Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, focusing on (...) discrimination and on fundamental egalitarian and social justice concerns. (shrink)

Are the small and indolent cancers found in abundance in cancer screening normal variations, risk factors, or disease? Naturalists in philosophy of medicine turn to pathophysiological findings to decide such questions objectively. To understand the role of pathophysiological findings in disease definition, we must understand how they mislead in diagnostic reasoning. Participants on all sides of the definition of disease debate attempt to secure objectivity via reductionism. These reductivist routes to objectivity are inconsistent with the Bayesian nature of clinical reasoning; (...) when they appeal to the sciences, they are inconsistent with what philosophy of biology tells us about its natural kinds. Proposals that we narrow the scope of our claims in the disease definition debates are useful, but paradigms can still distort our reasoning in particular cases, even when we are self-conscious about their status. (shrink)

The seriousness of the risk that healthcare workers faced during SARS, and their response of service in the face of this risk, brings to light unrealistic assumptions about duty and risk that informed the debate on duty to care in the early years of HIV/AIDS. Duty to care is not based upon particular virtues of the health professions, but arises from social reflection on what response to an epidemic would be consistent with our values and our needs, recognizing our shared (...) vulnerability to disease and death. Such reflection underwrites a strong duty of care, but one not to be borne solely by the altruism and heroism of individual healthcare workers. (shrink)

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional rather than a residual system. They argue that the concept contradicts the idea of comprehensiveness; leads to unsustainable expenditures; is too indeterminate for policy; and supports only a prioritarian distribution. I argue that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and that UHC is a (...) solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy are not transparent about the source of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option. (shrink)

Temkin asks how we should distribute resources between the social determinants of health and health care; Sreenivasan argues that if our goal is fair opportunity, funding universal health coverage is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly than he claims: it applies to any argument for UHC based on health (...) equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given what Sen calls the multidimensional nature of health equity and the role of UHC in cost containment, UHC may not be a threat to health equity. I also argue against Sreenivasan's claim that the data he discusses should not trouble sufficientists and prioritarians. The worst-off are not simply lagging in improvement; rather, their health status is stagnating or worsening. (shrink)

I discuss some reservations about the exegetical power of the claim that the Tractatus is “anti-metaphysical.” The “resolute” reading has the virtue of fidelity to important and neglected features of the work, both its anti-metaphysical moves and its account of the nature of the activity of philosophy and its status. However, its proponents underestimate the barriers to maintaining a consistent fidelity to these features of the text. The image of a ladder suggests a mere instrumental means to arrive at a (...) place that can itself be characterized independently of our means of arrival; where we arrive via the process of the TLP is the conclusion of an argument, and so cannot be characterized independently of the argument that got us there. In his commitments about the process of logical analysis “within language,” he strives as much as in his statements about the world to return us to our ordinary ways of talking and making sense of what we say to one another. Given the internal relationship Wittgenstein is at pains to emphasize between language, thought, and reality, he could hardly have philosophical commitments about one of these terms (have a residual metaphysics of language) and isolate this from how he thinks about the others. In a discussion of “Senator, you’re no Jack Kennedy” and “Chairman Mao is rare,” I argue that, pace Conant and Diamond’s claims to the contrary, logical categories are being invoked to explain why one cannot mean what one thinks one means in this phrase, and that Wittgenstein is both more anti-metaphysical in his treatment of these logical categories (in contrast with Frege) than the resolute readers consider him to be, and less successful in his treatment of how logical categories rule our judgments of sense and nonsense than they imply he is. Finally, I question the sharp boundary between logic and psychology and the “claustrophobic” feel that is created by a narrow construal of what one can make sense of in another’s words and person that underwrites their account of nonsense via a conflict between the meaning words can contain and our confused desires. Throughout, I discuss relevant passages of the Investigations that resolute readers treat as a re-expression of the themes of the Tractatus, to contrast the “anti-metaphysical” treatment these themes express in the Tractatus with the less dogmatic treatment they receive in the Investigations. (shrink)

Verweij and Dawson claim that population health has a distributive dimension; Coggon argues that this presupposes a normative commitment to equity in the very definition of population health, which should, rather, be neutral. I describe possible sources of the distributive view, several of which do not presuppose egalitarian commitments. Two relate to the nature of health as a property of individuals ; two relate to the epistemology and pragmatics of public and population health. A fifth source of the distributive view (...) is a critical stance on the concept of population health; I contrast this with Coggon’s account of the public as a shared political imaginary. None of these views is ‘neutral’: they exhibit several different kinds of normativity and quasi-normativity, but this is not problematic. I argue that the critical stance appropriately distinguishes and relates social justice and public health. (shrink)

