In philosophy, intelligence is less important than character, or so Wittgenstein once argued. In this paper, in a similar vein, I suggest that in health care ethics consultation character is of preeminent importance. I suggest that the activity of ethics consultation can be understood as "training in virtue," and what distinguishes the good health care ethics consultant from his/her average colleague are differences in traits of character. The underlying assumption is that one's use of knowledge and abilities are ultimately a (...) function of who one is and how one perceives and confronts situations of moral uncertainty and conflict. In discussing the original case presented by Mark Bliton, I focus on the virtues of wisdom, justice, courage, compassion and humility. (shrink)

Background There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. (...) The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds. Discussion The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill. Summary Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge. (shrink)

Medical discourse currently manages two broad visionary movements: "evidence-based medicine," the effort to make clinical medicine more responsive to the medical research, and "patient-centered care," the platform for a more humane health-care encounter. There have been strong calls to synthesize the two as "evidence-based patient-centred care" (Lacy and Backer 2008; see also Borgmeyer 2005; Baumann, Lewis, and Gutterman 2007; Krahn and Naglie 2008), yet many question the compatibility of the two competing programs.This might sound to some like a new version (...) of an old story. Despite the fact that evidence-based medicine and patient-centered care are relatively new programs, the story of their oppositional .. (shrink)

Prompted by the ever-increasing cesarean rate, this paper considers the interpretive disjunct between two significant strands of feminist analysis that have arisen in the last four decades as a consequence of the phenomenon of medicalized birth. In contrast to the dominant paradigm of bioethical “Principalism,” both modes of analysis, understood as “the critique of industrialized labor” and “the critique of idealized labor,” are attentive to the way in which social discourses inform bioethical deliberation and practice, but significantly diverge in the (...) nature of their accounts. The “industrialization critique” understands the culture of medical intervention to be impelled by an “obstetric desire” to appropriate women's reproductive potency, whereas the “idealization critique” relates new mothers’ “low childbirth satisfaction” to a pernicious normative ideal propagated by the natural childbirth movement. This paper will explore the anatomy of both critiques and interrogate their fidelity to the phenomenological insight of the body as chiasm between material and ideal. I will argue that while the insights of the idealization critique are well grounded, we must exercise caution about the critique's tendency to reductively understand the embodied experience of labor as entirely discursively produced, a gesture that risks re-performing the dematerialization of women often effected through obstetric intervention itself. (shrink)

Over the past three or four decades, the concept of medical ethics has changed from a limited set of standards to a broad field of debate and research. We define medical ethics as an arena of moral issues in medicine, rather than a specific discipline. This paper examines how the disciplines of health care ethics and health care law have developed and operated within this arena. Our framework highlights the aspects of jurisdiction (Abbott) and the assignment of responsibilities (Gusfield). This (...) theoretical framework prompted us to study definitions and changing responsibilities in order to describe the development and interaction of health care ethics and health law. We have opted for the context of the Dutch debate about end-of-life decisions as a relevant case study. We argue that the specific Dutch definition of euthanasia as 'intentionally taking the life of another person by a physician, upon that person's request' can be seen as the result of the complex jurisdictional process. This illustrates the more general conclusion that the Dutch debate on end-of-life decisions and the development of the two disciplines must be understood in terms of mutual interaction. (shrink)

Theological basis -- Religion and health care -- The dignity of human life -- The integrity of the human person -- Implications for health care -- Theological principles in health care ethics -- Method -- The levels and questions of ethics -- Freedom and the moral agent -- Right and wrong -- Metaethics -- Method in Catholic bioethics -- Catholic method and birth control -- The principle of double effect -- Application -- Forgoing treatment, pillar one: ordinary and extraordinary means (...) -- Forgoing treatment, pillar two: killing and allowing to die -- Forgoing treatment, pillar three: decisions by competent patients -- Forgoing treatment, pillar three: decisions for incompetent patients -- Forgoing treatment, pillar three: advance directives -- Hydration and nutrition -- Physician-assisted suicide and euthanasia -- Medical futility -- Pain and pain management -- Ethics committees -- Embryonic stem cells and the beginning of human personhood -- Genetic engineering -- Allocating health care resources -- The use and misuse of the allocation argument. (shrink)

