive to avoid increasingly severe dementia. It is also a ‘perfect storm’ of a disturbing case, revealing both the challenges that can arise with advance euthanasia directives generally and particular issues in the Dutch procedures. Kim, Miller and Dresser have done a distinct service to bioethics in detailing the case, in explaining the basis of the regional euthanasia review committee reprimand of the administering geriatrician and in highlighting (...) some significant deficiencies in Dutch procedures.1 Many readers, after encountering the case, may find themselves sceptical that AEDs can be an ethically viable vehicle for avoiding living into severe dementia. I will argue that caution and care, not resistance to AEDs for dementia, is in order. Real dilemmas of implementation are inherent in advance directives, to be sure, dilemmas that can be aggravated by a patient’s dementia. Yet much can be done in writing an AED to make its implementation in dementia less problematic, and the Dutch emphasis on intolerable suffering as a necessary condition for euthanasia is not the appropriate legal framework. The difficulties in the case begin with the directive itself. Any advance directive, whether for refusing lifesaving treatment or for physician-assisted death, needs to be clear about what is and is not to happen and when. At first Mrs A’s directive seems to provide a trigger point: ‘I want to make use of the legal right to … euthanasia when I am still at all mentally competent and am no longer able to live at home with my husband. I absolutely do not want to be placed in an institution for elderly dementia patients’. In a revision added a year before her death, the time had become ‘whenever I think the time …. (shrink)

In using quality of life as a guide to rationing health services, Oregon laid itself open to charges of bias against the disabled—charges that cannot be dismissed out of hand.

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: a principle of social justice, the Just Sharing of the costs of illness, and a related principle of fairness, the Prevention of Free-Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market failure” in health insurance and, in (...) the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested , and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. (shrink)

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free‐Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market failure” in health insurance (...) and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. -/- . (shrink)

In using quality of life as a guide to rationing health services, Oregon laid itself open to charges of bias against the disabled—charges that cannot be dismissed out of hand.

Refusal of lifesaving treatment, and such refusal by advance directive, are widely recognized as ethically and legally permissible. Voluntarily stopping eating and drinking 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. (shrink)

Volume 20, Issue 8, August 2020, Page 80-82.

Low opportunity cost, weak influence of quality of life in the face of death, the social value of life extension to others, shifting psychological reference points, and hope have been proposed as factors to explain why people apparently perceive marginal life extension at the end of life to have disproportionately greater value than its length. Such value may help to explain why medical spending to extend life at the end of life is as high as it is, and the various (...) factors behind this value might provide normative rationale for that spending. Upon critical analysis, however, most of these factors turn out to be questionable or incompletely conceived; this includes hope, which is examined here in special detail. These factors help to explain complexity and nuance in the normative issues, but they do not provide adequate justification for spending as high as it often is. In any case, two additional factors must be added to the descriptive explanation of high spending, and they throw its normative justification into further doubt: the “insurance effect” and provider-created demand. Overall, the perception of especially high value of life at the end of life provides some normative justification for high spending, but seldom strong justification, and not for spending as high as it often is. (shrink)

“The thing about life is that one day you’ll be dead.” Indeed. But even total and honest acceptance of this brute fact about our relationship to death does not diminish the value we see in short remaining life at the end of life. Few just “give in” and no more fight for life because death is seen as an inherent part of life. They still invest small amounts of additional life with huge value. How high may that value plausibly be? (...) What is the value of a relatively short extension of life when death is inevitably near? (shrink)

In a recent paper in JME, Shelton and Geppert use an approach by Menzel and Chandler-Cramer to sort out ethical dilemmas about the oral feeding of patients in advanced dementia, ultimately arguing that the usefulness of advance directives about such feeding is highly limited. They misunderstand central aspects of Menzel’s and Chandler-Cramer’s approach, and in making their larger claim that such directives are much less useful than typically presumed, they fail to account for five important elements in writing (...) good directives for dementia and implementing them properly: (1) Directives should be paired with appointment of trusted agents. (2) Appointed agents’ authority can be greatly weakened without advance directives to guide them. (3) Directives’ implementation does not require clinically precise assessment of dementia’s stage. (4) Palliative support is typically required for withholding of oral feeding to be compassionate. (5) The central purpose of stopping feeding is often not the avoidance of suffering but not prolonging unwanted life. (shrink)

An assumed core of normative ethical principles may constitute a philosophically proper framework within which public policy should be formulated, but it seldom provides any substantive solutions. To generate public policy on bioethical issues, participants still need to confront underlying philosophical controversies. Professional philosophers' proper role in that process is to clarify major philosophical options, to press wider-ranging concistency questions, and to bring more parties into the philosophical debate itself by arguing for particular substantive claims. Though questions of fact that (...) mediate final policy conclusions frequently fall outside philosophical competence, one sort of fact, lack of political support, should seldom cause philosophers to stand aside; philosophers still have an important role as critics of culture, politics, and profession. They have no authority, however, on even the philosophical presuppositions of public policy. Keywords: bioethics, philosophy, public policy CiteULike Connotea Del.icio.us What's this? (shrink)

The book, Against Fairness, by philosopher Stephen T. Asma is reviewed. Concepts of favoritism and justice are explored.

