: Although nothing could be less fashionable today than talk of comprehensive health care reform, the major problems of American health care have not gone away. Only a radical change in the way the U.S. finances health care--specifically, a single-payer system--will permit the achievement of universal coverage while keeping costs reasonably under control. Evidence from other countries, especially Canada, suggests the promise of this approach. In defending the single-payer approach, the author identifies several political and cultural factors that (...) make it difficult for Americans to obtain a clear view of this option. Finally, the author argues that much discussion of rationing is vitiated by bracketing more systemic questions to which the issue of rationing is inextricably linked. (shrink)
The meaning of the concept of fusion is discussed in relation with the works of Payer and those of Van Tieghem. It is pointed out that there is a difference, at the theoretical level, between the concept of fusion congénitale as defined by Payer and the concept of concrescence congénitale formulated by Van Tieghem. The former is inobservable by definition, while the latter deals with intercalary growth. For Van Tieghem, anatomy can prove the existence of fusion, even if (...) we do not see it during ontogenesis.We distinguish three complementary methods for explaining the unions of organs: ontogenetic, typological and phylogenetic. We have attempted, not so much to defend one or other of these methods, as to show that they often invoke very different interpretations for the same morphological phenomena. It is probable that only an analysis of the writings of 19th century botanists will clarify the concept of fusion and more generally the epistemology of plant morphology. (shrink)
Background: Omalizumab, an anti-immunoglobulin E antibody, reduces exacerbations and symptoms in uncontrolled allergic asthma. The study objective was to estimate the costs and consequences of omalizumab compared to usual care from a US payer perspective. Methods: We estimated payer costs, quality-adjusted survival (QALYs), and the incremental cost-effectiveness ratio (ICER) of omalizumab compared to usual care using a state-transition simulation model that included sensitivity analyses. Every 2 weeks, patients could transition between chronic asthma and exacerbation health states. The best (...) available evidence informed the clinical and cost input estimates. Five years of omalizumab treatment followed by usual care was assumed to estimate a lifetime horizon. Omalizumab responders (60.5% of treated) were modeled as a separate scenario where nonresponders reverted back to usual care after 16 weeks of active treatment. Results: The mean lifetime discounted costs and QALYs were $83 400 and 13.87 for usual care and $174 500 and 14.19 for omalizumab plus usual care resulting in $287 200/QALY (95% interval: $219 300, $557 900). The ICER was $172 300/QALY when comparing omalizumab to usual care in the responder scenario. One-way sensitivity analyses indicated that the results were sensitive to the difference in treatment-specific utilities for the chronic state, exacerbation-associated mortality, omalizumab price, exacerbation rates, and response definition. Conclusions: The results suggest that adding omalizumab to usual care improves QALYs at an increase in direct medical costs. The cost-effectiveness of omalizumab is similar to other chronic disease biologics. The value increases when omalizumab response is used to guide long-term treatment. (shrink)
: In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both more efficient (...) and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits. (shrink)
: Four principal arguments have been offered in support of requiring public and private third-party payers to help fund medical research: (1) many of the costs associated with clinical trial participation are for routine care that would be reimbursed if delivered outside of a trial; (2) there is a need to promote scientific research and medical progress and lack of coverage is an impediment to enrollment; (3) to cover the costs of trials expands health care and treatment options for the (...) sick; and (4) it is beneficial for private insurers to cover the costs associated with cancer clinical trials because doing so makes such companies more attractive to consumers. Although many see third-party-payer coverage as a victory for patients and for the future of research, requiring coverage of services provided in a trial beyond those that would be provided to a comparable patient outside the research context raises a number of concerns. (shrink)
In the 19th century, "Psychophysical Parallelism" was the most popular solution of the mind-body problem among physiologists, psychologists and philosophers. (This is not to be mixed up with Leibnizian and other cases of "Cartesian" parallelism.) The fate of this non-Cartesian view, as founded by Gustav Theodor Fechner, is reviewed. It is shown that Feigl's "identity theory" eventually goes back to Alois Riehl who promoted a hybrid version of psychophysical parallelism and Kantian mind-body theory which was taken up by Feigl's (...) teacher Moritz Schlick. (shrink)