Is it ever permissible to publish a patient’s confidences without permission? I investigate this question for the field of psychoanalysis. Whereas most medical fields adopted a 1995 recommendation for consent requirements, psychoanalysis continues to defend the traditional practice of nonconsensual publication. Both the hermeneutic and the scientific branches of the field justify the practice, arguing that it provides data needed to help future patients, and both branches advance generalizations and causal claims. However the hermeneutic branch embraces methods tending to undermine (...) the reliability of such claims, while the scientific branch aims to improve the field’s empirical base – in their words, to advance psychoanalysis as a science. The scientific branch therefore has the stronger claim to the traditional practice, and it their claim that I consider. An immediate concern arises. We seem unable to answer the applied ethical question without first determining which ethical theory is correct; for defenders of the practice appeal variously to therapeutic privilege, principlism, and utilitarianism, while opponents wage autonomy-based arguments. The concern turns out to be unfounded, however, because all of these ethical approaches fail to justify the traditional practice. The more promising defenses fail partly because even the scientific branch of the field lacks empirically sound methods for establishing its causal claims and generalizations, often appealing to authority instead. I conclude that it is currently unethical for analysts to continue publishing their patients’ confidences without permission, and I suggest that the field help future patients by attending to its methodological problems. (shrink)

This book, edited by a team of leading European bioethicists, is in all respects an innovative publication.

The purpose of this study was to examine the role of physicians on HEC including structural and process features. Four committees were selected from among 12 volunteering to participate with 12 sessions observed. Power analysis (0.8) confirmed an adequate number of communication exchanges, and no statistical significant difference (p < 0.05) among two prior surveys affirmed the sample. Data collection included established questionnaires and communication analyses with a tested method. Results revealed physician presence was robust and similar to prior reports (...) on HEC structure; however, physicians rated their role effectiveness lower than other occupations and lower than overall committee effectiveness. Communication exchanges representing process revealed three positive communication types, and consistent attempts to aid committee functions through consensual processes that also were substantiated by non-physician members. Findings suggested more attention to both structural and process functions of HEC and their members. (shrink)

Health Care Ethics examines the way ethical dilemmas are played out in everyday clinical practice and argues for an approach to ethical decision-making which focuses more on patient needs than competing professional interests. While advances in medical science and technology have improved the ability to save and prolong lives, they have also given rise to fundamental questions about what constitutes life and personhood, especially in the context of what are termed 'persistent vegetative state' and 'brain death'. Drawing on the example (...) of intensive care where such questions feature strongly in everyday practice, Kath M Melia examines how decisions are taken within the context of multiprofessional teamworking, including · whether to admit a patient and commence treatment · what the aim of treatment should be (i.e. palliation, care or cure) · when to limit, withhold or withdraw treatment · when to donate organs. As an area in which different professional groups work closely together, the author argues that there are lessons to be learnt from intensive care which can be applied to ethical decision making in all areas of health care for the greater good of patients. The book makes a significant contribution to the literature on ethics in health care and to the development of ethical decision making which prioritises the needs of patients. It is essential reading for ethicists, sociologists and health care professionals. (shrink)

This was designed for all instructors who teach aspects of biological evolution in their college courses.

To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original research articles while (12) (...) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues. (shrink)

From Harry and Louise through the McCaughey septuplets, this book explains stories and issues in health care ethics that have appeared in the news media.

