Online research in philosophy

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition_is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics. With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state of the art (...) introductions to the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation. This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field. Developments from the First Edition include:_ The focus on ‘Four Principles Method’ is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section. (shrink)

The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether (...) or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties. (shrink)

Providing health care in the most cost-effective way has become a priority in recent years. This book tackles the important issue of the potential conflict between economic expediency and the welfare of individual patients. Contributors examine different attitudes to this complex problem, along with a variety of legal and historical perspectives. The book addresses particular aspects of health care, such as medical expert systems, general practice, medical education, and clinical decision-making where the direct involvement of doctors (...) in allocating scarce and expensive resources is perhaps most obvious. (shrink)

Machine generated contents note: Preface; 1. Introduction; 2. Three approaches to conscientious objection in health care: conscience absolutism, the incompatibility thesis, and compromise; 3. Ethical limitations on the exercise of conscience; 4. Pharmacies, health care institutions, and conscientious objection; 5. Students, residents, and conscience-based exemptions; 6. Conscience clauses: too little and too much protection; References.

Many health care professionals (HCPs) are understandably reluctant to treat patients in environments infested with bedbugs, in part due to the risk of themselves becoming bedbug vectors to their own homes and workplaces. However, bedbugs are increasingly widespread in care settings, such as nursing homes, as well as in private homes visited by HCPs, leading to increased questions of how health care organizations and their staff ought to respond. This situation is associated with a range (...) of ethical considerations including the duty of care, stigmatization, vulnerability, confidentiality, risks for third parties, and professional autonomy. In this article, we analyze these issues using a case study approach. We consider how patients whose living environments are infested with bedbugs can receive care in the community setting in a manner that supports their well-being, is consistent with fairness in care provision, and takes into account risks for HCPs and third parties. We also discuss limits and obstacles to the provision of care in these situations. (shrink)

In recent years we have seen the emergence of “personalised medicine.” This development can be seen as the logical product of reductionism in medical science in which disease is increasingly understood in molecular terms. Personalised medicine has flourished as a consequence of the application of neoliberal principles to health care, whereby a commercial and social need for personalised medicine has been created. More specifically, personalised medicine benefits from the ongoing commercialisation of the body and of genetic knowledge, the (...) idea that health is defined by genetics, and the emphasis the state places on individual citizens as being “responsible for” their own health. In this paper I critique the emergence of personalised medicine by examining the ways in which it has already impacted upon health and health care delivery. (shrink)

This paper offers critical reflection on the contemporary tendency to approach health care in instrumentalist terms. Instrumentalism is means-ends rationality. In contemporary society, the instrumentalist attitude is exemplified by the relationship between individual consumer and a provider of goods and services. The problematic nature of this attitude is illustrated by Michael Oakeshott’s conceptions of enterprise association and civil association. Enterprise association is instrumental; civil association is association in terms of an ethically delineated realm of practices. The latter offers (...) a richer ethical conception of the relation between person and society than instrumentalism does. Oakeshott’s conception is further illustrated by reflection on the connection between morality and religion that he explores in an early essay concerning “religious sensibility”. Religious sensibility turns on the acknowledgement of the vulnerability of the self to the vicissitudes of life. This vulnerability cannot be bargained over instrumentally without imperilling the self. Religious sensibility is thus a valuable resource for criticising instrumentalist attitudes. It allows for the cultivation of ethical self-understanding that is essential to comprehending the conditions in virtue of which genuine civil life is possible. These conditions need to be taken into account in health care. Health care is not simply about substantive wants. It also necessarily concerns the universal and constant condition of being prey to illness that is the common lot of all citizens. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs (...) must answer two distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

This article provides a brief introduction to the interplay between law and religion in the health care context. First, I address the extent to which the commitments of a faith tradition may be written into laws that bind all citizens, including those who do not share those commitments. Second, I discuss the law’s accommodation of the faith commitments of individual health care providers—hardly a static inquiry, as the degree of accommodation is increasingly contested. Third, I expand (...) the discussion to include institutional health care providers, arguing that the legal system’s resistance to accommodating the morally distinct identities of institutional providers reflects a short-sighted view of the liberty of conscience. Finally, I offer some tentative thoughts about why these dynamics become even more complicated in the context of Islamic health care providers. (shrink)

South Africa currently has a pluralistic health care system with separate public and private sectors. It is, however, moving towards a socialised model with the introduction of National Health Insurance. The South African legislative environment has changed recently with the promulgation of the Consumer Protection Act and proposed amendments to the National Health Act. Patients can now be viewed as consumers from a legal perspective. This has various implications for health care systems, health (...) care providers and the doctor-patient relationship. (shrink)

Justice and Health Care: Selected Essays collects, in a systematic but non-chronological fashion, ten of Buchanan’s most significant essays on justice and health care, written over a period of almost three decades. As the Obama administration continues to struggle to implement much-needed comprehensive health care reform in the hopes of controlling rising health care costs and extending affordable health care to over 46 million uninsured Americans [1], there could hardly be (...) a more appropriate time to read Buchanan’s selected essays ... (shrink)

The aims of this paper are threefold. The first aim is to provide a critique of the reform proposal of the Harvard School of Public Health for Hong Kong's health care system through privatization of the public sector services. The second aim is to argue for the duty of society to guarantee every member equal access to a basic level of health care based on the values of equity, care and free choice. The third (...) aim is to explore some suggestions about delivery structures and financial arrangements of a dual sector health care system which will better enable society to provide a basic level of health care that is sustainable and affordable, while being at the same time consistent with the values of care, equity and free choice. (shrink)

: Widespread collection and use of identifiable information can promote social goods while, at the same time, infringing on personal privacy. Information systems are developing within the context of a fundamental transformation in the organization, delivery, and financing of health care. Changes in the health care system include rapid development of employer-sponsored health coverage, managed care organizations, and integrated delivery systems. These complex, multifaceted arrangements for delivering and paying for health (...) class='Hi'>care require ever-more-sophisticated information systems that facilitate extensive sharing of personal data. Systemic flows of sensitive health information occur both vertically and horizontally among employers, hospitals, insurers, laboratories, and suppliers. Beyond this complex web of vertical and horizontal sharing are the multiple demands for information management, quality assurance, research, governmental regulation, and public health. Theoretical problems exist with the law and ethics of informational privacy. The traditional method of exercising control over personal health information is through informed consent. Informed consent, however, within a modern health information infrastructure becomes highly complex. In this kind of environment, the doctrine of informed consent is flawed and does not provide sufficient control over personal information to assure adequate protection of privacy. (shrink)

