Online research in philosophy

This essay assess the compatibility of Eva Kittay's dependency critique with Rawlsian political liberalism. I argue for the inclusion of a modified version of Kittay's revisions within Rawlsian theory in order to yield a theory that suppports a substantial subset of dependency work. Beyond these selected changes, however, I argue that Kittay's other proposed changes should not be included because they are incompatible with Rawls, and furthermore, their incorporation does not yield a theory that includes utter dependents.

Protestant Christian ethicist Timothy Jackson and secular feminist philosopher Eva Feder Kittay each explore the relationship between love or care and justice through the lens of human dependency. Jackson sharply prioritizes agape over justice, whereas Kittay articulates a more complex and integrated understanding of the relationship of care and distributive justice. An account of Christian love and its relation to justice must account for the gratuity, mutuality, and reciprocity that pervade human existence. Such an account must integrate (...) provision for another's basic needs, a feature of agape, with a distributive justice that fairly allocates the material prerequisites of care and the burden of caring labor. Kittay's treatment of care and justice is more adequate to the realities of human embodiment and the social organization of care than Jackson's, but neither offers a fully adequate ground for the moral personhood of all human beings, including deeply dependent persons. (shrink)

According to the most important theories of justice, personal dignity is closely related to independence, and the care that people with disabilities receive is seen as a way for them to achieve the greatest possible autonomy. However, human beings are naturally subject to periods of dependency, and people without disabilities are only “temporarily abled.” Instead of seeing assistance as a limitation, we consider it to be a resource at the basis of a vision of society that is able (...) to account for inevitable dependency relationships between “unequals” ensuring a fulfilling life both for the carer and the cared for.**. (shrink)

the arguments in their favour are weak. Arguments based on reciprocity fail to explain why only means-tested public benefits should be subject to work requirements, and why unpaid dependant care work should not count as satisfying citizens’ obligations to reciprocate. Argu- ments based on promoting the work ethic misattribute recipients’ nonwork to deviant values, when their core problem is finding steady employment consistent with supporting a family and meeting dependant care responsibilities. Rigid work requirements impose unreasonable costs on (...) some of the poor. A welfare system based on a rebuttable presumption that recipients will work for pay, conjoined with more generous work supports, would promote justice better than either unconditional welfare or strict requirements [1]. (shrink)

This study attempts to identify differences in the perceptions of top management (defined as CEOs, directors, and presidents) and employees (defined as middle and supervisory management) regarding (a) the effects of dependent care responsibilities on job performance, and (b) the extent of a firm's responsibility in providing support for those faced with caring needs concerning eldercare, childcare, substance abuse, and mental/physical handicaps.The results indicate that these two groups have significantly different perceptions of the effect of dependent care responsibilities (...) on job performance, and on the firm's responsibility in providing support for three types of dependent care. (shrink)

In this essay, Ben-Porath begins from the assumption that just war theory should be extended to include a jus post bellum component. Postwar conduct should be significantly informed by a care ethics perspective, particularly its political aspects as developed by Joan Tronto and others. Care ethics should be extended to the international postwar arena with one significant amendment, namely, weakening the aim of ending dependence.

The Dutch system of obstetric care is often recommended for midwife-attended births, the high number of home deliveries, and the low rate of intervention during pregnancy and labour. In this contribution, the question is addressed whether processes of medicalization can be demonstrated in the Dutch midwife practice. Medicalization of pregnancy and childbirth is often criticized because it creates dependency on the medical system and infringement of the autonomy of pregnant women. It is concluded that medicalization is present in (...) the practice of Dutch independent midwives, however it is less clear and outspoken than in hospital policies. (shrink)

Analyses of care work typically speak of three necessary roles of care: the care worker, the care recipient, and an economic provider who makes care materially possible. This model provides no place for addressing the difficult political questions care poses for liberal representative democracy. I propose to fill this space with a new caring role to connect the care unit to the political sphere, as the economic provider connects the care unit to (...) the economic sphere. I call this role that of the “care claimant.” The labor of claiming care consists in the development, expression, and advancement of the interests of the care unit. The argument for employing this fourth care role begins by comparing Nel Noddings's phenomenological care unit to Sara Ruddick's family-based analysis. It then moves to discuss the way Eva Kittay emphasizes the dependency of the charge and its political ramifications to illustrate the need for a care claimant. After distinguishing the care claimant from the other roles of care, I examine the power relationships in the care unit and the position of the care claimant in the public sphere. (shrink)

An aging population is often taken to require a profound reorganization of the prevailing health care system. In particular, a more cost-effective care system is warranted and ICT-based home care is often considered a promising alternative. Modern health care devices admit a transfer of patients with rather complex care needs from institutions to the home care setting. With care recipients set up with health monitoring technologies at home, spouses and children are likely to (...) become involved in the caring process and informal caregivers may have to assist kin-persons with advanced care needs by means of sophisticated technology. This paper investigates some of the ethical implications of a near-future shift from institutional care to technology-assisted home care and the subsequent impact on the care recipient and formal- and informal care providers. (shrink)

The problem of standard-of-care in clinical research concerns the level of care that investigators ought to provide to research subjects in the control arm of their clinical trials. Commentators differ sharply on whether subjects in trials conducted in lower income countries should be provided with the same level of care as subjects in trials conducted in higher income countries. I consider an argument that commentators have employed on both sides of this debate: professional role arguments. These arguments (...) claim to justify a conclusion to the standard-of-care problem solely by appeal to the professional obligations that investigators possess. I argue that prominent versions of professional role arguments cannot justify a solution to the problem of standard-of-care that is both determinate and reasonable simply by appeal to the professional obligations of investigators. Instead, to do so, one must also (1) determine the level of care or types of treatment that individuals are entitled to as a matter of distributive justice, and (2) identify which agents possess the duties that correspond to these entitlements. The level of care that investigators owe to subjects in the control arm of their clinical trials is thus in part dependent on the level of care that these subjects are entitled to as a matter of distributive justice, and whether it is the investigators who possess the corresponding distributive obligation to provide them with the care that they are entitled to. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care (...) need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