There is consistent and strong empirical evidence for social inequalities in health, as a vast and fast growing literature shows. In recent years, these findings have helped to move health equity high on international research and policy agendas. This paper examines how the empirical identification of social inequalities in health relates to a normative judgment about health inequities and puts forward an approach which embeds the pursuit of health equity within the general pursuit of social justice. It defends an indirect (...) approach to health equity, which views social inequalities in health as unjust in so far as they are the result of an unjust basic structure of society in Rawls’ sense. (shrink)

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires as a condition of accreditation that every health care institution -- hospital, nursing home, or home care agency -- have a standing mechanism to address ethical issues. Most organizations have chosen to fulfill this requirement with an interdisciplinary ethics committee. The best of these committees are knowledgeable, creative, and effective resources in their institutions. Many are wellmeaning but lack the information, experience, and skills to negotiate adequately the complex ethical (...) issues that arise in clinical and organizational settings. Handbook for Health Care Ethics Committees is the first resource designed to address the range of work performed by ethics committees as part of their multiple responsibilities, including education, case consultation, and policy development. It features an eight-chapter curriculum reviewing the content of contemporary health care bioethics and discussing the ethical foundations of clinical practice, with each subsequent section focusing on a set of ethical issues that commonly arise in the clinical setting. Through case studies, the authors explore issues such as informed consent and refusal, decision making and decisional capacity, truth telling, decision-making concerns of minors, end-of-life issues, palliation, justice in and access to health care services, and organizational ethics. They offer sample policies and procedures, draft guidelines and protocols, and key legal cases. Providing both a strong theoretical foundation and practical applications, this handbook will be essential reading for every member of a health care ethics committee. (shrink)

As web instruction becomes more and more prevalent at universities across the country, instructors of ethics are being encouraged to develop online courses to meet the needs of a diverse array of students. Web instruction is often viewed as a cost-saving technique, where large numbers of students can be reached by distance education in an effort to conserve classroom and instructor resources. In practice, however, the reverse is often true: online courses require more of faculty time and effort than do (...) many traditional classes. Based on personal experience teaching an online course in health care ethics for students in the Allied Health Professions, it is evident that there are both benefits and challenges in teaching online courses, particularly in ethics. Examples of benefits are (1) the asynchronous nature of web instruction allows students to progress through the course at their own pace and at times that are convenient given their clinical responsibilities; (2) web courses allow for a standardization of content and quality of instruction over a diversity of programs; and (3) examples can be tailored to the differing experiences of students in the course. Some challenges to teaching online ethics courses include (1) the fact that online instruction benefits visual learners and disadvantages those lacking good reading comprehension or strong writing skills; (2) developing meaningful student-student and student-instructor interaction; and (3) teaching ethics involves teaching a process rather than a product. Allowing students to apply their knowledge to real-world cases in their disciplines and encouraging them to share experiences from clinical practice is an effective way to meet several of these challenges. Building an online community is another good way to increase the interaction of students and their engagement with the material. (shrink)

Founded on in-depth biblical studies and perceptive theological perspective, James Thobaben's book has given us a comprehensive treatment of the myriad ethical ...

In a world of rapid technological advances, the moral issues raised by life and death choices in healthcare remain obscure. Life and Death in Healthcare Ethics provides a concise, thoughtful and extremely accessible guide to these moral issues. Helen Watt examines, using real-life cases, the range of choices taken by healthcare professionals, patients and clients which lead to the shortening of life. The topics looked at include: euthanasia and withdrawal of treatment; the persistent vegetative state; abortion; IVF and cloning; and (...) life-saving treatment of pregnant women. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

Philosophy and Happiness addresses the need to situate any meaningful discourse about happiness in a wider context of human interests, capacities and circumstances. How is happiness manifested and expressed? Can there be any happiness if no worthy life projects are pursued? How is happiness affected by relationships, illness, or cultural variants? Can it be reduced to preference satisfaction? Is it a temporary feeling or a persistent way of being? Is reflection conducive to happiness? Is mortality necessary for it? These are (...) the questions people ask themselves when they stop and think about how they feel, how their lives are going, and how they would be going if different choices had been made or different values had been prioritized. These are the questions that contributors to this volume begin to answer, adopting different methodologies, among which the analysis of widespread intuitions about imaginary and real-life scenarios, and reflection on the interpretation of the relevant empirical evidence emerging from psychology and economics. (shrink)