Making use of facilitating payments is a very widespread form of corruption. These consist of small payments or gifts made to a person – generally a public official or an employee of a private company – to obtain a favour, such as expediting an administrative process; obtaining a permit, licence or service; or avoiding an abuse of power. Unlike the worst forms of corruption, facilitating payments do not usually involve an outright injustice on the part of the payer as (...) they are entitled to what they request. This may be why public opinion tends to condone such payments; often they are assumed to be unavoidable and are excused on the grounds of low wages and lack of professionalism among public officials and disorganisation in government offices. Many companies that take the fight against “grand” corruption very seriously are inclined to overlook these “petty” transgressions, which are seen as the grease that makes the wheels of the bureaucratic machine turn more smoothly. Despite this, facilitating payments have a pernicious effect on the working of public and private administrations: all too often they are the slippery slope to more serious forms of corruption; they impose additional costs on companies and citizens; and in the long run they sap the ethical foundations of organisations. Although many articles on corruption mention facilitating payments, there have been no systematic studies from a company’s point of view. This article thus focuses on facilitating payments from the point of view of the company that makes the payment, either as the active partner (when it is the company that takes the initiative) or as the passive partner (when the official or employee is the instigator). (shrink)
This article deals with Moritz Schlick's critical realism and its sources that dominated his philosophy until about 1925. It is shown that his celebrated analysis of Einstein's relativity theory is the result of an earlier philosophical discussion about space perception and its role for the theory of space. In particular, Schlick's "method of coincidences" did not owe anything to "entirely new principles" based on the work of Einstein, Poincaré or Hilbert, as claimed by Michael Friedman, but was already in place (...) before these principles were developed. The first part of the article is devoted to Alois Riehl's critical realism—a neo-Kantian variant which rejects the dominant interpretation of the thing-in-itself as a mere limiting concept and takes empirical theories of space perception into consideration. The second part deals with the central role of "Psychological Parallelism" for Riehl and its integration with Kant's epistemology. In the third part it is shown that Schlick's theory of knowledge is based on Riehl's intricate reworking of Kantian epistemology, physiological psychology, theory of sense perception and philosophy of mathematics. The conclusion stresses the position of the unity of consciousness in Riehl's philosophy which Schlick admittedly cannot cope with. (shrink)
Much has been written about medicine and the market in recent years. This book is the first to include an assessment of market influence in both developed and developing countries, and among the very few that have tried to evaluate the actual health and economic impact of market theory and practices in a wide range of national settings. Tracing the path that market practices have taken from Adam Smith in the eighteenth century into twenty-first-century health care, Daniel Callahan and Angela (...) A. Wasunna add a fresh dimension: they compare the different approaches taken in the market debate by health care economists, conservative market advocates, and liberal supporters of single-payer or government-regulated systems. In addition to laying out the market-versus-government struggle around the world -- from Canada and the United States to Western Europe, Latin America, and many African and Asian countries -- they assess the leading market practices, such as competition, physician incentives, and co-payments, for their economic and health efficacy to determine whether they work as advertised. This timely and necessary book engages new dimensions of a development that has urgent consequences for the delivery of health care worldwide. (shrink)
In A Thousand Plateaus, Deleuze and Guattari offer a description of what they call ‘nomad art’ by detailing its three primary characteristics: close-range vision, haptic space, and abstract line. In an attempt to unpack the significance of this provocative term, this paper will sketch the provenance of the first two of these characteristics, both of which come from Deleuze and Guattari's particular reading of Alois Riegl. Together, close-range vision and haptic space delineate the synaesthetic vision of the artist as (...) well as the space s//he creates in the work. Walter Benjamin will be invoked as a sort of phantom link between Riegl and Deleuze, a link that will both provide the proper orientation towards the central aspect of the haptic — against a Phenomenology of affect — as well as inject the necessary political significance into the discussion of nomad art. (shrink)
On January 1, 2006, Medicare Part D prescription drug coverage was initiated. Concern was immediately voiced by the American Association of Retired Persons (AARP) and Families USA that, in response to this program, the pharmaceutical industry may raise prices for drugs most often used by the elderly. This article examines the ethical implications of a revenue-maximizing pricing strategy in an industry in which third party financing mitigates an end product's true cost to the user. The perspectives of three stakeholder groups (...) are examined: the elderly, as consumers of prescription drugs, the pharmaceutical industry, as product manufacturer and beneficiary of derived profits, and the total U. S. population, as the ultimate payer for the program via tax revenues. Key questions explored include the relationships among price strategy and access to drugs at both the micro (Medicare cohort) and macro (total population) levels, and on drug development or enhancement. The role of profit in a capitalism-based health care system is also examined. Hospital industry impact on these same stakeholder groups in response to the original 1965 Medicare law is used to compare and contrast possible outcomes of the new drug program. It is predicted that pharmaceutical firms will mimic the hospital industry, adopting a price maximizing strategy for drugs covered by the program. In the process, a utilitarian effect occurs: the benefits of increased access and diffusion of drugs counterbalance inequities in financing Medicare Part D. (shrink)
INTRODUCTION: INFORMATION TECHNOLOGY AND COMPUTERS AS THEMES IN THE PHILOSOPHY OF TECHNOLOGY Philosophical interest in computers and information technology ...