Aid‐in‐dying laws in the United States have two important restrictions. First, only patients who are terminally ill, defined as having a prognosis of six months or less to live, qualify. Second, at the time the patients take the lethal medication, they must be competent to make medical decisions. This means that an advance directive requesting aid in dying for a later time when the patient lacks decision‐making capacity would be invalid. However, many people are more concerned about avoiding living into (...) severe dementia for years—a time when they will lack decision‐making capacity—than they are about preventing suffering or the loss of dignity or autonomy for a few months at the end of life.Gillian Bennett is an example of someone determined not to live into severe dementia. She opted for preemptive suicide in 2014, explaining why in a letter she posted online: “Every day I lose bits of myself, and it’s obvious that I am heading toward the state that all dementia patients eventually get to: not knowing who I am and requiring full‐time care.”A major problem with Bennett’s solution, however, is that the individual is likely thereby to be giving up some “good time.” A legal alternative to preemptive suicide is to create an advance directive stating the circumstances under which one wants not to receive any lifesaving or life‐sustaining treatment, even the most basic and noninvasive. This option is our focus in this paper: how to create effective advance directives to avoid living into severe dementia. To be relevant to progressive dementia, the directive would need to state what kinds of care should be withheld and when. At the same time, advance directives for severe dementia face serious challenges. Before addressing these, we review the normative force of directives themselves. (shrink)

Universal access to health care has historically faced strident opposition from political conservatives in the United States, although it has long been accepted by most conservatives in the rest of the industrialized world. Now, in a global economy where American business is crippled by the rising cost of market-based health care, the time may be ripe for change. The key to fostering a new mindset among American conservatives is to show why universal access fulfills many of the basic values that (...) all conservatives hold. (shrink)

What balance of government and private institution activity might stand a reasonable chance of achieving universal access to basic health care in the United States? David De Grazia makes a strong case that single-payer national health insurance with managed competition in delivery is morally the preferred structure for universal access: it best achieves the combination of universal access, cost control, freedom of patient choice, and quality of care. If we account for the realities of American political and moral culture, however, (...) is this the model for reform that people seriously committed to actually achieving universal access should be pushing? (shrink)

The arguments against doctors as "double agents" that are presented by Marcia Angell in the preceding article do not defeat the core justification for rationing some relatively high-expense, low-benefit care, and they do not enable us to conclude that clinicians should be barred from any active, substantive role in decisions to limit that care. They do, however, reveal several important conditions that need to govern cost-conscious medical practice in order to preserve an ethic of fidelity to patients: insurers' profits and (...) providers' incomes must be fair, providers must inform patients of any economic reasons that lead to the forgoing of care, and "direct incentive" arrangements must not be used to contain costs. (shrink)

Carney and Graber have recently claimed that religious ethics can have its ultimate foundation in charismatic divine love and grace, without logically presupposing independent ethical principles. While their defense of the autonomy of religious ethics is successful against many typical philosophical critiques, their derivation of ethical principles from divine realities is not essentially but only contextually religious. Since divine elements make no crucial difference to that derivation, religious ethics contains essentially the same derivation of ethical principles from facts as does (...) non-religious ethics. Religious ethics, however, should not resist this conclusion, since the conclusion does not weaken any of its important functions. (shrink)

We hardly regard politics—certainly not the words of politicians—as a realm where truth and honesty are closely protected. Public ignorance undoubtedly often pairs with politicians' disregard for accuracy to allow lies to pass. It is still galling, though, when political process and public reflection are stubbornly resistant to the obvious. It is more disturbing yet if the ignorance seems almost willing—a deeper kind of dishonesty in and with ourselves.By nature I am neither cynic, nor pessimist, nor one who disdains politics (...) and public life because they can be infused with ignorance. In the last twenty-four months, moreover, I have been encouraged by the distance insurance reform has traveled, notwithstanding .. (shrink)

has a wide range of options in choosing a health care system. Rational choice of a system depends on analysis and prioritization of the basis moral goals of equitable access to all citizens, the just sharing of financial costs between well and ill, respect for the values and choices of subscribers and patients, and efficiency in the delivery of costworthy care. These moral goals themselves, however, tell us little about what health care system the United States should have. Equitable access (...) does not demand a level and scope of care for the poor equal to that rationally chosen by the middle class, and there are ways within mixed systems, though not easy ways, to achieve a fair distribution of costs between well and ill. Despite pluralistic systems' apparent advantage in allowing subscribers to choose their own forms of rationing, problems in translating serious long-term subscriber choices into actual medical practice may be greater in pluralistic than in unitary systems. Final choice of a system hinges primarily on peculiar historical facts about U.S. political culture, not on moral principle. Keywords: access to health care, autonomy, efficiency, equality, experience rating, national health insurance CiteULike Connotea Del.icio.us What's this? (shrink)