Currently, any dentist in the UK who is HIV-seropositive must stop treating patients. This is despite the fact that hepatitis B-infected dentists with a low viral load can continue to practise, and the fact that HIV is 100 times less infectious than hepatitis B. Dentists are obliged to treat HIV-positive patients, but are obliged not to treat any patients if they themselves are HIV-positive. Furthermore, prospective dental students are now screened for hepatitis B and C and HIV, and are not (...) allowed to enrol on Bachelor of Dental Surgery degrees if they are infectious carriers of these diseases. -/- This paper will argue that: (i) the current restriction on HIV-positive dentists is unethical, and unfair; (ii) dentists are more likely to contract HIV from patients than vice versa, and this is not reflected by the current system; (iii) the screening of dental students for HIV is also unethical; (iv) the fact that dentists can continue to practise despite hepatitis B infection, but infected prospective students are denied matriculation, is unethical; and (v) that the current Department of Health protocols, as well as being intrinsically unfair, have further unethical effects, such as the waste of valuable resources on ‘lookback’ exercises and the even more damaging loss of present and future dentists. Regulation in this area seems to have been driven by institutional fear of public fear of infection, rather than any scientific evidence or ethical reasoning. (shrink)

The proliferation of ethics committees and ethics consultation services has engendered a discussion of the issue of the expertise of those who provide clinical ethics consultation services. In this paper, I discuss two aspects of this issue: the cognitive dimension or content knowledge that the clinical ethics consultant should possess and the practical dimension or set of dispositions, skills, and traits that are necessary for effective ethics consultation. I argue that the failure to differentiate and fully explicate these dimensions contributes (...) to the confusion over the issue of expertise and fuels, at least partly, the controversies about expertise (or authority) in ethics and the legitimacy of the use of ethical knowledge in clinical ethics consultation. (shrink)

These are some of the important questions that this book addresses in building an interdisciplinary understanding of health equity. (Midwest).

Practical medical decisions are closely integrated with ethical and religious beliefs in the Philippines. This is shown in a survey of Filipino physicians' attitudes towards severely compromised neonates. This is also the reason why the ethical analysis of critical care practices must be situated within the context of local culture. Kagandahang loob and kusang loob are indigenous Filipino ethical concepts that provide a framework for the analysis of several critical care practices. The practice of taking-from-the-rich-to-give-to-the-poor in public hospitals is not (...) compatible with these concepts. The legislated definition of death and other aspects of the Philippine Law on Organ Transplants also fail to be compatible with these concepts. Many ethical issues that arise in a critical care setting have their roots outside the seemingly isolated clinical setting. Critical care need not apply only to individuals in a serious clinical condition. Vulnerable populations require critical attention because potent threats to their lives exist in the water that they drink and the air that they breathe. We cannot ignore these threa ts even as we move inevitably towards a technologically dependent, highly commercialized approach to health management. (shrink)

Non-governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non-governmental organizations (NGOs) play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self-mandating and self-regulating. What is needed in terms of accountability is some means by which all the relevant (...) stakeholders can have their interests represented and considered. An ideally accountable decision-making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate based justifications and advocacy-based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long-term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole. (shrink)

In this paper we challenge the moral consensus against selection for disability. Our discussion will concern only those disabilities that are compatible with a life worth living from the point of view of the disabled individual. We will argue that an influential, impersonal argument against selection for disability falls to a counterexample. We will then show how the reach of the counterexample can be broadened to make trouble for anyone who objects to selection for disability. If we are right about (...) the problems for objections to selection for disability, why are objections are so widespread? We suggest that intuitions are being skewed against selection for disability by certain quirks in the usual ways of presenting the issue. Nevertheless, we must confess to finding our own result surprising. (shrink)

In this paper, we present an argument strengthening the view of Norman Daniels, Bruce Kennedy and Ichiro Kawachi that justice is good for one's health. We argue that the pathways through which social factors produce inequalities in sleep more strongly imply a unidirectional and non-voluntary causality than with most other public health issues. Specifically, we argue against the 'voluntarism objection' – an objection that suggests that adverse public health outcomes can be traced back to the free and voluntary choices of (...) individual actors. Our argument proceeds along two lines: an empirical line and a conceptual line. We first show that much of the empirical research on sleep supports the view that those with fewer opportunities are those who have poorer sleep habits. We then argue that sleep-related decisions are not of the same nature as most other lifestyle choices, and therefore are not as easily susceptible to the voluntarism objection. (shrink)