Abstract: In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through (...) this discussion we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders. (shrink)

This paper considers the way in which English law safeguards fundamental rights to respect for faith and belief in relation to the delivery of health care. It explores the implications of the Human Rights Act 1998 and the Equality Act 2010. It explores some of the challenges in attempting to reconcile fundamental rights to faith and belief and the delivery of health care, both now and in the future and whether this is a realistic (...) aspiration in a state funded health care service. (shrink)

This paper raises some issues about understanding religion, religions and spirituality in health care to enable a more critical mutual engagement and dialogue to take place between health care institutions and religious communities and believers. Understanding religions and religious people is a complex, interesting matter. Taking into account the whole reality of religion and spirituality is not just about meeting specific needs, nor of trying to ensure that religious people abandon their distinctive beliefs and insights when (...) they engage with health care institutions and policies. Members of religious groups and communities form an integral part of the structure and fabric of health care delivery, whether as users or in delivery capacities. Religion is both facilitator and resistor, friend and critic, for health care institutions, providers and workers. (shrink)

In the context of health care the aim of the article is to bring another meaning to the concept “need” that goes beyond the human activity; the drive to satisfy needs. Another meaning incorporates an ethical and existential nature of life phenomena. An example from empirical research on living with a chronic disease as seen from the patient’s point of view provides the basis for arguing another meaning of the concept “need”. The meanings and nuances in the life (...) phenomena of hope, doubt and life courage are exemplified in qualitative interviews with chronic sufferers. A combination of empirical research and Danish life philosophy. Research has shown that the interaction between the professional health care provider and the patient and family may lead to a more or less unconscious and inappropriate administration of power. Research also indicates that by overlooking or ignoring the existential qualities in human life and suffering, the professional health care provider may deprive the patient and family of their room for action. To add a deeper understanding of the existential meaning of being a person with an illness, the article shows the different human dimensions concerning life phenomena and needs. Developing sensitive, situation-specific attention offers a response to the challenge faced by health care providers in collaboration with the patient: How can we open our eyes to the most significant features of the situation which arise on the onset of illness. (shrink)

The purpose of the article is to argue for the significance of a clarified goal of health care for the setting of priorities. Three arguments are explored. First, assessment of needs becomes necessary in so far as the principle of need should guide the priority-setting. The concept of health care need includes a goal component. This component should for rational reasons be identical with the goal of health care. Second, in order to use resources (...) efficiently it is necessary to assess the effects of health care. It is not, however, a question of assessing whether there is an effect but a question of assessing whether there is the right effect. And what constitutes the right effect can only be determined in relation to the goal of the enterprise. Third, the health sector involves several groups of actors such as politicians, administrators, doctors, nurses, physiotherapists, occupational therapists, educationists and patients. It is common knowledge that successful teamwork requires an understanding of a common goal. The article ends with an example of a goal chosen from ethics. (shrink)

The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? -- Abandoning informed (...) consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (shrink)

Describing the U.S. health care system meansdescribing managed care under commercial forces.Managed care creates new moral tension forpractitioners, but more importantly, in its currentform it intensifies the commercialization of healthexpectations and interactions. The largely unregulatedmarketing of health services under managed care hasbeen a major factor in the increasing number ofuninsured citizens, while claims for cost reductionthrough managed care are equivocal. Risk-ratingpractices integral to the current medical marketplacethwart concerns for justice in allocation and createvulnerabilities (...) for almost everyone. Thepolitical-moral concern of the early 1990s for a rightto health care is nowhere in sight. (shrink)

The term ``paradox'' signifies acontradiction of some sort. Modern health careappears to be rich in contradictions, and it isclaimed to be paradoxical in a number of ways.In particular health care is held to be aparadox itself: it is supposed to do good, butis accused of doing harm. The objective of thisarticle is to investigate whether the conceptof paradox can serve as a framework foranalysing pressing problems in modern healthcare. To pursue this, three distinctive levelsof paradox are identified: (...) resolvableparadoxes, antinomies and aporias. The analysisreveals that when facing the challenges ofmodern health care the focus of attentionshould be to resolve the resolvable paradoxes,to acknowledge the antinomies and to learn tolive with the aporias. (shrink)

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are (...) nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare. (shrink)

During the past three decades, there has been an ongoing debate on the quality of health care. Defining quality is an important part of it. This paper offers a review of definitions and a conceptual analysis in order to understand and explain the differences between them. The analysis results in a semantic rule, expressing the meaning of quality as an optimal balance between possibilities realised and a framework of norms and values. This rule is postulated as a formal (...) criterion of meaning, e.g. when (correctly) applied people understand each other. The rule suits the abstract nature of the term quality. Quality doesn't exist as such. It is constructed in an interaction between people. This interaction is guided by rules in order to transfer information, e.g. communicate on quality. The rule improves our ability to discuss the debate on quality and to develop a theory grounding actions such as quality assurance or quality improvement. (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative (...) claim types. We identify the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

The article deals with the issue of solidarity in health care,with particular reference to the Italian context. It presents thedifficulties of the Italian NHS and assesses the current proposalto counter the crisis of the Welfare State by giving upinstitutional arrangements, in order to favour the so-called`social private'. Moreover, it addresses the question ofprioritisation and targeting in the context of health care,arguing for the insufficiency of the standard approach of neutralliberalism, and showing how the concept of solidarity (...) might helpto develop a different account. Lastly, it discusses the case oforgan transplantion in Italy, as an example ofsolidarity-inspired health care policy. (shrink)