. Critical realism is a frequently mentioned, but not very well-known, late nineteenth-/early twentieth-century philosophical tradition. Having its roots in Kantian epistemology, critical realism is best characterized as a revisionist approach toward the original Kantian doctrine. Its most outstanding thesis is the idea that Kantian things-in-themselves are knowable. This idea was—at least implicitly—suggested by thinkers such as Alois Riehl, Wilhelm Wundt, and Oswald Külpe. Interestingly enough, the philosophical position of the early Moritz Schlick stands in the critical realist tradition (...) as well. As will be outlined in the course of this paper, both Schlick’s magnum opus General Theory of Knowledge (1918) and his seminal Space and Time in Contemporary Physics (1917) are based on the assumption that the objects of science are relations and that relations have the status of Kantian things-in-themselves. By way of conclusion, I shall point out that this— more or less directly—leads to the current debate over ‘structural’ realism. (shrink)
Section: Philosophy of the Internet – Philosophie des Internets Science of Recording MAURIZIO FERRARIS, TURIN 109 Weltkommunikation und World Brain. ...
: The answer to the question of what health care services should be covered by a managed care plan is straightforward; the plan should cover whatever the consumer is willing to pay for. From the plan's perspective, the consumer is the payer, that is, the employer who negotiates the plan; not the individual patient whose personal preferences and interests may be quite different. Since managed care organizations contract with payers to arrange for health care services within a defined set (...) of benefits, there is a broader question as well: Within the benefits chosen by the payer, what actually is covered? Criteria for determining "medical necessity," which managed care plans frequently use as the basis for coverage, are discussed. (shrink)
The automatic tendency to anthropomorphize our interaction partners and make use of experience acquired in earlier interaction scenarios leads to the suggestion that social interaction with humanoid robots is more pleasant and intuitive than that with industrial robots. An objective method applied to evaluate the quality of human–robot interaction is based on the phenomenon of motor interference (MI). It claims that a face-to-face observation of a different (incongruent) movement of another individual leads to a higher variance in one’s own movement (...) trajectory. In social interaction, MI is a consequence of the tendency to imitate the movement of other individuals and goes along with mutual rapport, sense of togetherness, and sympathy. Although MI occurs while observing a human agent, it disappears in case of an industrial robot moving with piecewise constant velocity. Using a robot with human-like appearance, a recent study revealed that its movements led to MI, only if they were based on human prerecording (biological velocity), but not on constant (artificial) velocity profile. However, it remained unclear, which aspects of the human prerecorded movement triggered MI: biological velocity profile or variability in movement trajectory. To investigate this issue, we applied a quasi-biological minimum-jerk velocity profile (excluding variability in the movement trajectory as an influencing factor of MI) to motion of a humanoid robot, which was observed by subjects performing congruent or incongruent arm movements. The increase in variability in subjects’ movements occurred both for the observation of a human agent and for the robot performing incongruent movements, suggesting that an artificial human-like movement velocity profile is sufficient to facilitate the perception of humanoid robots as interaction partners. (shrink)
Before there was the digital divide there was the analog divide– and universal service was the attempt to close that analogdivide. Universal service is becoming ever more complex in terms ofregulatory design as it becomes the digital divide. In order to evaluatethe promise of the next generation Internet with respect to the digitaldivide this work looks backwards as well as forwards in time. Byevaluating why previous universal service mechanisms failed andsucceeded this work identifies specific characteristics ofcommunications systems – in particular (...) in billing and managinguncertainty – and argues that these characteristics underliesuccess or failure in terms of technological ubiquity. Developing a setof characteristics of services rather than a set of services is afundamental break with the tradition of universal service. In fact, theimplications of our proposal is that basic characteristics in theoffering of the service rather than the absolute price are critical toclose the digital divide: certainty of total charge, ability to avoiddeposits or disconnection via best effort service, and payer-basedcontrol of all charges. While all of these principles sound obvious infact none of these hold in the telephony network. Universal service hasevolved from common carriage (serve all with no discrimination) to aright to basic services (100% penetration). Universal service isnow discussed as the digital divide, as the access to information asopposed to services becomes increasingly critical. However, we arediscussing in this paper access to the bits and the network rather thanaccess to the information (or intellectual property) once