Just health: meeting health needs fairly is an ambitious book, in which Norman Daniels attempts to bring together in a single framework all his work on health and justice from the past 25 years. One major aim is to reconcile his earlier work on the special moral importance of healthcare with his later work on the social determinants of health. In his earlier work, Daniels argued that healthcare is of special moral importance because it protects opportunity. In this later work, (...) Daniels argues that the social determinants of health (which in fact tend to have a larger effect on health outcomes than healthcare does) should also be considered special. This paper argues that it is a mistake to base a theory of justice for health on the claim that health (or the social determinants of health) are "special", for three reasons. First, once we realise that health is to a large part socially determined by features such as distribution of income, which are also of independent importance for justice, we cannot talk about a theory of justice for health in isolation from an overall theory of justice. Second, when we are trying to work out the place of health in a general theory of justice, being told that health (or the social determinants of health) is special is unhelpful. The relevant starting point should rather be whether health matters in a fundamental way for justice, or whether it matters merely for the effects it has on those goods which are of fundamental importance for justice. Third, treating the social determinants of health as special would in fact be counterproductive in terms of the broad approach to justice Daniels favours. (shrink)

Asylum-seeking and refugee women (ASRW) are population groups characterized by diverse social, economic and legal backgrounds as well as diverse needs. Their backgrounds of forced migration have a profound impact on their overall health, including their sexual and reproductive health (SRH). In Europe, the SRH needs of ASRW are usually more pressing than those of the host country population. In the context of refugee health, it is important to distinguish between asylum seekers and statutory refugees, as asylum seekers have distinct (...) needs and often limited rights in their host country. Yet both groups face many barriers in accessing national health services. This article addresses the issue of entitlements to health services for asylum-seeking women in Europe, and highlights the wide range of difficulties of both asylum-seeking and refugee women in accessing (sexual and reproductive) health services. (shrink)

This review article of Shlomi Segall's Health, Luck, and Justice (Princeton University Press, 2010) addresses three issues: first, Segall’s claim that luck egalitarianism, properly construed, does not object to brute luck equality; second, Segall’s claim that brute luck is properly construed as the outcome of actions that it would have been unreasonable to expect the agent to avoid; and third, Segall’s account of healthcare and criticism of rival views. On the first two issues, a more conventional form of luck egalitarianism (...) – that is, one which objects to brute luck even if it creates equality, and which construes brute luck as the inverse of agent responsibility – is defended. On the third issue, strengths and weaknesses in Segall’s criticism of Rawlsian, democratic egalitarian, and all-luck egalitarian approaches to healthcare, and in his own luck egalitarian approach, are identified. (shrink)

The banner of deliberative democracy is attracting increasing numbers of supporters, in both the world's older and newer democracies. This effort to renew democratic politics is widely seen as a reaction to the dominance of liberal constitutionalism. But many questions surround this new project. What does deliberative democracy stand for? What difference would deliberative practices make in the real world of political conflict and public policy design? What is the relationship between deliberative politics and liberal constitutional arrangements? The 1996 publication (...) of Amy Gutmann and Dennis F. Thompsons Democracy and Disagreement was a signal contribution to the ongoing debate over the role of moral deliberation in democratic politics. In Deliberative Politics an all-star cast of political, legal, and moral commentators seek to criticize, extend, or provide alternatives to Gutmann and Thompson's hopeful model of democratic deliberation. The essays discuss the value and limits of moral deliberation in politics, and take up practical policy issues such as abortion, affirmative action, and health care reform. Among the impressive roster of contributors are Norman Daniels, Stanley Fish, William A. Galston, Jane Mansbridge, Cass R. Sunstein, Michael Walzer, and Iris Marion Young, and the editor of the volume, Stephen Macedo. The book concludes with a thoughtful response from Gutmann and Thompson to their esteemed critics. This fine collection is essential reading for anyone who takes seriously the call for a more deliberative politics. (shrink)