In 1991, the CDC recommended that health care workers (HCWs) infectedwith HIV or HBV (HbeAg positive) should be reviewed by an expert paneland should inform patients of their serologic status before engaging inexposure-prone procedures. The CDC, in light of the existing scientificuncertainty about the risk of transmission, issued cautiousrecommendations. However, considerable evidence has emerged since 1991suggesting that we should reform national policy. The data demonstratesthat risks of transmission of infection in the health care setting areexceedingly low. (...) Current policy, moreover, does not improve patientsafety. At the same time, implementation of current national policy atthe local level poses significant human rights burdens on HCWs.Consequently, national policy should be changed to ensure patient safetywhile protecting the human rights of HCWs. This article proposes a newnational policy, including: (1) a program to prevent bloodborne pathogentransmission; (2) a responsibility placed on infected HCWs to promotetheir own health and well-being and to assure patient safety; (3) adiscontinuation of expert review panels and special restrictions forexposure-prone procedures; (4) a discontinuation of mandatorydisclosure of a HCW's inflection status; and (5) the imposition ofpractice restrictions if a HCW is unable to practice safely because of aphysical or mental impairment or failure to follow careful infectioncontrol techniques. A new national policy, focused on management of theworkplace environment and injury prevention, would achieve high levelsof patient safety without discrimination and invasion of privacy. (shrink)

A recently published book, 'The Economics of Health Reconsidered' by Tom Rice, provides a strong critique of the role of markets in health care. Many of the issues of 'market failure' raised by Rice, however, have been, to varying extents, recognised previously in the health economics literature (at least outside the U.S.). What perhaps sets Rice's book apart from previous attempts to document such issues is its elegance and the methodical manner in which this critique is (...) delivered. Significantly the critique is based solely on conventional economic arguments. There has, however, been an emerging strand of the health economics literature not acknowledged in Rice's book which has approached some of these issues of market failure from a different perspective. Notably this research has involved, in part, borrowing from the ideas and methodological traditions of other disciplines. The emphasis in this work has been to expand the scope and the concerns of economic analysis in health care. (shrink)

New Zealand and United Kingdom governments have set new directives for increased consultation with the public about health care. Set against a legacy of modest success with past engagement with public consultations, this paper considers potentially adverse ethical implications of the new directives. Drawing on experiences from New Zealand and the United Kingdom, and on an Orthodox Jewish perspective, the paper seeks to answer two questions: What conditions can compromise the ethics of public consultation? How can the public (...) respond ethically to consultation? In answering these questions, the paper considers how Orthodox Judaism, as a specific positive morality, can aid the development of public policy. It is suggested that an Orthodox Jewish perspective does not require limiting the content of public consultations and helps to define a common procedural morality binding Jews and non-Jews. This procedural morality requires avoiding two conditions that, as shown from Jewish texts, make public consultation unethical. These are overpreparation and underpreparation. Members of the public who deem a consultation unethical should give feedback not on the proposal but on the conditions they perceive to prevent the consulting party from considering their viewpoints on the proposal. (shrink)

Background: Inclusion or not of a treatment strategy in the publicly financed health care is really a matter of prioritisation. In Sweden priority setting decisions are governed by law in which it is stated that decisions should be guided by firstly the principle of need and secondly the principle of cost-effectiveness.

The health care systems in Austria, Germany and Switzerland owe theirinstitutional structure to different historical developments. While Austriaand Germany voted for the Bismarck-Model of social health insurance,Switzerland adopted a voluntary system of health insurance. In all threecountries, until very recently, the different challenges which the healthcare sector faced were met by piecemeal approaches and by stop and gopolicies, which, in the long run were not very successful either incontaining costs or in improving efficacy and efficiency. During (...) the 1990 morefundamental reforms in the health care systems of all three countries tookplace. Germany and Switzerland chose the path of deregulation of thehealth insurance system, which consequently strengthened the competitionbetween the insurance companies, and, to some extent between thesuppliers of medical services. While this can be seen as an essential part ofthe reform process for these two countries, Austria favors a state-orientedand interventionist approach in order to meet the challenges. (shrink)

Those considering careers in medicine and other health and humanitarian disciplines as well as those concerned about the growing presence of militarized ...

Machine generated contents note: Introduction Chapter 1: The basics of ethical decision-making Chapter 2: Hospital ethics committees and clinical ethicists Chapter 3: The settings of health care ethical dilemmas Chapter 4: Advance directives Chapter 5: Do Not Resuscitate orders and "Code Blue" Chapter 6: Non-beneficial medical interventions Chapter 7: Quality of life and treatment burdens Chapter 8: Patient privacy and confidentiality Chapter 9: Refusing medical treatment Chapter 10: Health care at the end of life Chapter 11: (...) Transplant ethics Chapter 12: Neuroethics Chapter 13: Ethics and reproductive technology Chapter 14: Genetics and ethics Chapter 15: Pediatric ethics Chapter 16: Participating in a research study Appendix A: Resource List Appendix B: Glossary Index. (shrink)

The changing world of health care finance has led to a paradigm shift in health care with health care being viewed more and more as a commodity. Many have argued that such a paradigm shift is incompatible with the very nature of medicine and health care. But such arguments raise more questions than they answer. There are important assumptions about basic concepts of health care and markets that frame such arguments.

This article tries to analyze the meaning of a decent minimum of health care, by confronting the idea of decent care with the concept of justice. Following the ideas of Margalith about a decent society, the article argues that a just minimum of care is not necessarily a decent minimum. The way this minimum is provided can still humiliate individuals, even if the end result is the best possible distribution of the goods as seen from the (...) viewpoint of justice. This analysis is combined with an analysis from the perspective of solidarity, particularly of reflective solidarity, as a way to develop decent care, which is care that does not humiliate individuals and maintains their dignity. (shrink)

This essay serves as an introduction to this issue of the Journal of Medicine and Philosophy on commodification and health care. The essay attempts to sharpen the articulation of generally expressed worries about the commodification of health care. It does so by defining commodification, analyzing three components of the good of health care, and attempting to assess how commodification might distort the shape of each of those components. Next, it explores how the good of (...) health care might be distorted by the market-based principle of distributive justice, "to each according to ability to pay." Finally, it identifies two basic questions about the relationship of medicine and the market that merit further exploration. (1) How does the market-based language of "incentives" so pervasive in the world of managed care distort the complex patterns of virtue and vice that motivate actors in the health care arena? (2) If we recognize that we cannot eliminate the influence of money from the health care system, how can we insure that the good of health care remains, in Radin's terms, "incompletely commodified"? (shrink)