connected. Theprovision of universal service is seen as a technical problem only in thatthe technology costs money – universal service debates have longbeen the domain of economists. Yet the design of protocols has been thedomain of engineers, the building of systems the corporate domain, andthe discussion of equity the interest of ethicists. The design ofprotocols can define the parameters of the corporate decision-makers,the variables of the economist, and the questions for the ethicist. Thedesign decisions made at the fundamental levels can make communicationsequity more or less likely. In this work I focus on the design ofprotocols for the next generation Internet, protocols which willfundamentally change the best-effort nature of Internet services.Building on the economic and ethnographic work of others I argue thatthe effects of protocols adoption on universal service can be predictedto some degree. By examination of past and current technologies Iexamine a set of technical mechanisms to determine how such mechanismsmight harm or enhance universal service. I define each mechanism (e.g.denial of entry) and offer observations about each particularmechanism''s implicit pricing assumptions. I close with a discussion ofinterest to ethicists and regulators on evaluating communicationsprotocols with respect to universal access. Protocols for developingmultiple qualities of service for packet-switched networks have focusedon economic efficiency (e.g. Mackie-Mason, 1995; Choi, Stahl &Winston, 1997; Shapiro & Varian, 1998), billing to encouragewidespread adoption of network innovations (e.g. Xie & Sirbu, 1985)and billing in a manner consistent with the underlying network (e.g.Clark, 1996). Here we examine a set of protocols which include varyingquality of service mechanisms with respect to the compatibility of theprotocols with universal access. (shrink)
Like every major new technology, genetic engineering is affecting the hopes and fears of many people. The risks involved are perceived differently by different groups. One group regards genetic engineering as a simple extension of older techniques with no special risks, e.g. traditional breeding. This conservative denial of special risks is confronted with a different kind of conservatism from a group which, in the name of the preservation of nature, opposes any kind of genetic engineering. A third group, rooted in (...) the liberal tradition, is prepared to accept the risks of genetic engineering as long as they are outweighed by prospective benefits. The liberal as well as the two conservative approaches, however, face serious difficulties in trying to develop a sound ethical argument concerning genetic engineering. In order to avoid these difficulties, an ethical approach focused on paradigmatic examples of good and evil is proposed. Such examples constitute rules of moral description, much as standards of measurement constitute rules of physical description. These rules are elaborated and interpreted in processes of social learning. In the present state of development of genetic engineering, such social learning requires appropriate institutional procedures. (shrink)
This article examines the difficulties encountered in teaching professionalism to medical students in the current social and political climate where economic considerations take top priority in health care decision making. The conflict between the commitment to advocate at all times the interests of one’s patients over one’s own interests is discussed. With personal, institutional, tech industry, pharmaceutical industry, and third-party payer financial imperatives that stand between patients and the delivery of health care, this article investigates how medical ethics instructors (...) are to teach professionalism in a responsible way that does not avoid dealing with the principle of justice. (shrink)
The origins of object theory in the philosophical psychology and semantics of Alexius Meinong and the Graz school can be traced both to the insight and failure of Franz Brentano's immanent objectivity or intentional in-existence thesis. The immanence thesis is documented, together with its critical reception in Alois Höfler's Logik, Twardowski's Zur Lehre vom Inhalt und Gegenstand der Vorstellungen, and Meinong's mature Gegenstandstheorie, in which immanent thought content and transcendent intentional object are distinguished, and Brentano's thesis of immanent intentionality (...) as the mark of the mental is reinterpreted to imply that only content is the immanently intentional component of presentations. Brentano's thought from the early immanence thesis through the so-called Immanenzkrise and his later reism is explored against the background of his students' reactions to the original 1874 intentionality thesis and its idealist implications, in the emergence of Meinong's object theory and Edmund Husserl's transcendental phenomenology. Finally, Brentano's reism in the later ontology is critically examined, as his solution to ontic problems of immanent intentionality, limiting intentional objects to transcendent concrete particulars. (shrink)