The system of clinical ethics committees (CECs) in the United Kingdom is based on goodwill. No formal requirements exist as to constitution, membership, range of expertise or the status of their recommendations. Healthcare professionals are not obliged to use CECs where they exist, nor to follow any advice received. In addition, the make-up of CECs suggests that ethics itself may be under-represented. In most cases, there is one member with a training in ethics – the rest are healthcare professionals or (...) administrators, although a lawyer is generally also included in the membership. This begs the question as whether CECs can ‘do ethics’, as well whether or not they can take seriously the requirements of due process, formal justice and human rights. Moreover, the role of the patient in this system is opaque. (shrink)

This paper addresses the likely impact on women of being denied emergency contraception (EC) by pharmacists who conscientiously refuse to provide it. A common view—defended by Elizabeth Fenton and Loren Lomasky, among others—is that these refusals inconvenience rather than harm women so long as the women can easily get EC somewhere else nearby. I argue from a feminist perspective that the refusals harm women even when they can easily get EC somewhere else nearby.

: In this commentary on Eva Feder Kittay's Love's Labor: Essays on Women, Equality, and Dependency, I focus on Kittay's dependency theory. I apply this theory to an analysis of women's inadequate access to high-quality, cost-effective healthcare. I conclude that while quandaries remain unresolved, including getting men to do their share of dependency work, Kittay's book is an important and original contribution to feminist healthcare ethics and the development of a normative feminist ethic of care.

This paper is essentially concerned with defending the idea of a universal right to adequate health care coverage. It will argue for the existence of a human right grounded in Catholic social thought. At the outset, a statement of clarification is needed. This paper does not pretend to offer the panacea for all ills relating to health care provision. Rather, it is an inquiry into the kinds of value that should inform decision making relating to health policy. A universal right (...) to adequate health care cannot be established without questioning the underlying values that inform the debate and bring them firmly to the level of deliberative consciousness. It is these value concerns that structure the dynamic of health care provision and the general provision of wider resources in society. (shrink)

Based on a general thesis regarding the proper resolution of interpersonal conflicts, this paper suggests a normative framework for the distribution of scarce health resources. The proposed thesis includes two basic ideas. First, individual well-being is the fundamental value. Second, interpersonal conflicts affecting well-being should be resolved in light of several conceptions of fairness, reflecting the independent value of persons and the moral significance of responsibility of individuals for the existence of interpersonal conflicts. These ideas are elaborated in several principles (...) that are applied with respect to the distribution of scarce health resources. (shrink)

Several bioethical topics received a great deal of news coverage here in Scotland in 2009. Three important issues with transatlantic connections are the swine flu outbreak, which was handled very differently in Scotland, England and America; the US debate over healthcare reform, which drew the British NHS into the controversy; and the release to Libya of the Lockerbie bomber, which at first glance might not seem particularly bioethical, but which actually hinged on the very public discussion of the prisoner’s medical (...) records. On a national level, there have been attempts in both Scotland and England to change the law on assisted suicide, where success looks more likely than ever. This paper will discuss each of these issues, and hopefully raise awareness of how these issues were dealt with in the UK and its component countries. (shrink)

It is clearly unethical for the NHS to tell people that they will die sooner unless they pay for private treatment, and then to tell them that if they pay for private treatment they will have to pay the NHS for its insufficient service. This is all the more true if people in other parts of the country are receiving all the drugs they need for the same condition on the NHS. Patients who discover that the NHS care that they (...) have paid for will not keep them alive should be able to supplement their care privately if they can afford it, without the added burden and insult of being told their independently inadequate NHS care will cease unless they pay for it too. Mired in self-contradiction as it is, the NHS’ "anti-two-tier" policy must change. (shrink)

Many nations in the developing world invest scarce funding into training health workers. When these workers migrate to richer countries, particularly when this migration occurs before the source community can recoup the costs of training, the destination community realizes a net gain in resources by obtaining the workers' skills without having to pay for their training. This effect of health worker migration has frequently been condemned as 'poaching' or a case of theft. I assess the charge that the rich nations (...) of the world poach the resources of the developing world through the active recruitment of migrants. I argue that the charge of poaching is misguided in these cases. The misuse of the term poaching is particularly troubling as it distracts attention away from the many actual moral wrongs taking place through the process of health worker migration and objectifies health workers. (shrink)

I would like to thank all of the respondents to my article both for their expansions on the theme of health worker migration and for their criticisms of my argument against the use of the term ’poaching’ in the context of international health worker migration. In this response, I will clarify my argument in light of the worries raised primarily by Tache and Schillinger and Ari Zivotofsky and Naomi Zivotofsky.