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

This paper 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)

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)

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)

The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care (all life is sacred), the issue of who provides (...) health care has evolved as individual rights have trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a ‘negative right to health care’ (e.g., prevention of a socially-caused, preventable health hazard), to various forms of a ‘positive right to health care’. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a ‘right’, which is unconditional, a ‘privilege’ has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one’s health must for elevated. To have access to health care in the future will mean some loss of personal rights (e.g., unhealthy behaviors) and an increase in personal responsibility for gaining or maintaining one’s health. (shrink)

Explicit forms of rationing have already been implemented in some countries, and many of these prioritization systems resort to Norman Daniels’ “accountability for reasonableness” methodology. However, a question still remains: is “accountability for reasonableness” not only legitimate but also fair? The objective of this paper is to try to adjust “accountability for reasonableness” to the World Health Organization’s holistic view of health and propose an evolutionary perspective in relation to the “normal” functioning standard proposed by Norman Daniels. To accomplish this (...) purpose the authors depart from the “normal” functioning standard to a model that promotes effective opportunity for everyone in health care access, because even within the “normal” functioning criteria some treatments and medical interventions should have priority upon others. Equal opportunity function is a mathematical function that helps to hierarchize moral relevant necessities in health care according to this point of view. It is concluded, first, that accountability for reasonableness is an extremely valuable tool to address the issue of setting limits in health care; second, that what is called in this paper “equal opportunity function” might reflect how accountability for reasonableness results in fair limit-setting decisions; and third, that this methodology must be further specified to best achieve fair limit-setting decisions. Indeed, when resources are especially scarce the methodology suggested in this paper might allow not only prioritizing in an “all or nothing” basis but can contribute to a hierarchy system of priorities in health care. (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)

Despite recent efforts to improve on counterfactual theories of causation, failures to explain how effects depend on their causes are still manifest in a variety of cases. In particular, theories that do a decent job explaining cases of causal preemption have problems accounting for cases of causal intransitivity. Moreover, the increasing complexity of the counterfactual accounts makes it difficult to see why the concept of causation would be such a central part of our cognition. In this paper, I propose an (...) account of our causal thinking that not only explains the hitherto puzzling variety of causal judgments, but also makes it intelligible why we would employ such an elusive concept. (shrink)

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)

Chenyang Li argues, in an article originally published in Hypatia, that the ethics of care and Confucian ethics constitute similar approaches to ethics. The present paper takes issue with this claim. It is more accurate to view Confucian ethics as a kind of virtue ethics, rather than as a kind of care ethics. In the process of criticizing Li's claim, the distinctiveness of care ethics is defended, against attempts to assimilate it to virtue ethics.

This article focuses on the ethical implications of so-called ‘collateral damage’. It develops a moral typology of collateral harm to innocents which occurs as a side effect of military or quasi-military action. Distinguishing between accidental and incidental collateral damage, it introduces four categories of such damage: negligent, oblivious, knowing, and reckless collateral damage. Objecting mainstream versions of the doctrine of double effect, in the article it is argued that in order for any collateral damage to be morally permissible, violent agents (...) must comply with high standards of care. In order for incidental harm to be permissible, an agent must take pains to avoid such harm even at higher cost to him. Adding to the doctrine, it is argued that accidentally, but negligently caused collateral damage may be just as difficult to excuse as incidental harm. Only if high precautionary standards of care are met, unintended harm to innocents – incidental or accidental – can be permissible. In practice, such a strong commitment to avoiding harm to civilians may well lead us to question more generally and rethink more radically how violent conflicts ought to be fought, how military violence ought to be used and whether there are better ways of achieving those aims that we think are legitimate than those we are currently taking. (shrink)

Care ethicists have long insisted that Kantian moral theory fails to capture the partiality that ought to be present in our personal relationships. In her most recent book, Virginia Held claims that, unlike impartial moral theories, care ethics guides us in how we should act toward friends and family. Because these actions are performed out of care, they have moral value for a care ethicist. The same actions, Held claims, would not have moral worth for a (...) Kantian because of the requirement of impartiality. Although Kantian moral theory is an impartial theory, I argue that the categorical imperative in the Formulation of Humanity as an End and the duty of respect require that we give special treatment to friends and family because of their relationships with us. Therefore, this treatment does have moral value for a Kantian. (shrink)

This paper argues that the concept of care is significant not only for ethics, but for epistemology as well. After elucidating caring as a five-step dyadic relation, I go on to show its epistemic significance within the general framework of virtue epistemology as developed by Ernest Sosa, Alvin Goldman, and Linda Zagzebski. The notions of "care-knowing" and "care-based epistemology" emerge from construing caring (respectively) as a reliabilist and responsibilist virtue.

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

Despite receiving considerable philosophical attention, the concept of autonomy remains contested. In this paper, we diagnose one source of the continuing problem—an excessive emphasis on reflective self-appraisal in the dominant procedural models of autonomy—and suggest a solution. We argue that minimalist conceptions of rational self-appraisal are subject to fatal counterexamples. Yet, attempts to provide a more robust account of rational self-appraisal are too demanding to capture our intuitions about who counts as an autonomous agent. We argue that no procedure of (...) rational reflection will confer autonomy; rather autonomy is a matter of an agent’s actions flowing from her substantive commitments. Instead of rational self-reflection, autonomous actions are the product of the motive of care, which anchors an agent’s occurent desires to her system of value. (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.