Abstract: It is not too early to suggest that the attempts to place medical care in private hands (through group insurance arrangements) has not fulfilled its promise—or better, the promises that were made for it. Yet history has not been kind to plans to make government the single payer, and the laudable progress in medical technology has placed high-technology medical care beyond the reach of most private budgets. In this paper I suggest that the major problem of the U.S. (...) health care system as presently conceived is a failure of legitimacy, and I put forward a proposal that purports to solve that problem. The proposal is to localize health care, on the model of a public school system, on the argument that such localization will answer most of the questions of legitimacy at the core of the private insurance imbroglio, provide a brake for medical costs, while preserving our ability to take advantage of the most advanced medical interventions. I present some initial arguments for the proposal, but await its proof in the dialogue emerging as the present insurance system collapses. (shrink)
This paper offers a critique of recent attempts, by George Sher and others to justify compensation to be paid to descendants of deceased victims of past wrongs. This recent attempt (the ‘continuing injustice argument’) is important as it endeavours to avoid some well-known critiques of previous attempts, such as the non-identity problem. Furthermore, this new attempt is grounded in individual rights, without invoking a more controversial collectivist assumption. The first step in this critique is to differentiate between compensation and restitution. (...) Once this important distinction is clear, an examination of several factors follows: the importance of the passage of time vis-à-vis claims for compensation and/or restitution (and especially the passing away of the original victims and wrongdoers), the responsibility of the would be payers, the responsibility of the descendants of the victims, the welfare level of the descendants of the victims, information-related issues, and several additional factors. The conclusion is that once we take into account the distinction between compensation and restitution, and the additional factors mentioned, the case for compensation and/or restitution under the ‘continuing injustice argument’, is highly limited. (shrink)
This study used a laboratory experiment with monetary incentives to test the impact of three personal factors (moral reasoning, value orientation and risk preference), and three situational factors (the presence/absence of audits, tax inequity, and peer reporting behavior), while controlling for the impact of other demographic characteristics, on tax compliance. Analysis of Covariance (ANCOVA) reveals that all the main effects analyzed are statistically significant and robustly influence tax compliance behavior. These results highlight the importance of obtaining a proper understanding of (...) these factors for developing effective policies for increasing the level of compliance, and indicate that standard enforcement polices based on punishment alone should be supplemented by an information system that would acquaint tax payers with the compliance level of other tax payers; reinforce the concept of fairness of the tax system among tax payers; and develop programs that enhance and appeal to a taxpayer''s moral conscience and reinforce social cohesion. (shrink)
Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes (...) be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence. (shrink)
Manuscript type Empirical. Research question/issue This paper aims to contribute to an improved theoretical and empirical understanding of the role that corporation has to play in anticorruption efforts. Research findings/insights Using cross-country data from three databases (Bribe Payers Index, Corruption Perceptions Index, and Doing Business) we found that pro-bribery Investment Climate conditions in host countries are not related to the payments of bribes by multinational companies when these corporations operate abroad. Theoretical/academic implications After describing the conceptual and policy framework that (...) surrounds the discussion on the role played by firms in anticorruption, we present the current debate regarding the effectiveness of international bribery control instruments, with the World Bank-GAC (2006-2008) report as a basis. Both literature and policy seem to be divided into two main, although not mutually exclusive, positions: one demands improvements in Investment Climate conditions from a joint public-private consensus led by international agencies; the other one supports the effectiveness of self-regulation by firms, independent of Investment Climate improvements. The study provides empirical support to the idea that a better Investment Climate is not enough for reducing corrup tion. Practitioner/policy implications This study offers insights to policy makers interested in promoting the involvement of corporations in the fight against corruption. (shrink)
In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially medical judgments. In (...) contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)
Abstract: This essay examines the impact of the imposition of businesses techniques, in particular, those associated with Total Quality Management, on the relationships of important components of the health care delivery system, including payers, managed care organizations, institutional and individual providers, enrollees, and patients. It examines structural anomalies within the delivery system and concludes that the use of Total Quality Management techniques within the health care system cannot prevent the shift of attention of other components away from the enrollee and (...) the patient, and may even contribute to it. It speculates that the organization ethics process may serve as a quality control mechanism to prevent this shift and so help eliminate some of the ethically problematic processes and outcomes within the health care delivery system. (shrink)