The proliferation of ethics committees and ethics consultation services has engendered a discussion of the issue of the expertise of those who provide clinical ethics consultation services. In this paper, I discuss two aspects of this issue: the cognitive dimension or content knowledge that the clinical ethics consultant should possess and the practical dimension or set of dispositions, skills, and traits that are necessary for effective ethics consultation. I argue that the failure to differentiate and fully explicate these dimensions contributes (...) to the confusion over the issue of expertise and fuels, at least partly, the controversies about expertise (or authority) in ethics and the legitimacy of the use of ethical knowledge in clinical ethics consultation. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

This paper will consider the right not to know in the context of psychiatric disorders. It will outline the arguments for and against acquiring knowledge about the results of genetic testing for conditions such as breast cancer and Huntington’s disease, and examine whether similar considerations apply to disclosing to clients the results of genetic testing for psychiatric disorders such as depression and Alzheimer’s disease. The right not to know will also be examined in the context of the diagnosis of psychiatric (...) disorders that are associated with stigma or for which there is no effective treatment. (shrink)

Evidence suggests that research participants often fail to recall much of the information provided during the informed consent process. This study was conducted to determine the proportion of consent information recalled by drug court participants following a structured informed consent procedure and the neuropsychological factors that were related to recall. Eighty-five participants completed a standard informed consent procedure to participate in an ongoing research study, followed by a 17-item consent quiz and a brief neuropsychological battery 2 weeks later. Participants performed (...) within the normal range on most of the neuropsychological measures, although roughly one third showed deficits on measures of executive functioning. Participants failed to recall over 65% of the consent information within 2 weeks of entering the study, and their recall was significantly correlated with verbal IQ, drug problem severity, reading ability, memory, and attention. These factors may be useful in determining whether research participants require enhanced consent procedures. (shrink)

The Catholic Church in the United States provides extensive health care service through its more than 600 health facilities. The Church, on the basis of its moral teaching, sees health care as a basic human right and supports universal coverage. At the same time, the Church considers abortion morally wrong and opposes coverage of abortion as a health service in a national health plan. Mandated coverage of abortion would violate the moral commitments of Catholic hospitals and the consciences of Catholics (...) who would be required to financially support provision of abortion services. Keywords: abortion, Catholic hospitals, Clinton health plan, health care reform CiteULike Connotea Del.icio.us What's this? (shrink)

The system of clinical ethics committees (CECs) in the United Kingdom is based on goodwill. No formal requirements exist as to constitution, membership, range of expertise or the status of their recommendations. Healthcare professionals are not obliged to use CECs where they exist, nor to follow any advice received. In addition, the make-up of CECs suggests that ethics itself may be under-represented. In most cases, there is one member with a training in ethics – the rest are healthcare professionals or (...) administrators, although a lawyer is generally also included in the membership. This begs the question as whether CECs can ‘do ethics’, as well whether or not they can take seriously the requirements of due process, formal justice and human rights. Moreover, the role of the patient in this system is opaque. (shrink)