The realities and myths of long-term care and the challenges it poses for the ethics of autonomy are analyzed in this perceptive work. The book defends the concept of autonomy, but argues that the standard view of autonomy as non-interference and independence has only a limited applicability for long term care. The treatment of actual autonomy stresses the developmental and social nature of human persons and the priority of identification over autonomous choice. The work balances analysis of the (...) ethical concepts associated with autonomy with discussion of the implications of the ethical analysis for long term care. A central chapter involves a phenomenological analysis of four general features of everyday experience (space, time, communication, and affectivity) and explores their practical implications for long term care. This work concludes with a discussion of the advantages associated with a phenomenologically-inspired treatment of actual autonomy for the ethics of long-term care. (shrink)

The ideal of distributive justice as a means of ensuring fair distribution of social opportunities is a cornerstone of contemporary feminist theory. Feminists from various disciplines have developed arguments to support the redistribution of the work of care through institutional mechanisms. I discuss the limits of such distribution under the conditions of theories that do not idealize human agents as independent beings. People’s reliance on care, understood as a response to needs, is pervasive and infuses almost all human (...) interaction. I argue that the effect of care on shaping the social opportunities of all individuals is huge, although often invisible. Much of the optimism of theories of distributive justice comes from ignoring or downplaying the way in which care influences most factors of social success. Jonathan Wolff distinguished between three types of resources whose fair distribution is important: internal, external and structural. Care, I argue, does not fit well in any of these types. Inseparably interwoven with relational realities, care cuts across these categories and thus poses a challenge to the feasibility of equal chances. I focus on the under-analyzed issue of bad care and show how difficult it is to dismantle legacies of bad care. Their effect on even close-to-ideal social arrangements is too significant to be disregarded, yet very difficult to tackle through institutional mechanisms. A commitment to certain elements of individual ethics – as opposed to merely political institutions – is required in order to bridge the gap between ideal theories of justice and feasible practical aims. (shrink)

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on (...) its ability to improve quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

We care for our own future experiences. Most of us, trivially, would rather have them pleasurable than painful. When we care for our own future experiences we do so in a way that is different from the way we care for those of others (which is not to say that we necessarily care more about our own experience). Prereflectively, one would think this is because these experiences will be ours and no one else's. But then, of (...) course, we need to explain what it means to say that a future experience will be mine and how knowledge of this fact renders it rational for me to care for this experience in a special way. Indeed most philosophers take this route. But in doing so, they quickly stumble on insuperable problems. I shall argue that the problem of egocentric care, as it is sometimes called, can be solved by turning things upside down: it is much more fruitful to think that the special kind of care we feel for some future experiences (and not others) is part of what makes them ours should they occur. This requires an explanation of egocentric care for future experiences that does not draw in a theory of personal identity, but rather contributes to one. I will attempt to provide this explanation by making use of the idea of a diachronic mental holism. (shrink)

This book offers a long-overdue exploration of care at a pivotal moment in the history of health care.

It is a philosophy of patient care, and is therefore open to critique and evaluation.Using the Oxford Textbook of Palliative Medicine Third Edition as their ...

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)

Reviews the basic Catholic moral principles that apply to health care, then uses them to assess three major current trends in the health care industry.

Decision making is a crucial element in the field of medicine. The physician has to determine what is wrong with the patient and recommend treatment, while the patient has to decide whether or not to seek medical care, and go along with the treatment recommended by the physician. Health policy makers and health insurers have to decide what to promote, what to discourage, and what to pay for. Together, these decisions determine the quality of health care that is (...) provided. Decision Making in Health Care is an up-to-date, comprehensive overview of the field of medical decision making. It includes quantitative theoretical tools for modeling decisions, psychological research on how decisions are actually made, and applied research on how physician and patient decision making can be improved. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only (...) relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

The prospective robots in healthcare intended to be included within the conclave of the nurse-patient relationship—what I refer to as care robots—require rigorous ethical reflection to ensure their design and introduction do not impede the promotion of values and the dignity of patients at such a vulnerable and sensitive time in their lives. The ethical evaluation of care robots requires insight into the values at stake in the healthcare tradition. What’s more, given the stage of their development and (...) lack of standards provided by the International Organization for Standardization to guide their development, ethics ought to be included into the design process of such robots. The manner in which this may be accomplished, as presented here, uses the blueprint of the Value-sensitive design approach as a means for creating a framework tailored to care contexts. Using care values as the foundational values to be integrated into a technology and using the elements in care, from the care ethics perspective, as the normative criteria, the resulting approach may be referred to as care centered value-sensitive design. The framework proposed here allows for the ethical evaluation of care robots both retrospectively and prospectively. By evaluating care robots in this way, we may ultimately ask what kind of care we, as a society, want to provide in the future. (shrink)

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

In her essay ‘The Curious Coincidence of Feminine and African Moralities’ (1987), Sandra Harding was perhaps the first to note parallels between a typical Western feminist ethic and a characteristically African, i.e., indigenous sub-Saharan, approach to morality. Beyond Harding’s analysis, one now frequently encounters the suggestion, in a variety of discourses in both the Anglo-American and sub-Saharan traditions, that an ethic of care and an African ethic are more or less the same or share many commonalities. While the two (...) ethical perspectives are indeed sisters, in this article I argue, first, that they are not identical twins, and, more strongly, that the family resemblance between the two is significantly less than has been recognized. I highlight key differences between representative forms of an ethic of care and a sub-Saharan communitarian morality, after which I argue, second, that the latter better captures some central feminist concerns and moral considerations generally. That is, I maintain that an African ideal of community, when understood in a philosophically refined way, provides an important, relational corrective to the ethic of care. (shrink)

