How far should we go in protecting and promoting public health? Can we force people to give up unhealthy habits and make healthier choices, or does everyone have the right to decide their own lifestyle? Should we stop treating smokers who refuse to give up smoking? Should we put a tax on fatty foods and ban vending machines in schools to address the obesity epidemic? Should parents be required to have their children vaccinated? Are some of our screening programmes unethical (...) Downs syndrome screening, for example or should we be screening people for more conditions, such as Huntington disease? Such questions are at the heart of public health ethics. Holland shows that to understand and debate these issues requires philosophy: moral philosophies, such as utilitarianism and deontology, as well as political philosophies such as liberalism and communitarianism. And philosophy informs other aspects of public health, such as epidemiology and health promotion. The aim of this book is to provide a lively, accessible and philosophically informed introduction to such issues. It is an ideal textbook for students taking courses in public health ethics. And since this book develops systematic discussions of issues in public health ethics, there is also much here to engage and challenge the more advanced reader. (shrink)
Nursing ethics centres on how nurses ought to respond to the moral situations that arise in their professional contexts. Nursing ethicists invoke normative approaches from moral philosophy. Specifically, it is increasingly common for nursing ethicists to apply virtue ethics to moral problems encountered by nurses. The point of this article is to argue for scepticism about this approach. First, the research question is motivated by showing that requirements on nurses such as to be kind, do not suffice to establish virtue (...) ethics in nursing because normative rivals (such as utilitarians) can say as much; and the teleology distinctive of virtue ethics does not transpose to a professional context, such as nursing. Next, scepticism is argued for by responding to various attempts to secure a role for virtue ethics in nursing. The upshot is that virtue ethics is best left where it belongs – in personal moral life, not professional ethics – and nursing ethics is best done by taking other approaches. (shrink)
Some brain injured patients are left in a permanent vegetative state, i.e., they have irreversibly lost their capacity for consciousness but retained some autonomic physiological functions, such as breathing unaided. Having discussed the controversial nature of the permanent vegetative state as a diagnostic category, we turn to the question of the patients’ ontological status. Are the permanently vegetative alive, dead, or in some other state? We present empirical data from interviews with relatives of patients, and with experts, to support the (...) view that the ontological state of permanently vegetative patients is unclear: such patients are neither straightforwardly alive nor simply dead. Having defended this view from counter-arguments we turn to the practical question as to how these patients ought to be treated. Some relatives and experts believe it is right for patients to be shifted from their currently unclear ontological state to that of being straightforwardly dead, but many are concerned or even horrified by the only legally sanctioned method guaranteed to achieve this, namely withdrawal of clinically assisted nutrition and hydration. A way of addressing this distress would be to allow active euthanasia for these patients. This is highly controversial; but we argue that standard objections to allowing active euthanasia for this particular class of permanently vegetative patients are weakened by these patients’ distinctive ontological status. (shrink)
: This essay examines the increasing commodification of the body with respect to tissues, gametes, and embryos. Such commodification contributes to a diminishing sense of human personhood on an individual level, even as it erodes commitments to human flourishing at the societal level. After the case for social harm resulting from the increasing commodification of the body is made, the question becomes whether that harm is best remedied by following any of three approaches by which government traditionally seeks to promote (...) the flourishing of its citizens. The author concludes that it is not, and that what is needed is a pragmatic and somewhat casuistic approach to the regulation of contested commodities--that which legal scholar Margaret Jane Radin calls "incomplete commodification.". (shrink)
_Arguing About Bioethics_ is a fresh and exciting collection of essential readings in bioethics, offering a comprehensive introduction to and overview of the field. Influential contributions from established philosophers and bioethicists, such as Peter Singer, Thomas Nagel, Judith Jarvis Thomson and Michael Sandel, are combined with the best recent work in the subject. Organised into clear sections, readings have been chosen that engage with one another, and often take opposing views on the same question, helping students get to grips with (...) the key areas of debate. All the core issues in bioethics are covered, alongside new controversies that are emerging in the field, including: embryo research selecting children and enhancing humans human cloning using animals for medical purposes organ donation consent and autonomy public health ethics resource allocation developing world bioethics assisted suicide. Each extract selected is clear, stimulating and free from unnecessary jargon. The editor’s accessible and engaging section introductions make _Arguing About Bioethics_ ideal for those studying bioethics for the first time, while more advanced readers will be challenged by the rigorous and thought-provoking arguments presented in the readings. (shrink)
: Genetics researchers often work with distinct communities. To take moral account of how their research affects these communities, they need a richer conception of justice and they need to make those communities equal participants in decision-making about how the research is conducted and what is produced and published out of it.
