Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on (...) one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”. (shrink)
This book, written by four internationally renowned bioethicists and first published in 2000, was the first systematic treatment of the fundamental ethical issues underlying the application of genetic technologies to human beings. Probing the implications of the remarkable advances in genetics, the authors ask how should these affect our understanding of distributive justice, equality of opportunity, the rights and obligations as parents, the meaning of disability, and the role of the concept of human nature in ethical theory and practice. The (...) book offers a historical context to contemporary debate over the use of these technologies by examining the eugenics movement of the late nineteenth and early twentieth centuries. The questions raised in this book will be of interest to any reflective reader concerned about science and society and the rapid development of biotechnology, as well as to professionals in such areas as philosophy, bioethics, medical ethics, health management, law, and political science. (shrink)
How should modern medicine's dramatic new powers to sustain life be employed? How should limited resources be used to extend and improve the quality of life? In this collection, Dan Brock, a distinguished philosopher and bioethicist and co-author of Deciding for Others (Cambridge, 1989), explores the moral issues raised by new ideals of shared decision making between physicians and patients. The book develops an ethical framework for decisions about life-sustaining treatment and euthanasia, and examines how these life and death decisions (...) are transformed in health policy when the focus shifts from what is best for a patient to what is just for all patients. Professor Brock combines acute philosophical analysis with a deep understanding of the realities of clinical health policy. This is a volume for philosophers concerned with medical ethics, health policy professionals, physicians interested in bioethics, and undergraduate courses in biomedical ethics. (shrink)
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The Human Genome Project will produce information permitting increasing opportunities to prevent genetically transmitted harms, most of which will be compatible with a life worth living, through avoiding conception or terminating a pregnancy. Failure to prevent these harms when it is possible for parents to do so without substantial burdens or costs to themselves or others are what J call “wrongful handicaps”. Derek Parfit has developed a systematic difficulty for any such cases being wrongs — when the harm could be (...) prevented only by preventing the existence of the individual who would have a worthwhile life even with the handicap, then bringing him into existence with the handicap does not make him worse off and so does not wrong him. I argue that a non “person‐affecting” principle requiring the avoidance of suffering and limited opportunity correctly accounts for cases of wrongful handicaps without requiring that the individuals with the handicap have been made worse off and therefore wronged. It is an advantage, not a difficulty, of this account that it does not imply that the person with the handicap has been wronged or is a victim with a special moral complaint. (shrink)
In this paper I will address whether the restriction on the creation of human embryos solely for the purpose of research in which they will be used and destroyed in the creation of human stem cell lines is ethically justified. Of course, a cynical but perhaps accurate reading of the new Obama policy is that leaving this restriction in place was done for political, not ethical, reasons, in light of the apparent public opposition to creating embryos for use in this (...) research. But the issue of whether the restriction is ethically justified remains important, even if only for another day in the policy arena. (shrink)
Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life-sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life-sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices (...) is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life-sustaining treatment in order to bring accepted end-of-life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end-of-life decisions is radically mistaken. (shrink)
If stem cell-based therapies are developed, we will likely confront a difficult problem of justice: for biological reasons alone, the new therapies might benefit only a limited range of patients. In fact, they might benefit primarily white Americans, thereby exacerbating long-standing differences in health and health care.
Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by markets. (...) Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)
: Bioethics has focused principally on ethical issues arising in clinical medicine. When it has addressed justice or equity, it has focused on access to health care and on defending a general moral right to health care. This dual focus on establishing a right to health care and on health care rather than health has left bioethics largely silent on two issues of fundamental importance for a full account of justice and health. First, the focus on establishing a right to (...) health care has contributed to a failure to address difficult issues in developing ethical standards for equitably prioritizing limited resources in health care. Second, the focus on inequalities in access to health care has ignored the much greater impact of social determinants of health, in particular socioeconomic class and inequality, on health and health inequalities. Bioethics must broaden its agenda. (shrink)
It is widely recognized that prioritizing health care resources by their relative cost-effectiveness can result in lower priority for the treatment of disabled persons than otherwise similar non-disabled persons. I distinguish six different ways in which this discrimination against the disabled can occur. I then spell out and evaluate the following moral objections to this discrimination, most of which capture an aspect of its unethical character: it implies that disabled persons' lives are of lesser value than those of non-disabled persons; (...) it constitutes or violates Frances Kamm's non-linkage principle; it conflicts with equality of opportunity; it conflicts with fairness, which requires ignoring (some/most) differential impacts of treatment; it wrongly gives lower priority to disabled persons for equally effective treatment; it conflicts with giving all persons an equal chance to reach their full potential; and, it is in conflict with giving priority to the worse off. (shrink)
In this paper I address the relation between just claims to health care and severe cognitive impairment from dementia. Two general approaches to justice in allocation of health care are distinguished – prudential allocation and interpersonal distribution. First, I analyze why a patient who has died has no further claims to health care. Second, I show why prudential allocators would not provide for health care treatment should they be in a persistent vegetative state. Third, I argue that the destruction of (...) personal identity from severe dementia implies that only claims to palliative, but not life-sustaining, health care remain. Finally, I argue that the prudential allocator approach is indeterminate regarding life-sustaining care for the moderately demented and that social policy should not deny that care to patients. Keywords: elderly, health care, the severely-demented, justice CiteULike Connotea Del.icio.us What's this? (shrink)
We report on the deliberations of an interdisciplinary group of experts in science, law, and philosophy who convened to discuss novel ethical and policy challenges in stem cell research. In this report we discuss the ethical and policy implications of safety concerns in the transition from basic laboratory research to clinical applications of cell-based therapies derived from stem cells. Although many features of this transition from lab to clinic are common to other therapies, three aspects of stem cell biology pose (...) unique challenges. First, tension regarding the use of human embryos may complicate the scientific development of safe and effective cell lines. Second, because human stem cells were not developed in the laboratory until 1998, few safety questions relating to human applications have been addressed in animal research. Third, preclinical and clinical testing of biologic agents, particularly those as inherently complex as mammalian cells, present formidable challenges, such as the need to develop suitable standardized assays and the difficulty of selecting appropriate patient populations for early phase trials. We recommend that scientists, policy makers, and the public discuss these issues responsibly, and further, that a national advisory committee to oversee human trials of cell therapies be established. **NB we did not reccommend a NAC, we think it might be appropriate**. (shrink)
The dominant methodology in health policy for prioritizing and rationing health care resources is cost-effectiveness analysis, typically using quality adjusted life years (QALYs) or disability adjusted life years (DALYs) to measure health outcomes. The construction of these measures involves a number of moral or value choices, including: How should states of health and disability be evaluated, and whose preferences (e.g., the disabled or non-disabled) should be used? How should these evaluations reflect that prioritization will involve tradeoffs between health benefits for (...) different persons or groups? Do all QALYs count equally, no matter what age at which they are received? Should discount rates be applied to health benefits? I will show the nature of the moral issues at stake in answering these questions, and briefly argue how they should be answered. (shrink)
In 1990 the landmark Americans with Disabilities Act (ADA) became federal law with the express purpose to “establish a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities."l The act includes separate titles prohibiting discrimination on the basis of disability in employment, public services, transportation and public accommodations. Since it prohibits discrimination on the basis of disability in both public and private services and programs, in health care “it applies to programs provided by the government, (...) benefits provided by employers, and services pro- ”2 vided by physicians.Moreover, the ADA defines disability broadly to include “any.. (shrink)
It is sometimes said that a society should be judged ethically by how it treats its least-fortunate or worst-off members. In one interpretation this is not a point about justice, but instead about moral virtues such as compassion and charity. In our response to the least fortunate among us, we display, or show that we lack, fundamental moral virtues of fellow feeling and concern for others in need. In a different interpretation, however, this point is about justice and a just (...) society—the justice of a society is shown especially in how it treats its least-fortunate members. (shrink)