The central topic for this book is the ethics of treating individuals as though they are members of groups. The book raises many interesting questions, including: why do we feel so much more strongly about discrimination on certain grounds e.g. of race and sex - than discrimination on other grounds? Are we right to think that discrimination based on these characteristics is especially invidious? what should we think about rational discrimination discrimination which is based on sound statistics. To take just (...) one of dozens of examples from the book. Suppose a landlord turns away a prospective tenant, because this prospective tenant is of a particular ethnicity arguing that statistics show that one in four of this group have been shown in the past to default on their rent. That seems clearly unfair to people of this ethnicity. But we are routinely being judged in this way not just on the basis of our ethnicity, but assumptions are made about us and decisions taken about us based on our gender, religion, job, post-code, hobbies, blood-group, nationality, etc., etc., etc.. Now suppose that another landlord turns away a convicted criminal, arguing that one in four of convicted criminals have been shown to be unreliable rent payers. Is our intuition the same as before? Should it be? The book will be suitable for all students of philosophy, especially those with an interest in applied ethics. (shrink)
A new economic phenomenon, in which physicians refer their patients to ancillary facilities of which they themselves are owners or substantial investors, presents a ‘laboratory’ for assessing philosophers' potential contributions to public policy issues. In this particular controversy, ‘prohibitionists’ who wish to ban all such self-referral focus on the dangers that patients and payers may receive or be billed for unnecessary or poor-quality care. ‘Laissez-fairists’, in contrast, argue that self-referral should be freely permitted, with a reliance on personal ethics and (...) internal professional monitoring to guard against abuse. Undue government regulation, they argue, infringes providers' and patients' economic freedom, and stifles the competition that can yield better quality care at lower prices. As this debate features basic values and large amounts of money, it has been marked by rancorous rhetoric, shallow argument, and muddled reasoning. The philosopher's first contribution, therefore, is to expose simplistic and fallacious arguments, whether empirical, conceptual, moral, or legal. Beyond this, the philosopher can help to identify the important values at stake and, perhaps, to identify resolutions that honor those values better than the more simplistic answers proffered previously. For abusive self-referral, as distinguished from kickbacks, the author recommends that civil remedies be favored over criminal prohibitions. She suggests that the doctrine of ‘bad faith breach of contract’ might appropriately be extended into this new area to provide a powerful means by which aggrieved patients and payers can hold physicians personally accountable for abusive self-referrals. Keywords: bad faith breach of contract, civil law, criminal law, self-referral, simplistic reasoning CiteULike Connotea Del.icio.us What's this? (shrink)
This essay examines the impact of the imposition of businesses techniques, in particular, those associated with Total QualityManagement, on the relationships of important components of the health care delivery system, including payers, managed care organizations, institutional and individual providers, enrollees, and patients. It examines structural anomalies within the delivery system and concludes that the use of Total Quality Management techniques within the health care system cannot prevent the shift of attention of other components away from the enrollee and the patient, (...) and may even contribute to it. It speculates that the organization ethics process may serve as a quality control mechanism to prevent this shift and so help eliminate some of the ethically problematic processes and outcomes within the health care delivery system. (shrink)
Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. (...) The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)
Poor quality medical care is sometimes attributed to physicians’ unwillingness to act on evidence about what works best. Evidence-based performance standards (EBPSs) are one response to this problem, and they are increasingly employed by health care regulators and payers. Evidence in this instance is judged according to the precepts of evidence-based medicine (EBM); it is probabilistic, and the randomized controlled trial (RCT) is the gold standard. This means that EBPSs suffer all the infirmities of EBM generally—well rehearsed problems with the (...) external validity of research findings as well as the inferential leap from study results in the aggregate to individual patient care. These theoretical weaknesses promise to have a practical impact on the care of patients. To avoid this, EBPSs should be understood as guidelines indicative of average effectiveness rather than standards to be applied in every case. (shrink)