Health care resource distribution is a subject of debate among health policy analysts, economists, and philosophers. In the United States, there is a widening gap between the more-and less-advantaged socioeconomic sub-populations in terms of both health care resource distribution and outcomes. Conventional wisdom suggests that there is a tradeoff, a zero-sum game, between efficiency and fairness in the distribution of health care resources. Promoting fairness in the distribution of health care resources (...) and outcomes is not efficient in terms of maximization of a health outcome production function. On the other side of the coin, improving efficiency comes at the expense of fairness. Such conventional wisdom is supported in part by standard static Paretian welfare analysis. However, in this paper it is shown that in a dynamic setting in which there are efficiency gains in the health production function, fairness in distribution of health care resources can improve simultaneously. (shrink)

This book shows how environmental decline relates to human health and to health care practices in the U.S. and other industrialized countries. It outlines the environmental trends that will strongly affect health, and challenges us to see the connections between ways of practicing medicine and the very environmental problems that damage ecosystems and make people sick. In addition to philosophical analysis of the converging values of bioethics and envrionmental ethics, the book offers case studies as well (...) as a number of practical suggestions for moving health care toward sustainability. (shrink)

The context of international health research involving human subjects, and this should appear obvious, is the human community. As such, basic questions of how human beings should be treated by other human beings, particularly in situations of unequal power – e.g., in the form of control, choice, or opportunity – lay at the foundations of related ethical discourse when ethics are discussed at all. I trace a narrative that follows upon a recent revision process of international guidelines for biomedical (...) research involving human subjects. I focus in particular upon the issue of a standard of care. In the second section, I draw upon philosophers John Rawls, Claudia Card, and Allen Buchanan to discuss concerns regarding the 'least advantaged members of society' in the context of global inequality. The paper includes reflections upon pedagogy in courses focused upon international health research involving human subjects. (shrink)

The cost of health care imposes an extremely difficult, and often impossible, burden for many people to bear. It is also a burden that men and women do not experience in the same way. Evidence shows that “women have greater difficulty affording health care” (Patchias and Waxman 2007, 6). In the United States, 62 percent of working-age women in 2007—compared to 48 percent of working-age men—reported problems in affording health care, including not being able (...) to pay medical bills, foregoing or delaying needed care because of cost, or both (Rustgi, Doty, and Collins 2009). An additional 10 percent of working-age adults reported being uninsured or underinsured. The Affordable Health Care for America Act .. (shrink)

A complex interaction of ideological, financial, social, and moral factors makes the financial sustainability of health care systems a challenge across the world. One difficulty is that some of the moral commitments of some health care systems collide with reality. In particular, commitments to equality in access to health care and to fair equality of opportunity undergird an unachievable promise, namely, to provide all with the best of basic health care. In addition, (...) commitments to fair equality of opportunity are in tension with the existence of families, because families are aimed at advantaging their own members in preference to others. Because the social-democratic state is committed to fair equality of opportunity, it offers a web of publicly funded entitlements that make it easier for persons to exit the family and to have children outside of marriage. In the United States, in 2008, 41% of children were born outside of wedlock, whereas, in 1940, the percentage was only 3.8%, and in 1960, 5%, with the further consequence that the social and financial capital generated through families, which aids in supporting health care in families, is diminished. In order to explore the challenge of creating a sustainable health care system that also supports the traditional family, the claims made for fair equality of opportunity in health care are critically reconsidered. This is done by engaging the expository device of John Rawls’s original position, but with a thin theory of the good that is substantively different from that of Rawls, one that supports a health care system built around significant copayments, financial counseling, and compulsory savings, with a special focus on enhancing the financial and social capital of the family. This radical recasting of Rawls, which draws inspiration from Singapore, is undertaken as a heuristic to aid in articulating an approach to health care allocation that can lead past the difficulties of social-democratic policy. (shrink)

: 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 United States has a population of three hundred million, according to latest Census Bureau estimates. Forty-seven million, including many non-citizens, are uninsured. That is, 16% of the total United States population has no health insurance. Millions more have inadequate coverage and are in danger of losing that. Private, corporatized medical coverage, structured by the insurance industry, is the basis for the current system. This article is an attempt to lay out the principal health care issues, to (...) look at the alternatives and the cost of those alternatives, and to try to determine whether there is a particular regime that, despite its imperfections, is the best available to us now. (shrink)

The traditional paradigm of medicine assumes that health is a natural given depending on a body's intrinsic teleology, and that medicine aims at restoring or preserving health, making a physician only an "assistant to nature." I argue that nowadays this paradigm is becoming obsolete, because the concept of health is no longer a "natural given" and interventions on the human body attempt not only to help nature's teleology, but also to change it whenever doing so can satisfy (...) human needs and wants. We should abandon the term "medicine" and adopt the term "health care" to mark such an epoch-making transition, analogous to that marking the passage from "alchemy" to "chemistry.". (shrink)

In this article, I offer an abridged reconstruction of the foundational elements of Confucian moral commitments, which, I will argue, still provide the background moral substance for moral reflection in mainland China, Hong Kong, Taiwan, Singapore, and Korea. The essay presents implications of Confucianism for establishing an appropriate health care system and critically assesses the features of current health polices in mainland China, Hong Kong, and Singapore. The goal is to offer a family-oriented, non-individualist account of resource (...) allocation that takes family authority and responsibility seriously. (shrink)

The current debate on health care resource allocation in the Netherlands is characterized by a social context in which two values are generally and traditionally accepted as being equally fundamental: solidarity and equity. We will present an outline of the distinctive features of the Dutch health care system, and analyze the present state of affairs in the resource allocation debate. The presuppositions of the political call for constraint and (renewed) government supervision and the role of the (...) specific value context in recent proposals for reconstruction of the Dutch health care system will be evaluated. Keywords: distributive justice, equity, health policy, resource allocation, solidarity CiteULike Connotea Del.icio.us What's this? (shrink)