This book offers a rich variety of thoughtful explorations on the nature of the human person especially as related to health care, medicine, and mental health. Rarely are so many different viewpoints collected in one place about the intriguing puzzle that is the concept of person, human dignity, and the special place human beings hold in the goals of healing and the social structures of medical delivery. Ramifications of the theory of personhood are presented for bioethics, genetics, individuality, uniqueness, (...) international law, feminism, and human rights in health care. Intended for professionals in the fields of philosophy of medicine, law, and bioethics, this book will also appeal to psychologists and medical anthropologists. (shrink)

Telecare is often regarded as a win/win solution to the growing problem of meeting the care needs of an ageing population. In this paper we call attention to some of the ways in which telecare is not a win/win solution but rather aggravates many of the long-standing ethical tensions that surround the care of the elderly. It may reduce the call on carers' time and energy by automating some aspects of care, particularly daily monitoring. This can release (...) carers for other caring activities. On the other hand, remote and impersonal monitoring seems to fall short of providing care. Monitoring may be used to help elderly users retain independence. But it may also increase the amount of information which flows from users to carers, which can result in a form of function-creep that actually undermines independence. (shrink)

The prospective robots in healthcare intended to be included within the conclave of the nurse-patient relationship—what I refer to as care robots—require rigorous ethical reflection to ensure their design and introduction do not impede the promotion of values and the dignity of patients at such a vulnerable and sensitive time in their lives. The ethical evaluation of care robots requires insight into the values at stake in the healthcare tradition. What’s more, given the stage of their development and (...) lack of standards provided by the International Organization for Standardization to guide their development, ethics ought to be included into the design process of such robots. The manner in which this may be accomplished, as presented here, uses the blueprint of the Value-sensitive design approach as a means for creating a framework tailored to care contexts. Using care values as the foundational values to be integrated into a technology and using the elements in care, from the care ethics perspective, as the normative criteria, the resulting approach may be referred to as care centered value-sensitive design. The framework proposed here allows for the ethical evaluation of care robots both retrospectively and prospectively. By evaluating care robots in this way, we may ultimately ask what kind of care we, as a society, want to provide in the future. (shrink)

It is important and urgent to question therelationship between evidence-based medicineand power shifts in health care systems.Although definitions of EBM are phrased as ascientific approach to medicine, EBM is anormative concept: it aims to improve medicineand health care. Both proponents and opponentsuse a normative concept. More particularly,they provide particular views on positions,responsibilities, possibilities, norms andrelationships between professionals, patientgroups, governments and other parties in healthcare and society. From this perspective, wewant to analyse the role of EBM in modernwestern societies. (...) By using citizenshiptheory, we will argue that the role of EBM isnot fixed but depends on the relation betweenstate and society. We will first analyse thefundamental change in western societies duringthe past decades, from modern to post-modernsocieties. Then, we will elaborate a fourfoldmodel of possible relationships between stateand society, and discuss the issue of how EBM mayfit in, by giving some examples of the practiceof EBM in different European countries. On thisbasis, we conclude to consider EBM as a publicforum where proponents and opponents of EBMdiscuss diverse and possibly conflicting waysof changing medicine, health care, and healthpolicy. This requires the incorporation of theperspective of citizens and their socialnetworks, professionals with practical andtacit knowledge, and diverse public views onwhat is regarded as `a good life'. Inasmuch asEBM is expected to be practically relevant, itought to be tied to rather than separated fromthe normative world of emancipated patients anddiverse health care practices. Proponents andopponents of EBM should be prepared to defendthe normative claims and power effects that areinherently tied to any presentation ofevidence. (shrink)

The rapid development of assisted reproduction technologies for the treatment of infertility appears to empower women through expanding their individual choice, but it is also creating new forms of suffering for them and their collaborators, especially in the context of transnational third-party reproduction. This paper explores the possibility of framing the ethical discourse around third-party reproduction by bringing attention to concerns of altruistic empathy for women who collaborate in the reproductive process, in addition to those of individualistic choice. This would (...) entail moving beyond an ethic of liberty that is based on self-interest and the language of rights, to an alternative ethic of care that is based on self-restraint and the language of responsibilities. An ethic of care and responsibility would cultivate the empathetic self-reflection of the autonomous actor in relation to those others who are part of the enterprise of bringing a child into the world. (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)

When read as a theory that is supposed to mirror, represent or fit some collection of historical data, critics argue that Kuhn’s theory of paradigm shift in Structure of Scientific Revolutions fails by cherry-picking and underdetermination. When read as the ground for a socio-epistemological conception of rationality, critics argue that Kuhn’s theory fails by either the naturalistic fallacy or underarticulation. This paper suggests that we need not view Structure as a historian’s attempt to accurately depict scientific theory change or a (...) philosopher’s attempt to suggest, more normatively, the factors we ought to consider in theory choice. Instead, we might use Kuhn’s theory as a metaphilosophical frame through which to better understand the limits of otherwise intractable philosophical debates. We can focus on Kuhn’s theory not as a proposition or model to confirm, but as something we might use as a tool for understanding. Philosophers have discussed the justice and care orientations in ethics as two theories for which there will be some common, constraining set of intuitions to confirm one theory over the other, to demonstrate that protecting rights is fundamentally more valuable that fulfilling needs or that fulfilling needs is fundamentally more valuable that protecting rights. Instead of conceptualizing this conversation as a choice between two theories, this paper looks to Ian Hacking’s interpretation of Kuhn’s paradigm concept to suggest that working in the world of justice is very different than working in the world of care, as each orientation is a paradigm with its own cognitive and contextual standards of theory assessment. To start, after Larry Laudan, each has its own ontology, methodology, aims and values. But moreover, after Ian Hacking, each has an even larger, entrenched collection of projectible predicates. Though Carol Gilligan herself uses the metaphor of gestalt shift in a few places to characterize the move from the justice to the care perspective, the insight—that what many assume to be a standard exercise in theory choice is really more of a paradigm shift—has been under theorized by ethicists and ignored by philosophers of science. This paper brings the full resources of Structure and its secondary literature to this metaethical issue, while making the larger point that Structure has an important pragmatic role to play, when it comes to the understanding philosophical debates, even if we cannot secure the truth of Kuhn’s theory. (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)