This paper discusses the viability of a virtue-based approach to bioethics. Virtue ethics is clearly appropriate to addressing issues of professional character and conduct. But another major remit of bioethics is to evaluate the ethics of biomedical procedures in order to recommend regulatory policy. How appropriate is the virtue ethics approach to fulfilling this remit? The first part of this paper characterizes the methodology problem in bioethics in terms of diversity, and shows that virtue ethics does not simply restate this (...) problem in its own terms. However, fatal objections to the way the virtue ethics approach is typically taken in bioethics literature are presented in the second section of the paper. In the third part, a virtue-based approach to bioethics that avoids the shortcomings of the typical one is introduced and shown to be prima facie plausible. The upshot is an inviting new direction for research into bioethics' methodology. (shrink)
What is death? The question is of wide-ranging practical importance because we need to be able to distinguish the living from the dead in order to treat both appropriately; specifically, the permissibility of retrieving vital organs for transplantation depends upon the potential donor's ontological status. There is a well-established and influential biological definition of death as irreversible breakdown in the functioning of the organism as a whole, but it continues to elicit disquiet and rejoinders. The central claims of this paper (...) are that the best way to address the question as to what death is, is to attend closely to our ordinary concept of death; doing so reveals that, whilst our ordinary understanding accommodates the biological definition, it also includes the thought that, for someone who has died, there will never again be anything it is like to be that person. Support for these claims is provided, and their academic and practical implications traced. The important practical implication is that we are left in quandary as to whether certain potential organ donors — for example, anencephalic babies and the permanently vegetative — are dead, a quandary that has serious implications for the relevance of the dead donor rule in transplant ethics. (shrink)
This book provides a clear and stimulating introduction to bioethics - from the more familiar debates on euthanasia, living wills and new reproductive technologies such as IVF, through to the philosophical implications of recent developments in genetics such as prenatal genetic therapy, genetic enhancement and human cloning. Offers a clear and stimulating textbook introduction to contemporary issues in bioethics. Provides original and provocative contributions to ongoing debates. Guides the reader from the more familiar debates on euthanasia, advance directives, and new (...) reproductive technologies, through to the philosophical implications of developments such as prenatal genetic therapy, genetic enhancement and human cloning. The book is built around four important themes: the nature of moral status ; life, death, and killing ; the threat to personal identity; the question of whether biomedical innovations can be ‘unnatural’. (shrink)
This paper addresses two research questions. The first is theoretical: What is trust? In the first half of this paper we present a distinctive tripartite analysis. We describe three attitudes, here called reliance, specific trust and general trust, each of which is characterised and illustrated. We argue that these attitudes are related, but not reducible, to one another. We suggest that the current impasse in the analysis of trust is in part due to the fact that some writers allude to (...) these distinctions, but unclearly so, whilst others elide them altogether. The second research question focuses on doctor–patient interaction. Trust is often said to be central in medical encounters but this strikes us as too vague. The success of doctor–patient relations in part depends on adopting the most appropriate of the three attitudes we delineate. We argue that reliance is the appropriate attitude for most medical encounters. When circumstances do require trust, the distinction between specific trust and general trust is crucial. We describe medical encounters requiring specific trust. General trust is less often required in medicine; but it is appropriate in some cases and, when called for, it is called for strongly. (shrink)
The need for new “pull” incentives to stimulate antibiotic R&D is widely recognized. Due to the global diversity of health systems, combined with different challenges faced by antibiotics used in different types of healthcare settings, there is no one-size-fits-all solution. Instead, different “pull” incentives should be tailored to local contexts, priorities, and antibiotic types. Policymakers and industry should collaborate to identify appropriate solutions at the local, regional, and global levels.
The Diagnosis Confirmation Model includes a dual-pricing mechanism designed to support value-based pricing of novel antibiotics while improving the alignment of financial incentives with their optimal use in patients at high risk of drug-resistant infections. DCM is a market-based model and complementary to delinked models. Policymakers interested in stimulating antibiotic innovation could consider tailoring the DCM to their reimbursement systems and incorporating it into the suite of incentives to improve the economics of antibiotics.