This is the primary question which this essay will answer. But there is a prior methodological question that also needs to be addressed: How do we go about rationally (non-arbitrarily) assessing whether DRGs are just or not? I would suggest that grand, ideal theories of justice (Rawls, Nozick) have only very limited utility for answering this question. What we really need is a theory of "interstitial justice," that is, an approach to making justice judgments that is suitable to assessing the (...) social practices and institutions that comprise the interstices of our social life as opposed to its basic structure. Rawls's appeal to "our considered moral judgments" provides us with a useful starting point for this task, which we shall discuss in the first part of this essay. In the second part, we shall actually assess DRGs from the perspective of interstitial justice. What we shall show is that DRGs violate a large number of our considered judgments regarding a just approach to financing health care for the elderly in a cost-effective manner. This is true to such an extent that efforts to reform DRGs and make them fairer, such as the recent effort by Robert Veatch, should be abandoned. In the concluding section of the essay we discuss one especially pernicious feature of DRGs, namely, that they represent an invisible approach to rationing access to health care. In the minds of many this is one of the virtues of DRGs. That claim needs critical examination. Keywords: DRGs, rationing scarce resources, justice, nonideal justice CiteULike Connotea Del.icio.us What's this? (shrink)

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually (...) increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity. (shrink)

Commodification of health care is a central tenet of managed care as it functions in the United States. As a result, price, cost, quality, availability, and distribution of health care are increasingly left to the workings of the competitive marketplace. This essay examines the conceptual, ethical, and practical implications of commodification, particularly as it affects the healing relationship between health professionals and their patients. It concludes that health care is not a commodity, (...) that treating it as such is deleterious to the ethics of patient care, and that health is a human good that a good society has an obligation to protect from the market ethos. (shrink)

America's patchwork quilt of health care coverage is coming apart at the seams. The system, such as it is, is built upon an inherently problematic base: employment. By definition, an employment-based approach, by itself, will not assure universal coverage of the entire population. If an employment-based approach is to be the centerpiece of a system that provides universal coverage, special attention must be paid to all the categories of individuals who are not employees – children, unemployed spouses (...) or singles, the unemployable ill and disabled, persons between jobs, students, retirees, the elderly. Moreover, in a purely voluntary employment-based arrangement, some employers will not provide insurance at all, and others will provide inadequate coverage, necessitating other special provisions for coverage. As a consequence, about one out of six people now has no health coverage whatsoever, and even more have inadequate coverage. All the while, the rapidly-increasing transaction costs of sustaining this grossly inadequate pluralistic system eat up sufficient funds to provide basic benefits to the entire population. The time for systematic reforms has come and gone; what is now needed is action to prevent disaster, followed by a complete rebuilding of this country's health coverage system. Although perhaps more likely to be tried than more radical, completely nationalized, ones, stepwise reforms may not go far enough to cure the significant ills of the current employment-based system. Passage of inadequate reforms, then, could well set the stage for nationalized health care in the not too distant future. Keywords: employment-based health insurance, health insurance, health insurance reforms, national health insurance, health care coverage CiteULike Connotea Del.icio.us What's this? (shrink)

In this paper we explore the intersection of three topics which have historically been singled out for ethical consideration in advertising and marketing: the use of fear appeals, marketing to the elderly, and the marketing of health care services and products. Issues relevant to using fear appeals in promoting health care issues to the elderly are explored with a consumer psychologist's theoretical view of fear appeals. Next the assumption of the elderly market's vulnerability and indicants of (...) social or psychological function which would differentiate the elderly recipients of marketing communications are examined both in terms of function and ethical concerns.Overall, our review of the theoretical underpinnings of fear-based communication and the psychological characteristics does not indicate that the elderly of today are particularlyvulnerable. While the elderly are probably somewhat more dogmatic than younger consumers and perhaps view outcomes from the perspective of their age, there are no indications that their psychological responses to fear-based appeals differ significantly from those of younger consumers. (shrink)

The Private Finance Initiative (PFI) is a specific example of health care privatization within the British National Health Service. In this essay, I critically assess the ways in which various Private Finance Initiatives have increased health care efficiency and effectiveness, as well as encouraged medical innovation. Indeed, as the analysis will demonstrate, significant empirical evidence supports the conclusion that Private Finance Initiatives are a driving force of innovation within the British Health Care System.

The current health care system is not operating with a properly functioning market. Health care costs are hidden and often shifted, consumers and providers are insulated from the economic consequences of their decisions, and costs therefore go up dramatically. Instead of attacking both the structural deficiencies and the consequent inequities of the current employer based insurance system, the Clinton Plan simply expands them, and adds a heavier level of government regulation. The ultimate choice for the public (...) is between a health care system based on consumer choice or a government controlled system. In pursuing a market based health care reform that enhances personal freedom and responsibility, two ethical principles are served. First, American consumers will be made aware of the true costs of health care services, and market forces will thus introduce incentives on the part of providers to control costs. Second, justice will be served; for not only will providers of medical services receive their due, but public policy makers can target relief more effectively to those who need it most. Keywords: Clinton health plan, free market, freedom, responsibility CiteULike Connotea Del.icio.us What's this? (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)

Comparative effectiveness research (CER) is one of the Patient Protection and Affordable Care Act's significant initiatives that aims to improve treatment outcomes and lower health care costs. This article takes CER a step further and suggests a novel clinical application for it. The article proposes the development of a national framework to enable physicians to rapidly perform, through a computerized service, medically sound personalized comparisons of the effectiveness of possible treatments for patients' conditions. A treatment comparison for (...) a given patient would be based on data from electronic health records of a cohort of clinically similar patients who received the treatments previously and whose outcomes were recorded. This framework has unique potential to simultaneously improve the quality of health care, reduce its cost, and alleviate public concerns about rationing and “one size fits all” medicine. (shrink)

: The move from a notion that community values ought to play a role in health care decision making to the creation of health care policies that in some way reflect such values is a challenging one. No single method will adequately measure community values in a way appropriate for setting health care priorities. Consequently, multiple methods to measure community values should be employed, thereby allowing the strengths and weaknesses of the various methods to (...) complement each other. A preliminary research agenda to bring together empirical research on community values with more traditional research on health care ethics is outlined, with the goal of identifying and measuring acceptable community values that are relatively consistent across measurement methods and, ultimately, developing ways to incorporate these values into health care priority decision making. (shrink)

This paper presents the Norwegian national health care system and the manner in which the problems of rationing and pluralism of values create new ethical and political challenges. The paper concludes with some doubts about the feasibility of the transformation taking place within this kind of health care system, with special reference to governmental control and consumer preference. Keywords: national health care, pluralism, rationing, two-tier system CiteULike Connotea Del.icio.us What's this?