Economic competition threatens equity in the delivery of health care. This essay examines four of the various ways in which it does that: the reduction of charity care, increased patient cost-sharing, "cream-skimming" of healthy subscribers, and lack of information to patients about rationed care that is not prescribed. In all four cases, society must guard against distinct inequities and injustices, but also in all four, either the particular problem is not inherent in competition or, though inherent, it is not irremediable. (...) Competition therefore cannot be finally morally accepted or rejected as an economic structure for delivering health care without knowing what among a wide range of supplementary things our society is actually going to do with it. Keywords: for-profit medicine, competition, patient-physician relationship, informed consent CiteULike Connotea Del.icio.us What's this? (shrink)

In their normative role in shaping the basic structure of a health care system, liberty and equality are often thought to conflict so sharply that health policy is condemned to remain an ideological battleground. In this paper, I will articulate my own view of why much of the apparently fundamental conflict between individual liberty and responsibility, on the one hand, and equality and equality's related concern for cost-efficiency, on the other hand, is less intractable than it is usually assumed to (...) be. The result will be to break the rigid and stereotypical association of liberty-emphasizing social philosophies with the pluralistic market paradigm for a health care system and egalitarian, equity-emphasizing social philosophies with the unitary public system paradigm. Understanding better the moral ingredients of liberty and equitable distribution as well as the complexity of how liberty and equality actually intersect in a health care system opens the door to seeing the possibility of significant reconciliation. I will conclude, among other things, that even semi-libertarian views of distributive justice should strongly embrace compulsory, universal coverage of health care for some significant level of care, and that egalitarian views ought not to regard different levels of coverage for people of different income levels as necessarily unjust. (shrink)

Book reviewed in this article: Health Care Politics, Policy, and Distributive Justice: The Ironic Triumph. By Robert P. Rhodes.

Book reviewed in this article: Health Care Politics, Policy, and Distributive Justice: The Ironic Triumph. By Robert P. Rhodes.

Rationing Health Care in America:Perceptions and Principles of Justice by Larry R. Churchill. American Health Care:Realities, Rights, and Reforms by Charles J. Dougherty. Should Medical Care Be Rationed by Age? edited by Timothy M. Smeeding, with Margaret P. Battin, Leslie P. Francis, and Bruce M. Landesman, Totowa, N.J., Rowman and Littlefield.

Rationing Health Care in America:Perceptions and Principles of Justice by Larry R. Churchill. American Health Care:Realities, Rights, and Reforms by Charles J. Dougherty. Should Medical Care Be Rationed by Age? edited by Timothy M. Smeeding, with Margaret P. Battin, Leslie P. Francis, and Bruce M. Landesman, Totowa, N.J., Rowman and Littlefield.

With his Affordable Care Act decision, Chief Justice Roberts saved conservatives from themselves. A constitutional regime that prohibited a mandate for basic health insurance while permitting Medicare and the Veterans Health Administration, presumably on the basis of government taxing authority, would have been a conservative nightmare. These partial U.S. versions of single payer and national health service are permissible, but a coherent private health insurance market is not?! The surprising thing is not that the generally conservative Roberts had the historical (...) and logical sense to realize this, but that he was the only one of his conservative colleagues who did. It is not the only irony presented by promarket, conservative constitutionalism in this case. (shrink)

For much of the last year and a half, the US has appeared on the verge of extensively reforming its financing and provision of health care, guaranteeing universal coverage for basic care and significantly controlling the long-term growth of costs. But it now appears that with a new Republican-led Congress we will at best adopt only selected insurance reforms: guaranteeing portability of insurance between jobs, banning insurers from excluding preexisting conditions from a person's coverage, and perhaps increasing subsidies for the (...) purchase of insurance by low-income families and small businesses. The long struggle throughout this century for a societal sharing of the financial burdens of illness will again have yielded only a small increment. (shrink)

With his Affordable Care Act decision, Chief Justice Roberts saved conservatives from themselves. A constitutional regime that prohibited a mandate for basic health insurance while permitting Medicare and the Veterans Health Administration, presumably on the basis of government taxing authority, would have been a conservative nightmare. These partial U.S. versions of single payer and national health service are permissible, but a coherent private health insurance market is not?! The surprising thing is not that the generally conservative Roberts had the historical (...) and logical sense to realize this, but that he was the only one of his conservative colleagues who did.It is not the only irony presented by promarket, conservative constitutionalism in this case. (shrink)