Research ethics is predominantly taught and practiced in Anglophone countries, particularly those in North America and Western Europe. Initiatives to build research ethics capacity in developing countries must attempt to avoid imposing foreign frameworks and engage with ethical issues in research that are locally relevant. This article describes the process and outcomes of a capacity-building workshop that took place in Kinshasa, Democratic Republic of Congo in the summer of 2011. Although the workshop focused on a specific ethical theme – the (...) responsibilities of researchers to provide health-related care to their research participants – we argue that the structure of the workshop offers a useful method for engaging with research ethics in general, and the theme of ancillary care encourages a broad perspective on research ethics that is highly pertinent in low-income countries. The workshop follows an interactive, locally driven model that could be fruitfully replicated in similar settings. (shrink)

With places at nursery school promised for every child above the age of four, this book raises the stakes by looking at the quality of what is provided, and how that compares to what should be provided. Beyond Quality In Early Childhood Education and Care challenges received wisdom and the tendency to reduce philosophical issues of value to purely technical issues of measurement and management. In its place, it offers alternative ways of understanding early childhood, early childhood institutions and (...) pedagogical work. The book places issues of early childhood into a global context and relates them to writers from many fields. Drawing on work with aboriginal peoples in Canada, on the experience of Reggio-Emilia in Italy and on a project in Stockholm inspired by Reggio, the book considers the implications of these alternative ways of understanding, for practice and a reconceptualization of early childhood education and care. (shrink)

Together with large biobanks of human samples, medical registries with aggregated data from many clinical centers are vital parts of an infrastructure for maintaining high standards of quality with regard to medical diagnosis and treatment. The rapid development in personalized medicine and pharmaco-genomics only underscores the future need for these infrastructures. However, registries and biobanks have been criticized as constituting great risks to individual privacy. In this article, I suggest that quality with regard to diagnosis and treatment is an inherent, (...) morally normative requirement of health care, and argue that quality concerns in this sense may be balanced with privacy concerns. (shrink)

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)

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)

Palliative care is a recent branch of health care. The doctors, nurses, and other professionals involved in it took their inspiration from the medieval idea of the hospice, but have now extended their expertise to every area of health care: surgeries, nursing homes, acute wards, and the community. This has happened during a period when patients wish to take more control over their own lives and deaths, resources have become scarce, and technology has created controversial life-prolonging treatments. (...) Palliative care is therefore faced with more ethical problems that other areas of health care. This book, by a clinician, teacher, and writer on health care ethics, has been written to provide all those who care for the terminally ill--doctors, nurses, social workers, clergymen, physiotherapists--with the concepts and principles which will assist them with difficult decisions. It challenges many received doctrines of palliative care, but its well-illustrated central theme is that technical expertise must be controlled by humane, non-technical judgments. (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)

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)

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)

As palliative care develops across many of the countries of Europe, we find that it continues to raise important ethical challenges. Palliative care practice requires ethical sensitivity and understanding. At the same time the very existence of palliative care calls for ethical explanation. Ethics and palliative care meet over some vital issues: 'the good death', sedation at the end of life, requests for euthanasia, futile treatment, and the role of research. Yet palliative care appears uncertain (...) about its goals and there is evidence that its ethical underpinnings are changing. Likewise, the moral problems of palliative care are only partly served by the four 'principles' of modern bioethics. This innovative book, with contributions by clinicians, ethicists, philosophers and social scientists, provides the first ever picture of palliative care ethics in the European context. It will be of interest to those involved in the delivery and management of palliative care services, as well as to students and researchers. (shrink)

Background: Audio-visual teleconsultation is expected to help home-based palliative patients, hospital-based palliative care professionals, and family physicians to jointly design better, pro-active care. Consensual knowledge of the possibilities and limitations of teleconsultation in transmural palliative care is, however, largely lacking.This paper aims at describing elements of both the physical workplace and the cultural-social context of the palliative care practice, which are imperative for the use of teleconsultation technologies. Methods: A semi-structured expert meeting and qualitative, open interviews (...) were deployed to explore professionals’ assumptions and wishes, which are considered to contain latent presumptions about the practice’s physical workplace and latent elements of the cultural-social context, regarding (1) the mediating potential of audio-visual teleconsultation, (2) how the audio-visual teleconsultations will affect medical practice, and (3) the design and usage of the teleconsultation technology. We used a qualitative analysis to investigate how palliative care professionals interpret the teleconsultation package in preparation. The analysis entailed open and axial coding techniques developed in a grounded theory approach. Results: Respondents assume: 1. teleconsultation will hinder physical proximity, thereby compromising anamnesis and diagnosis of new or acutely ill patients as well as “real contact” with the person behind the patient; 2. teleconsultation will help patients becoming more of a pivotal figure in their own care trajectory; 3. they can use teleconsultation to keep a finger on the pulse; 4. teleconsultations have a healing effect of their own due to offered time and digital attention; 5. teleconsultation to open up an additional “gray” network outside the hierarchical structures of the established chain of transmural palliative care. This network could cause bypassing of caregivers and uncertainty about responsibilities; 6. teleconsultations lead to an extended flow of information which helps palliative care professionals to check the stories of patients and medical specialists. Conclusions: Professionals assume teleconsultation co-defines a new patient–professional relationship by extending hospital-based caregivers’ perceptions of as well as attention for their patients. At the cost, however, of clinical and personal connectedness. Secondly, a hermeneutics is needed to carefully interpret teleconsultation images. Thirdly, teleconsultations transform caregiving cultures as formerly separated care domains collide, demanding a redefinition of roles and responsibilities. (shrink)

Crito revisited -- Blindness, narrative, and meaning : moral living -- Radical experience and tragic duty : moral dying -- Needing assistance to die well : PAS and beyond -- Experiencing lost voices : dying without capacity -- Dying young : what interests do children have? -- Caring for patients : cure, palliation, comfort, and aid in the process of dying.