Many journalism organizations have published codes of ethics in recent years. The Association of Newspaper Editors, for example, lists 47 different codes on its website. But an organization of health care journalists felt that none of those codes addressed the unique challenges of covering complex health care topics. The Association of Health Care Journalists (AHCJ) is an independent, non-profit organization dedicated to advancing public understanding of health care issues. Its mission is to (...) improve the quality, accuracy and visibility of health care reporting, writing and editing. AHCJ has written a statement of principles for its 750 members. In it, AHCJ states some of the unique challenges faced by journalists covering health care, and offers suggestions on how to face those challenges. Bioethicists are invited to comment on the statement, and to help generate continued discussion of the issues addressed therein. (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)

Ethics: The Heart of Health Care - a classic ethics text in medical, health and nursing studies - is recommended around the globe for its straightforward introduction to ethical analysis. In this new edition David Seedhouse demonstrates tangibly and graphically how ethics and health care are inextricably bound together, and creates a firm theoretical basis for practical decision-making. He not only clarifies ethics but, with the aid of the acclaimed Ethical Grid, teaches an essential practical (...) skill which can be productively applied in day-to-day health care. This edition, which is even more readable than the first, includes additional case studies and teaching exercises, contains new material on ethical theory and offers two further decision-making tools - The Rings of Uncertainty and the Autonomy Test. The engaging new introduction reveals the genesis of the Ethical Grid, illuminates the intent and argument of the first edition, and explains why the book is needed today as much as ever. Intended for all who work in health care or health studies - indeed for anyone with an interest in health issues - this is a highly original, innovative and accessible work on a subject traditionally regarded as lofty and obscure. It clarifies a wide variety of complex ethical issues and will give the reader fresh inspiration and renewed confidence in dealing with the demands of modern health work. (shrink)

: The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed the (...) philosophical landscape and encouraged some in bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice. (shrink)

No Chance, No Value, or No Way: Reassessing the Place of Futility in Health Care and Bioethics Content Type Journal Article Pages 121-122 DOI 10.1007/s11673-011-9303-5 Authors Sarah Winch, School of Medicine, The University of Queensland, Brisbane, Australia Ian Kerridge, Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529 Journal Volume Volume 8 Journal Issue Volume 8, Number 2.

This essay explores some of the conceptual and moral issues raised by illegal actions in health care. The author first identifies several types of illegal action, concentrating on civil disobedience, conscientious objection or refusal, and evasive noncompliance. Then he sketches a framework for the moral justification of these types of illegal action. Finally, he applies the conceptual and normative frameworks to several major cases of illegal action in health care, such as "mercy killing" and some decisions (...) not to treat incompetent patients. Keywords: illegal actions, mercy killing, non-treatment of incompetent patients, civil disobedience, conscientious objection, evasive non-compliance, moral justification and disobedience, dissent in health care CiteULike Connotea Del.icio.us What's this? (shrink)

Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the (...) ethically relevant dimensions that should be considered for the utilization of each principle. (shrink)

This essay argues that Hume's theory of justice can be useful in framing a more persuasive case for universal access in health care. Theories of justice derived from a Rawlsian social contract tradition tend to make the conditions for deliberation on justice remote from the lives of most persons, while religiously-inspired views require superhuman levels of benevolence. By contrast, Hume's theory derives justice from the prudent reflections of socially-encumbered selves. This provides a more accessible moral theory and a (...) more realistic path to the establishment of universal access. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in (...) determining the relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

Conscience and Conscientious Objection of Health Care Professionals Refocusing the Issue Content Type Journal Article Pages 351-364 DOI 10.1007/s10730-009-9113-x Authors Natasha T. Morton, The University of Western Ontario Ontario Canada N6A 5B9 Kenneth W. Kirkwood, Arthur and Sonia Labatt Health Sciences Building London Ontario Canada N6A 5B9 Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4.

Erratum: “ This is Why you’ve Been Suffering”: Reflections of Providers on Neuroimaging in Mental Health Care Content Type Journal Article Pages 107-107 DOI 10.1007/s11673-011-9284-4 Authors Emily Borgelt, National Core for Neuroethics, University of British Columbia, Vancouver, Canada Daniel Z. Buchman, National Core for Neuroethics, University of British Columbia, Vancouver, Canada Judy Illes, National Core for Neuroethics, University of British Columbia, Vancouver, Canada Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529 Journal Volume Volume 8 Journal (...) Issue Volume 8, Number 1. (shrink)

There is a move away from a market economy in health care in the United States and a move towards such a market in Germany.1 This article tries to make explicit what underlies the moral intuition that there is a tension between a market economy and health care. First, health care is analyzed in terms of the economic theory of the market and incompatibilities are described. The moral problem is identified as the danger of (...) liquefying the distinction between persons and things . The basic moral intuition seems to be the classical social contract: as a functioning market is governed by the principle of commutative justice , free riders have to be kept away, which is achieved by coercion that is not provided by the market; coercion can be justified by a social contract. The special moral problems of a social contract for health care are discussed. It is argued that public coercion in order to collect contributions for essential health care is justified. (shrink)

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools (...) to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change. (shrink)

Nearly $2 trillion is spent annually in the U.S. treating chronic illness — yet accessibility to quality health care services in rural communities for the chronically ill and dying remains problematic. Unique barriers present special challenges to a meaningful discussion of and subsequent strategies for addressing these issues in the context of increasingly scarce resources.

Recently implemented Chinese health insurance schemes have failed to achieve a Chinese health care system that is family-oriented, family-based, family-friendly, or even financially sustainable. With this diagnosis in hand, the authors argue that a financially and morally sustainable Chinese health care system should have as its core family health savings accounts supplemented by appropriate health insurance plans. This essay’s arguments are set in the context of Confucian moral commitments that still shape the background (...) culture of contemporary China. (shrink)

Physician-Assisted Suicide: Views of Swiss Health Care Professionals Content Type Journal Article DOI 10.1007/s11673-010-9246-2 Authors Eliane Pfister, Institute of Biomedical Ethics, University of Zurich, CH-8032 Zurich, Switzerland Nikola Biller-Andorno, Institute of Biomedical Ethics, University of Zurich, CH-8032 Zurich, Switzerland Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529 Journal Volume Volume 7 Journal Issue Volume 7, Number 3.