The professionalism movement has animated medical education and practice; an extensive literature expresses and categorizes many interpretations of the concept (Hafferty 2006a; Hafferty and Levinson 2008). The inception of the current wave of the movement was in the American Board of Internal Medicine's Project Professionalism. In the face of threats from the growth of managed care and public concerns about conflict of interest, the ABIM's "Physician Charter" called for the profession to publically commit to values of patient welfare, social justice, (...) and respect for patient autonomy (Brennan et al. 2002). The concept of professionalism, or the physician as occupying the role of professional, has taken hold in .. (shrink)

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the conceptual specification of health system boundaries and (...) on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries. (shrink)

Scientism in medical education distracts educators from focusing on the content of learning; it focuses attention instead on individual achievement and validity in its measurement. I analyze the specific form that scientism takes in medicine and in medical education. The competencies movement attempts to challenge old “scientistic” views of the role of physicians, but in the end it has invited medical educators to focus on validity in the measurement of individual performance for attitudes and skills that medicine resists conceptualizing as (...) objective. Academic medicine should focus its efforts instead on quality and relevance of care. The social accountability movement proposes to shift the focus of academic medicine to the goal of high quality and relevant care in the context of community service and partnership with the institutions that together with medicine create and cope with health and with health deficits. I make the case for this agenda through a discussion of the linked histories of the opioid prescribing crisis and the professionalism movement. (shrink)

First published in 2002. Routledge is an imprint of Taylor & Francis, an informa company.

Originally published in 1961. This book is a study of some important ways of knowledge and experience and of the symbols through which they become articulate. Both ‘knowledge’ and ‘experience’ are interpreted in wide senses which are sanctioned by common use – though not always by the usage of philosophers and scientists. The four main fields considered are: the arts, religion, moral knowledge, and our knowledge of one another. These fields, though distinguishable, are nevertheless found to be interrelated in subtle (...) and interesting ways, and it is contended that increase of ‘wisdom’, or ‘educated understanding’, can be achieved only through acceptance and assimilation of all their many-sided disciplines into personal insight. The book deals in a new way with questions of perennial interest which, because they are fundamental, are difficult. Nevertheless, the writing is lucid and untechnical and addressed to a wide range of readers. (shrink)

: This paper examines the nature of the harm-benefit tradeoff in early clinical research for interventions that involve remote possibility of direct benefit and likelihood of direct harms to research participants with fatal prognoses, by drawing on the example of gene transfer trials for glioblastoma multiforme. We argue that the appeal made by the component approach to clinical equipoise fails to account fully for the nature of the harm-benefit tradeoff—individual harm for social benefit—that would be required to justify such research. (...) An analysis of what we label "collateral affective benefits," such as the experience of hope or exercise of altruism, shows that the existence of these motivations reinforces rather than mitigates the necessity of justification by reference to social benefit. Evaluations of social benefit must be taken seriously in the research ethics review process to avoid the exploitation of research participants' motivations of hope or altruism and to avoid the possibility of inadvertent exploitation of high-risk research participants and the harms that would associate with such exploitation. (shrink)

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models in which physicians provide insured services while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such (...) practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician–patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy. (shrink)

This article draws on in-depth interviews with nine white, middle-class, male-to-female transsexuals to examine how they produce and experience bodily transformation. Interviewees’ bodywork entailed retraining, redecorating, and reshaping the physical body, which shaped their feelings, role-taking, and self-monitoring. These analyses make three contributions: They offer support for a perspective that embodies gender, further transsexual scholarship, and contribute to feminist debate over the sex/gender distinction. The authors conclude by exploring how viewing gender as embodied could influence medical discourse on transsexualism and (...) have personal and political consequences for transsexuals. (shrink)

Originally published in 1961. This book is a study of some important ways of knowledge and experience and of the symbols through which they become articulate. Both ‘knowledge’ and ‘experience’ are interpreted in wide senses which are sanctioned by common use – though not always by the usage of philosophers and scientists. The four main fields considered are: the arts, religion, moral knowledge, and our knowledge of one another. These fields, though distinguishable, are nevertheless found to be interrelated in subtle (...) and interesting ways, and it is contended that increase of ‘wisdom’, or ‘educated understanding’, can be achieved only through acceptance and assimilation of all their many-sided disciplines into personal insight. The book deals in a new way with questions of perennial interest which, because they are fundamental, are difficult. Nevertheless, the writing is lucid and untechnical and addressed to a wide range of readers. (shrink)

Is it proper to call art (or the arts) in any sense 'true' or 'false'? reid suggests that though abstract arts like abstract painting and sculpture, or music, are not true to the independent world in the somewhat guarded sense in which the representative arts are; still the former reveal new aspects of the relationships of space, color and movement and the latter reveals a reality of the relationships of sounds in time. (staff).