The growing proportion of elderly people in society, together with recent advances in robotics, makes the use of robots in elder care increasingly likely. We outline developments in the areas of robot applications for assisting the elderly and their carers, for monitoring their health and safety, and for providing them with companionship. Despite the possible benefits, we raise and discuss six main ethical concerns associated with: (1) the potential reduction in the amount of human contact; (2) an increase in (...) the feelings of objectification and loss of control; (3) a loss of privacy; (4) a loss of personal liberty; (5) deception and infantilisation; (6) the circumstances in which elderly people should be allowed to control robots. We conclude by balancing the care benefits against the ethical costs. If introduced with foresight and careful guidelines, robots and robotic technology could improve the lives of the elderly, reducing their dependence, and creating more opportunities for social interaction. (shrink)

Protecting the Vulnerable explores the reality of patient control and choice in health care and analyzes how decisions should be made on behalf of those deemed incapable of making decisions. The contributors, distinguished experts from the disciplines of medicine, ethics, theology, and law, look at the complex problem of autonomy and consent in health care and clinical research today from an illuminating perspective--its impact on the vulnerable members of society. The essays move from the exploration of lingering paternalism (...) in health care to the acute dilemma of treatment of and research on newborn babies. In covering both general and specific problems the collection reveals how exploitation can occur when the right of autonomy is eroded and where informed consent is illusory. Particularly vulnerable groups, such as children and people with mental handicaps, are discussed alongside cases where the vulnerability is itself an issue. Other areas covered include: `gesture' suicides, the practical problems of doctors in dealing with dependent patients, and the limits of proxy consent. All health care professionals, ethicists, policy makers, and lawyers currently engaged in the study or practice of health care ethics will find Protecting the Vulnerable to be a vital source of information for many years to come. (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)

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health (...) class='Hi'>care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well. (shrink)

The main purpose of this paper is to clarify some senses of dignity that are particularly relevant for the treatment and care of the elderly. I make a distinction between two quite different ideas of dignity, on the one hand the basic kind of dignity possessed by every human being, and on the other hand the dignity which is the result of a person's merits, whether these be inherited or achieved. Common to both these ideas is that having a (...) dignity entails having a set of rights, in the case of basic dignity the set of rights which we call human rights, the rights which the United Nations, among others, has tried to determine. The dignities of merit also provide some rights, although normally rights with limited scope covering, for instance, a professional area. This observation gives my preliminary answer to the fundamental question of what distinguishes dignity from other high values that could be attached to humans. I discuss further a kind of value that might be mistaken for a kind of dignity, viz. what I call public status. This status is to be distinguished from social status (the status of e.g. kings, governors, and officials) that I take to be a proper dignity of merit. The public status is the status gained solely via public perception and not directly via any merits on the part of the dignified. Finally, I turn to the topic of the dignity of the elderly and try to determine whether there is some dignity peculiar to the elderly, and which is over and above the basicMenschenwrde. My two preliminary proposals are the following: the elderly have a dignity of wisdom and they have a highly general dignity of merit, which results from their life-long efforts and achievements, and for this they deserve our gratitude. (shrink)

Equity in health and health care is animportant issue. It has been proposed that thepursuit of equity in health care is beinghampered by the dominance of individualism inhealth care practices. This paper explores theway in which communitarian ideals and practicesmight lend themselves to the pursuit of equity.Communitarians acknowledge, respect and fosterthe bonds that unite and identify communities.The paper argues that, to achieve equity inhealth care, these bonds need to be recognisedand harnessed rather than ignored. The notionof (...) individual autonomy in the context of thecommunity is examined. Alternative concepts ofautonomy – social autonomy and communityautonomy – are seen to be more respectful andnurturing of both the individual and thecommunity. Moreover, these concepts appeardesirable for the pursuit of health care equitygoals. The paper concludes with some thoughtsabout how equity in Australia's health caresystem can reasonably progress within acommunitarian vision. Disadvantaged communitiesare discussed throughout, in particular,Australian Aboriginal communities. (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)

In this article I wish to show how care ethics puts forward a fundamental critique on the ideal of independency in human life without thereby discounting autonomy as a moral value altogether. In care ethics, a relational account of autonomy is developed instead. Because care ethics is sometimes criticized in the literature as hopelessly vague and ambiguous, I shall begin by elaborating on how care ethics and its place in ethical theory can be understood. I shall (...) stipulate a definition of care ethics as a moral perspective or orientation from which ethical theorizing can take place. This will mean that care ethics is more a stance from which we can theorize ethically, than ready-made theory in itself. In conceiving care ethics in this way, it becomes possible to make clear that, for instance, a moral concept of autonomy is not abandoned, but instead is given a particular place and interpretation. In the final part of this article I will show how ‘relational autonomy’ can be applied fruitfully in the practice of psychiatric care. (shrink)