While a national health care system may be greeted with enthusiasm on many grounds, it poses substantial moral problems – not the least of which would be the clash between the ‘standardization’ of care for the sake of efficiency and the needs of individual patients. Such problems are best seen in the treatment of dying patients. Keywords: best buy, cost-saving, dying, efficiency, practice guidelines, Rilke, standards of practice, two tier CiteULike Connotea Del.icio.us What's this?

E. Haavi Morreim's book, Holding Health Care Accountable , insightfully describes several features of the current crisis in malpractice in relation to the health care marketplace. In this essay, I delineate the key and eminently practical guide for reform that she lays out. I argue that her insights bring us to more fundamental aspects than immanent medical economy and accountability - aspects that are ignored at present. I describe the features of immanent economy and how they (...) tend to cover over epistemological and existential finitude in medicine, show how economy can in fact create new medical knowledge, and show that necessary error is a real feature of day-to-day medical practice. The current system, even with Morreim's reforms, remains at the level of immanent economy, but with modifications may point to the features of medicine that transcend medical knowledge and economy. The gifts of medicine cannot be reduced to the immanent medical economy, and any attempt to do so results in crisis. A health care that points to finitude and fallibility is one that points to the mystery of human existence and mortality. Any health care financing system that helps to delineate finitude - both epistemological and existential - is one that will give patients a new lease on living and dying. (shrink)

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness (...) of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing. Keywords: principles, health care reform, rationing, universal access CiteULike Connotea Del.icio.us What's this? (shrink)

To properly comply with the Health Sector Act of 1992 a functioning competition should be introduced in the interests of the insured of the German Statutory Health Insurance, while still maintaining the principle of solidarity. This is a critical order-political aim, because the principles of solidarity and selfresponsibility as typically understood are functionally in contradiction. This paper analyzes the important measures of the Organizational Reform and concludes, that the principle of self-responsibility ought to obtain priority. Therefore, the (...) German legislature ought to focus on further competitively oriented reform steps. Keywords: health care reform, order-politics, sickness funds, self-responsibility, solidarity CiteULike Connotea Del.icio.us What's this? (shrink)

Health care professionals who travel from their home countries to participate in humanitarian assistance or development work experience distinctive ethical challenges in providing care and services to populations affected by war, disaster or deprivation. Limited information is available about organizational practices related to preparation and support for health professionals working with non-governmental organizations. In this article, we present one component of the results of a qualitative study conducted with 20 Canadian health care professionals who (...) participated in international aid work. The findings reported here relate to expatriate clinicians’ experiences and perceptions of ethics preparation, training and support. The strategies examined include pre-departure training and preparation, in-field supports and retrospective debriefing of ethical issues. Participants experienced a range of training and supports as beneficial for addressing ethical challenges in humanitarian assistance and development work. Participants also expressed ambivalence or scepticism about the benefits offered by specific modalities. This analysis can contribute to informing discussions of how organizations and individual practitioners can best develop, implement and utilize ethics training and support for international aid work. (shrink)

The paper argues that a particular version of moral realism constitutes an important basis for ethics in medicine and health care. Moral realism is the position that moral value is a part of the fabric of relational and interpersonal reality. But even though moral values are subject to human interpretations, they are not themselves the sole product of these interpretations. Moral values are not invented but discovered by the subject. Moral realism argues that values are open to perception (...) and experience and that moral subjectivity must be portrayed in how moral values are discovered and perceived by the human subject. Moral values may exist independent of the particular subject’s interpretative evaluations as a part of reality. This epistemological point about normativity is particularly significant in medical care and in health care. The clinician perceives moral value in the clinical encounter in a way that is important for competent clinical understanding. Clinical understanding in medical care and health care bears on the encounter with moral values in the direct and embodied relations to patients, with their experiences of illness and their vulnerabilities. Good clinical care is then partly conditioned upon adequate understanding of such moral realities. (shrink)

In addition to good medical services, all aspects of an economy must work together to ensure a high level of public health. However, the abundant economies of the North are contributing heavily to global environmental disaster, with increasing concomitant damage to human health. Environmental health problems result from toxicity (i.e., pollution), scarcity (i.e., poverty), and energy degradation (i.e., entropy). Common to these three factors in environmental demise are the limits of the Earth. Production has evolved to a (...) point where the Earth is no longer safe from radical depletion. Therefore, simple living is a necessary feature of global public health. Rarely do readers of this journal see these limits first hand, but they are real. Our limited perceptions and efforts hinder our ability to understand how to reduce the impact of production on natural ecosystems. Contrary to standard media portrayals, growth and technology cannot solve our public health problems, because they are unequally distributed across the world and neither can they solve the problem of limits. The need for modest consumption in developed nations is an essential and almost completely ignored element of the answer to environmental and associated health problems. A radical and rapid change to public health is needed in order to avoid abysmal global health consequences during the next century. These changes involve a restructuring of our economy, including the health care industry. In the short run, this is an ethical demand. In the long run, this is an inevitability. The actual and appropriate role of bioethicists in championing these changes is unclear. (Abstract by Bruce R. Smith). (shrink)

This paper reviews the work of several authors, D.W. Brock, D. Callahan, L. Churchill, L.M. Kopelman, R. Tong who consider assumptions and arguments about how to allocated health and dental care to children fairly. They use various approaches including feminist, rights based, and principled considerations, applying general notions of duty or justice to the issues of children's access to basic health and dental care. Two discuss these issues in relation to the work of David Hume. (...) These authors consider children's greatest unmet health needs, including that of dental care, often mistakenly regarded as medically unimportant in terms of children's wellbeing, opportunities, and self-image. They review possible age bias against children in the allocation of health and dental care, the gap between what we say and do where children are concerned, and whether some fundamental shift in social thinking needs to occur. (shrink)

Though written corporate codes of ethics have been touted as a panacea for the embarrassments and uncertainties of the past two decades, the absence of clear evaluation procedures severely compromises their usefulness. An ethnographic study comparing development processes and compliance outcomes in large health care facilities and energy companies shows that neither of the two industries has encountered much success with a codes of ethics program. Companies that distribute copies of their code of ethics seldom ensure the process (...) is completed or that employees understand the purpose of the document, and staff responsible for the code give it a low priority relative to their overall responsibilities. Contrary to expectations, health care facilities are no more likely to develop or implement codes of ethics effectively than are energy companies. More extensive research is needed in order to generate the data necessary for the development of realistic standards for the evaluation of codes of ethics. (shrink)