Medical decisions concerning noncompetent patients that are most morally problematical are those that involve life and death choices. In making these choices for others, I urge that decision-makers carefully attend to the degree and history of a person's noncompetence, and distinguish four relevant categories of competence: partial, potential, lost and never possessed. Attending to these will help enable us to sort out when and how autonomous choice is possible and desirable and when and how to rely upon a judgment of (...) a patient's best interests instead. This conflict is explored with particular reference to the Quinlan, Fox and Saikewicz cases. I argue that respect for autonomy, wherever possible, has presumptive priority, and that it is more often possible than frequently supposed. On the other hand, the notion of autonomous choice itself is perverted when forced upon inappropriate cases, such as those presented by the never competent. Here it is not merely legitimate, but inescapable to use a best interest criterion that ignores autonomy in making treatment decisions. Specific cases in which these normally distinct guidelines for decision-making concur, conflict and need resolution are discussed. In the end it is often more important to determine who will choose than by what substantive criteria he or she will be guided. In considering this issue, I try to show that the substantive criteria have implications for who the proper decision-makers are in many problematical cases. (shrink)

This paper is essentially concerned with defending the idea of a universal right to adequate health care coverage. It will argue for the existence of a human right grounded in Catholic social thought. At the outset, a statement of clarification is needed. This paper does not pretend to offer the panacea for all ills relating to health care provision. Rather, it is an inquiry into the kinds of value that should inform decision making relating to health policy. A universal right (...) to adequate health care cannot be established without questioning the underlying values that inform the debate and bring them firmly to the level of deliberative consciousness. It is these value concerns that structure the dynamic of health care provision and the general provision of wider resources in society. (shrink)

Women's access to reproductive health care is an ongoing source of conflict in U.S. politics; however, women in the military are often overlooked in these debates. Reproductive health care, including family planning, is a fundamental component of health care for women. Unintended pregnancy carries substantial health risks and financial costs, particularly for servicewomen. Compared with their civilian counterparts, women in the military experience greater challenges in preventing unwanted pregnancy and have less access to contraceptive services and abortion. Current military policies, (...) federal laws, and health care practices are not always consistent with evidence-based research and patient-centered care. A multidisciplinary effort on the part of military personnel, lawmakers, and health care providers is needed to eliminate these disparities. We discuss recommendations in the following categories: improving contraceptive education and adherence, expanding research, broadening access to the full range of contraceptive options including emergency contraception, and ensuring access to safe abortion. (shrink)

Current General Medical Council guidelines state that any doctor who does not wish to carry out a non-therapeutic circumcision (NTC) on a boy must invoke conscientious objection. This paper argues that this is illogical, as it is clear that an ethical doctor will object to conducting a clinically unnecessary operation on a child who cannot consent simply because of the parents’ religious beliefs. Comparison of the GMC guidelines with the more sensible British Medical Association guidance reveals that both are biased (...) in favour of NTC and subvert standard consent procedures. It is further argued that any doctor who does participate in non-therapeutic circumcision of a minor may be guilty of negligence and in breach of the Human Rights Act. In fact, the GMC guidance implies that doctors must claim conscientious objection if they do not wish to be negligent. Both sets of guidelines should be changed to ensure an objective consent process and avoid confusion over the ethics of NTC. (shrink)

We are all familiar with assertions of rights: we talk of the right to confi dentiality, the right to health care and, more controversially, the right to die. But beneath this surface familiarity lies a heap of diffi culties about what it is to have a right, how we should go about determining which assertions of rights are genuine and what role (if any) rights should play in our broader moral thinking. This chapter aims to offer a guide through these (...) perplexities. (shrink)

Philosophy and Happiness addresses the need to situate any meaningful discourse about happiness in a wider context of human interests, capacities and circumstances. How is happiness manifested and expressed? Can there be any happiness if no worthy life projects are pursued? How is happiness affected by relationships, illness, or cultural variants? Can it be reduced to preference satisfaction? Is it a temporary feeling or a persistent way of being? Is reflection conducive to happiness? Is mortality necessary for it? These are (...) the questions people ask themselves when they stop and think about how they feel, how their lives are going, and how they would be going if different choices had been made or different values had been prioritized. These are the questions that contributors to this volume begin to answer, adopting different methodologies, among which the analysis of widespread intuitions about imaginary and real-life scenarios, and reflection on the interpretation of the relevant empirical evidence emerging from psychology and economics. (shrink)

A number of theoretical ideas have emerged recently in the legal, bioethical and philosophical fields that could usefully be applied to these and other issues ...