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

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

This paper discusses the question whether care work for dependent persons (children, the elderly, and disabled persons) may be entrusted to the market; that is, whether and to what extent there is a normative justification for the “commodification of care.” It first proposes a capability theory for care that raises two relevant demands: a basic capability for receiving care and a capability for giving care. Next it discusses and rejects two objections that aim to show (...) that market-based care undermines the caring motives essential to care, one of them because of its reliance on contracts and the other because of the corrupting influence of payment on motivation. If market care is in principle legitimate, the commodification question transforms into one about the appropriate combinations of market and non-market care. This question can be answered only by adding an additional complication: care is to be balanced against other activities, most notably work for the labor market. This brings in the problem of gender inequality, since paid work has been traditionally distributed to men and caring activities to women. I show how the capability theory of caring presented in this paper can help resolve the dispute between competing models for balancing work and caring. (shrink)

Lying is a common phenomenon amongst human beings. It seems to play a role in making social interactions run more smoothly. Too much honesty can be regarded as impolite or downright rude. Remarkably, lying is not a common phenomenon amongst normally intelligent human beings who are on the autism spectrum. They appear to be ‘attractively morally innocent’ and seem to have an above average moral conscientious objection against deception. In this paper, the behavior of persons with autism with regard to (...) deception and truthfulness will be discussed in the light of two different ethical theories, illustrated by fragments from autobiographies of persons with autism. A systemizing ‘Kantian’ and an empathizing ‘ethics of care’ perspective reveal insights on high-functioning autism, truthfulness and moral behavior. Both perspectives are problematic from the point of view of a moral agent with autism. High-functioning persons with autism are, generally speaking, strong systemizes and weak empathizers. Particularly, they lack ‘cognitive empathy’ which would allow them to understand the position of the other person. Instead, some tend to invent a set of rules that makes their behavior compatible with the expectations of others. From a Kantian point of view, the autistic tendency to always tell the truth appears praiseworthy and should not be changed, though it creates problems in the social life of persons with autism. From a care ethics perspective, on the other hand, a way should be found to allow the high-functioning persons with autism to respect the feelings and needs of other persons as sometimes overruling the duty of truthfulness. We suggest this may even entail ‘morally educating’ children and adolescents with autism to become socially skilled empathic ‘liars’. (shrink)

Clarifying and analysing moral problems arising in the practice of palliative care was the objective of participatory observations in five palliative care settings. The results of these observations will be described in this contribution. The moral problems palliative caregivers have to deal with in their daily routines will be explained by comparison with the findings of a previously performed literature study. The specific differences in the manifestation of moral problems in the different palliative care settings will be (...) highlighted as well. (shrink)

What this book is about -- Theoretical perspectives : modernity and postmodernity, power and ethics -- Constructing early childhood institution : what do we think it is? -- Constructing the early childhood institution : what do we think they are for? -- Beyond the discourse of quality to the discourse of meaning making -- The stockholm project : constructing a pedagogy that speaks in the voice of the child, the pedagogue and the parent -- Pedagogical documentation : a practice for (...) reflection and democracy -- Minority directions in the majority world : threats and possibilities. (shrink)

In this paper I argue that the metaphysical ethics of Emmanuel Levinas captures some essential moral intuitions that are central to health care. However, there is an ongoing discussion about the relevance of ethical metaphysics for normative ethics and in particular on the question of the relationship between justice and individualized care. In this paper I take part in this debate and I argue that Levinas' idea of an ethics of the Other that guides politics and justice can (...) shed important light on issues that are central to priorities in health care. In fact, the ethics of Levinas in seeking the foundation of normativity itself, captures the ethical coreand central values of health care. (shrink)

: The principle of equipoise traditionally is grounded in the special obligations of physician-investigators to provide research participants with optimal care. This grounding makes the principle hard to apply in contexts with limited health resources, to research that is not directed by physicians, or to non-therapeutic research. I propose a different version of the principle of equipoise that does not depend upon an appeal to the Hippocratic duties of physicians and that is designed to be applicable within a wider (...) range of research contexts and types—including health services research and research on social interventions. I consider three examples of ethically contentious research trials conducted in three different social settings. I argue that in each case my version of the principle of equipoise provides more plausible and helpful guidance than does the traditional version of the principle. (shrink)

This paper explores the notion of ‘expert’ health care practitioner in the context of critical thinking and health care education where scientific rather than philosophical inquiry has been the dominant mode of thought. A number of factors have forced are appraisal in this respect: the challenge brought about by the identification of complex ethical issues in clinical situations; medicine's `solving' of many of the simple health problems; the recognition that uncertainty is a common and perhaps innate feature of (...) clinical practice; debate about the concepts of illness and disease; plus insights from psychology,sociology and medical anthropology. Together these have prompted alternative ways of thinking which have the aim of identifying the best rather than the right decision (where best equates to good and right equates to correct in the sense of true or approved). It is argued that phronesis adds a necessary corrective dimension to modern Western medicine's over-emphasis on techne and is one of the factors that differentiates novice from expert practitioner. However, this attracts certain conflicts of interest: phronesis can only be gained and assessed from experience of praxis; agencies with legitimate interests in medicine such as government and professional registering bodies require more substantive criteria. (shrink)

Health care systems in different countries and cultures differ and tend toreflect the particular values and, therefore, the particular socialstructure of a given society. Each of these has ethical problems unique toitself. Some of these problems are briefly discussed. So as to have anindividual ethical problem in the context of medical care, access tomedical care needs to be assured. It is argued that individual problems arethe primary issue in societies in which there is fair access whereas theyare (...) of lesser importance in societies which have thus far failed toprovide fair access. (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)