In a recent article in this journal I presented a sceptical argument about the current prominence of virtue ethics in nursing ethics. Daniel Putman has responded with a defence of the relevance of virtue in nursing. The present article continues this discussion by clarifying, defending, and expanding the sceptical argument. I start by emphasizing some features of the sceptical case, including assumptions about the nature of sceptical arguments, and about the character of both virtue ethics and nursing ethics. Then I (...) respond to objections of Putman's such as that, according to virtue ethics, virtue is relevant to the whole of a human life, including one's behaviour in a professional context; and that eudaimonia should be central in explaining and motivating a nurse's decision to enter the profession. Having argued that these objections are not compelling, I go on to discuss an interesting recent attempt to reassert the role of virtue ethics in the ethics of professions, including nursing. This centres on whether role‐specific obligations – e.g. the obligations that arise for a moral agent qua lawyer or mother – can be accommodated in a virtue ethics approach. Sean Cordell has argued that the difficulty of accommodating role‐specific obligations results in an ‘institution‐shaped gap’ in virtue ethics. He suggests a way of meeting this difficulty that appeals to the ergon of institutions. I endorse the negative point that role‐specific obligations elude virtue ethics, but argue that the appeal to the ergon of institutions is unsuccessful. The upshot is further support for scepticism about the virtue ethics approach to nursing ethics. I end by gesturing to some of the advantages of a sceptical view of virtue ethics in nursing ethics. (shrink)
This paper traces missing links in the history of economic thought. In outlining Hume's concept of 'the reflexive mind' it shows that this opened frontiers between philosophy and psychology which Bertrand Russell denied and which logical positivism in philosophy and positive economics displaced. It relates this to Hume's influence not only on Smith, but also on Schopenhauer and the later Wittgenstein, with parallels in Gestalt psychology and recent findings from neural research and cognitive psychology. It critiques Kant's reaction to Hume's (...) claim that one may assume but cannot prove cause and effect and how Samuelson's Foundations of Economic Analysis has been Kantian but wrong in claims for axioms that are universal truths. It illustrates how Samuelson's presumption that language and mathematics are 'identical' was as mistaken as the logical atomism of Russell and the early Wittgenstein, relates this to Kleinian splitting, denial and projective identification and suggests that recovery of greater realism in economics needs to regain links with such philosophy and psychology. (shrink)
Information is clearly vital to public health, but the acquisition and use of public health data elicit serious privacy concerns. One strategy for navigating this dilemma is to build 'trust' in institutions responsible for health information, thereby reducing privacy concerns and increasing willingness to contribute personal data. This strategy, as currently presented in public health literature, has serious shortcomings. But it can be augmented by appealing to the philosophical analysis of the concept of trust. Philosophers distinguish trust and trustworthiness from (...) cognate attitudes, such as confident reliance. Central to this is value congruence: trust is grounded in the perception of shared values. So, the way to build trust in institutions responsible for health data is for those institutions to develop and display values shared by the public. We defend this approach from objections, such as that trust is an interpersonal attitude inappropriate to the way people relate to organisations. The paper then moves on to the practical application of our strategy. Trust and trustworthiness can reduce privacy concerns and increase willingness to share health data, notably, in the context of internal and external threats to data privacy. We end by appealing for the sort of empirical work our proposal requires. (shrink)
The financial crash of 2008 following the selling of fictitious derivatives was a crisis of both rationality and values whose aftermath has thrown the legitimation of deregulated markets, and governments, into question. This paper critiques the Becker metaphor of human capital and submits that human value is central to and the fulcrum of both economic and social values. It illustrates that Hume and Adam Smith directly countered the Hobbesian hypothesis that human nature is based only on self-interest, distinguishes market values (...) from social values, explicit from implicit values and parallels Sen in adopting an ordinal ranking of what people value rather than a search for cardinality. It draws on cognitive psychology, neural research, revealed preference theory and a principle of implicit verification. It also outlines implications for what Adam Smith centrally valued as concern for the welfare of the whole of society. (shrink)