Recent studies of the Brazilian case suggest that successful litigation can have regressive effects and negatively impact the health care system. While the data to support this claim is not conclusive, this paper assumes that such immediate regressive effects are indeed taking place, but asks if these are the only consequences that should be analyzed in assessing the impact of right to health litigation in Brazil. The answer is no. The current perspective adopted to assess right to (...) health litigation in Brazil is too narrow. Other consequences can and should be considered in analyzing the overall impact of litigation. To go beyond the set of questions asked by the existing experts on the topic, this paper analyzes whether the right to health litigation in Brazil has the potential, and could be generating: (i) policy changes within the health care system; (ii) institutional changes within the health care system; and (iii) institutional changes outside the health care system. After presenting anecdotal evidence that suggests these three types of changes may be happening in Brazil, I conclude the paper by discussing what would be required to assess them, and how these changes may affect our overall assessment of the more immediate and supposedly negative impact that litigation has had on the system. (shrink)

A major issue facing the health of young adults in the United States is the often unintentional lack of confidentiality maintained in the provision of sensitive health services. Of primary concern is that young adults who remain on their parents' health insurance plans forgo Sexually Transmitted Infection screening and treatment, as well as other sensitive services such as family planning services and mental health treatment out of a concern that explanation of benefit forms from such services (...) will inform their parents, the policyholders. The challenges of providing confidential health care to young adults have become more prominent and concerning following the passage of the Affordable Care Act, as adult children can now remain on their parents' plans until the age of 26. While this change will grant more young adults access to health care services, ensuring confidential care remains a challenge whenever the parent and not the patient is the policyholder. This article discusses these serious challenges and offers potential solutions to ensuring confidentiality for specific services for young adults. (shrink)

Ethics of Health Care: A Guide for Clinical Practice, 3E is designed to guide health care students and practitioners through a wide variety of areas involving ethical controversies. It provides a background in value development and ethical theories, including numerous real-life examples to stimulate discussion and thought.

: As the twentieth century closes, marked by triumphal strides in medical advances, the American society has yet to ensure that each person has access to affordable health care. To correct this injustice, this article calls on the nation's political and corporate leaders, providers, and faith-based groups to join all Americans in a new national conversation on systemic health care reform. The Catholic faith tradition is one that compels both a proclamation to ministry values and a (...) commitment to speak out against the challenges or threats to what are essential to the well-being of individuals and society. The Catholic health ministry must therefore be both a voice for the voiceless and an agent of transformation. The nation's goal should be to "reposition" health care from its status as an important, but ultimately optional building block to one that is essential. (shrink)

Because medicine can preserve and restore health and function, it has been widely acknowledged as a basic good that a just society should provide its members. Yet there is wide disagreement over the scope of what is to be provided, to whom, how, when and why. In this uniquely comprehensive book some of the best-known philosophers, doctors, lawyers, political scientists, and economists writing on the subject discuss the concerns and deepen our understanding of the theoretical and practical issues that (...) run through the contemporary debate. The first section lays a broad theoretical basis for understanding the subject of justice, particularly as it relates to the distribution of health care. The second section critically examines how medical care is distributed in different countries around the world and the particular advantages and injustices associated with those systems. The third section draws attention to the special needs of different social groups and the specific issues of justice that are raised by the impact of various policies on health care distribution. The concluding section delves into the dilemmas that confront those designing health care systems - the politics, the priorities, and the place of desires as opposed to needs in a socially just scheme. (shrink)

: When health care workers migrate from poor countries to rich countries, they are exercising an important human right and helping rich countries fulfill obligations of social justice. They are also, however, creating problems of social justice in the countries they leave. Solving these problems requires balancing social needs against individual rights and studying the relationship of social justice to international justice.

Effectiveness, efficiency and equity in health care are discussed in this article against the background of concerns that cost containment may lead to reductions in quality of care. It is suggested that effectiveness is best seen from the patient's point of view and that it relates to more than simply improved health status. Efficiency and equity are better viewed from a societal stance.The paper discusses the role of the medical profession in effectiveness, efficiency and equity and (...) argues that the role of medical doctors needs to be constrained. (shrink)

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform.Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and health (...) care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms. (shrink)

My assigned task in today’s colloquium is to review philosophers’ perspectives on the broad question of whether health care rationing ought to target the elderly. This is a revolutionary question, particularly in a society that is so sensitive to apparent discrimination, and the question must be approached carefully if it is to be successfully dealt with. Three subordinate questions attend this one and must be addressed in the course of answering it. The first such question has to (...) do with the issue of justice: how is it fair to target the elderly in achieving reductions in health care costs? Isn’t the proposal, or for that matter, isn’t targeting any age group, morally objectionable as a species of ageism, just as targeting members of a particular race or sex would be racist or sexist? The second subordinate question has to do with the issue of fittingness. Given that we can show in some way that targeting the elderly is not inherently unjust, why would limiting health care to them be a fitting thing for medicine to do? How would it fit, for example, with the traditional commitments of medicine, to sustain life, to relieve suffering, to heal and cure and restore function? And in particular, if medicine has the ability to save and relieve and restore the elderly, why should it replace that set of commitments with a different set for this particular population? The third subordinate question seems political, an arena reserved for one of my speaker colleagues today. There are, I believe, some underlying philosophical dimensions to its answer, and so I will say something about it. The philosophical/political questions is, Given that rationing health care to the elderly is not patently unjust, and given that a case can be made out that the ends of medicine are not violated by such limitation, shy should the elderly, as a group, assent to such a limitation? I want to address these subordinate questions, for I believe them to be the chief stumbling blocks for the possibility of an affirmative answer to our.... (shrink)

In considering the challenges medical educators face in addressing the needs of today's health-care system, it is instructive to review the challenges Abraham Flexner (1910) was called upon to address at the turn of the last century. As Flexner surveyed the state of U.S. medical schools 100 years ago, he found a legacy system of medical education that was failing to prepare 20th-century physicians to meet the evolving needs and expectations of patients. That legacy system was based largely (...) on an outmoded apprenticeship model of education, was failing to incorporate the rapidly developing natural sciences, and to make matters worse, was devoid of external scrutiny and uniform standards by which medical schools .. (shrink)