Awareness of farm animal welfare issues is growing in Canada, as part of a larger food movement. The baseline Canadian standards for farm animal welfare—the Recommended Codes of Practice for the Care and Handling of Farm Animals —are up for revision. The success of these standards will depend in part on perceived legitimacy, which helps determine whether voluntary code systems are adopted, implemented, and accepted by target audiences. In the context of the Codes, legitimacy will also hinge on whether (...) the standards-developers marshal narratives about farm animals that accord with their audiences’ expectations. The aim of this paper is to catalogue factors that influence legitimacy in farm animal welfare standard-setting, including which narratives of animal welfare are emphasized by standard-setters. Drawing upon the example of the baseline Canadian standards, and the National Farm Animal Care Council, the paper will present a theoretical and methodological framework for analyzing legitimacy in the context of animal welfare standards-development and discuss associated policy considerations. (shrink)

During the last decade a technical approach has become increasingly influential in health care priority setting. The various country reports illustrate, however, that non-technical considerations cannot be avoided. As they often remain implicit in health care package decisions, this paper aims to make these normative judgements an explicit part of the procedure. More specifically, it aims to integrate different models of distributive justice as well as the principle of solidarity in four different phases of a decision-making procedure, and (...) to identify important moral choices which present themselves. First four important justice models are discussed, then a justification is given for their inclusion in a four-step decision making procedure. This is followed by a discussion of different justice and solidarity problems—with their inherent conceptual difficulties in each of these stages. The paper concludes with a summary of the major moral choices that are to be made in health care package decisions. (shrink)

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired moral attitude of physicians. In a series of three articles, three of the discussed concepts are presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of the series, “empathy” has (...) been developed as a mainly cognitive and morally neutral capacity of understanding. In the second article, the emotional and virtuous core of the desired professional attitude—compassion—has been presented. Compassion as a professional attitude has been distinguished from a spontaneous feeling of compassion, and has been related to a general idea of man as vulnerable and solidary being. Thus, the dignity of the patient is safeguarded in spite of the asymmetry of compassion. In this article, the third concept of the triad—“care”—is presented. Care is conceived as an attitude as well as an activity which can be directed to different objects: if it is directed to another sentient being, it is regarded as intrinsically morally valuable; implying (1) the acceptance of being addressed, (2) a benevolent inclination to help and to foster, and (3) activity to realize this. There are different forms of benevolence that can underlie caring. With regard to the professional physician’s ethos, the attitude of empathic compassion as developed in the two previous articles is proposed to be the adequate underlying attitude of care which demands the right balance between closeness and professionalism and the right form of attention to the person of the patient. ‘Empathic compassionate care’ does not, however, describe the whole of the desired attitude of a physician, but focuses on the morally-emotive aspects. In order to get also the cognitive and practical aspects of biomedicine into the picture, ‘empathic compassionate care’ has to be combined with an attitude of responsibility that is more directed to decision-making and outcome than a caring attitude alone can be. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” and “responsibility” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions. (shrink)

Contemporary industrialized societies have been confronted with the fact and consequences of women's increased participation in paid employment. Whether this increase has resulted from women's desire for equality or from changing economic circumstances, women and men have been faced with a crisis in the organization of work that concerns dependents, that is, those unable to care for themselves. This is labor that has been largely unpaid, often unrecognized, and yet is indispensable to human society.

The interaction between evidence-based medicineand doctors' duty of care to patients iscomplex. One the one hand, there is surely anobligation to take account of the bestavailable evidence when offering health care topatients. On the other hand, it is equallyimportant to be aware of important shortcomingsin the processes and practices ofevidence-based medicine. There are tensionsbetween the population focus of evidence-basedmedicine and the duties that doctors have toindividual patients. Implementingevidence-based medicine may have unpredictableconsequences upon the overall quality of healthcare. Patients (...) may have a range of reasons forpreferring one form of treatment over another,not all of which are captured by currentformulations of evidence. This paper examinesthese issues, using relevant examples fromevidence-based medicine. (shrink)

Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy choices, but insufficient because (...) different approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context. (shrink)

This paper introduces this mini-series on verticalequity in health care. It reflects on the fact that byand large equity policies in health care have failedand that there is a need for positive discriminationto promote equity better in future. This positivediscrimination is examined under the heading of`vertical equity'.The paper considers Varian's notion of `envy' as abasis for equity in health care but concludes thatthis is not a helpful route to go down. Better itwould seem to pursue the idea (...) from Sen of `freedoms'and `communitarian claims' (as raised previously bythis author). While it is argued that proceduraljustice is to be preferred in the longer run as abasis for equity there are gains in adopting a shortrun goal of promoting distributive justice. Somepreliminary evidence is presented on the weighting ofhealth gains to reflect such vertical equityconcerns. (shrink)

This article discusses the latest developments regarding euthanasia and palliative care in the Netherlands. On the one hand, a legally codified practice of euthanasia has been established. On the other hand, there has been a strong development of palliative care. The combination of these simultaneous processes seems to be rather unique. This contribution first focuses on these remarkable developments. Subsequently, the analysis concentrates on the question of how these new developments have influenced the ethical debate.

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). (...) Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on good care’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’. (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)

I Conceptual Foundations Ethical problems emerging from modern medical technology have been evaluated on an issue-by-issue basis. ...

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does not mean that everyone will (...) have whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered. (shrink)

Client participation in elderly care organizations requires shifting traditional power relations and establishing communicative action that involves the lifeworlds of clients and professionals alike. This article describes a particular form of client participation in which one client was part of a team of professionals in a residential care home. Their joint remit was to plan the implementation of a new personal care file for residents. We describe the interactions within this team through an ethnodrama, based on participant (...) observations and the embodied presence of the researcher (first author). The narratives and voices of all team members are dramatized in this ethnodrama. Throughout the project the team members experienced confusion relating to the confrontation between lifeworld and system, as experienced by the client and professionals in the team. We analyze these tensions by making use of a Habermasian theoretical framework. We conclude that forms for collective client participation in residential care homes should be developed based on communicative action between clients and professionals, with room for emotional engagement. (shrink)