Decisions on which new health technologies to provide are controversial because of the scarcity of healthcare resources, the competing demands of payers, providers and patients and the uncertainty of the evidence base. Given this, additional information about new health technologies is often considered valuable. One response is to make access to a new health technology conditional on further research. Access can be restricted to patients who participate in a research study, such as a randomised controlled trial; alternatively, a new treatment (...) can be made generally available, but only on condition that further evidence is collected (eg, on long-term outcomes and adverse events, in patient registries). The National Institute for Health and Clinical Excellence (NICE), which provides guidance on which new health technologies to make available under the UK's NHS, for example, has made some research conditional recommendations, and the current interest in such options suggests that they are likely to become more prevalent in the future. This paper identifies and discusses the main ethical issues created by this distinctive range of recommendations. We argue that decisions to put research conditions on access to new technologies are compatible with widely accepted values, principles and practices relevant to resource allocation. However, there are important features of these distinctive judgements that must be taken into account by resource allocation decision-making bodies and research ethics committees, and that require new sorts of empirical data. (shrink)
Evaluating public health measures is one of the central tasks in public health ethics. Some public health measures incur the charge that they are paternalistic in an objectionable way. In a recent intriguing contribution to this journal, Thomas Nys responds to this complaint by setting out three challenges to be met if the charge is to be made good. The first challenge is that putatively objectionable public health measures in fact preserve autonomy; the second is that autonomy is not undermined (...) by measures that are the upshot of democratic processes; the third is that it is a mistake to charge measures intended to benefit others with being objectionably paternalistic. Nys's explicit aim in presenting these challenges is not to show that the charge of paternalism in public health is never sound, but to stimulate further discussion. My paper takes up this invitation by responding to each of the challenges Nys presents, including discussing where they fail and identifying which succeed. (shrink)
This paper presents, defends and applies a conception of public health ethics as focused on liberty-limiting public health action. This approach has been persistently criticised, but the criticism is ambiguous between two challenges: that the focus on liberty makes an objectionable presumption in favour of liberal values and that the focus on liberty fails to address institutionalised social injustice. Part One of the paper addresses both challenges to show they can be met by a nuanced account of a liberty-oriented public (...) health ethics. Part Two establishes that debates about policy responses to the current Covid-19 pandemic illustrate and vindicate this conception of public health ethics as focused on liberty-limiting public health action. The discussion then turns to the methodological question as to how public health policies are to be evaluated, focusing particular on the role of normative theory in such evaluations. The methodology of ‘wide reflective equilibrium’ is described and endorsed; the paper ends with a case study to illustrate this evaluative methodology, focused on the ethics of COVID-19 immunity passports. (shrink)
Aristotle warned against a 'missing middle' in logic. This paper submits that one of the reasons why there has been no major breakthrough in macroeconomics since the financial crisis of 2007-08 has been a missing middle in mainstream micro-macro syntheses, constrained by partial and general equilibrium premises. It maintains that transcending this needs recognition that large and dominant multinational corporations between small micro firms and macro outcomes – while also influencing both – merit the conceptual paradigm of mesoeconomics. Drawing on (...) a range of uses of the concept, it relates this to reasons for 'too big to fail' and suggests implications for policies to gain accountability of big business, including how a meso dimension to input-output could yield transparency on risk-prone financial transactions by banks, and of corporations contributing to climate change. It also critiques misrepresentation of Walras and Pareto, as well as suggesting areas for research which could address, and potentially redress, 'missing middles' in mainstream micro-macro syntheses. (shrink)
The point of Pragmatic Bioethics is to view bioethics through the lens of American pragmatism. The book is in three parts. The papers in part one look at the “pragmatic method” and bioethics in general; those in part two are intended to suggest that bioethical debates can be informed by parts of the canon of classical American pragmatism; those in part three apply aspects of pragmatism to specific bioethical issues more overtly. This structure is odd in two related respects: the (...) difference between the papers in parts two and three is unclear, and papers dealing in similar ways with similar bioethical issues are placed in each of these parts.My view of how philosophy does, and should, apply to bioethics is at odds with that implied by Pragmatic Bioethics. I think bioethics can be informed by philosophy in two ways. Firstly, specific bioethical problems can be elucidated by substantive philosophical data . Secondly, and more pervasively, bioethics would benefit from acquiring certain intellectual habits distinctive of philosophy . The different view taken in this book is that bioethics might look to the methodology implied by American pragmatism, and specific bioethical issues might be addressed by reference to American pragmatist writings. I feel that this different view was only partially convincing. There are two main sets …. (shrink)
This article is a reflection on the use of case study material in the teaching of ethics to nursing students. Given the main aims of a course in ethics for nurses and the limited effectiveness of formal moral theory, it seems inevitable that the mainstay of nursing ethics courses will continue to be case study material. This approach has recently been criticized on a number of grounds. The author suggests here that disquiet over teaching ethics in this way should motivate (...) a concern not with whether, but how, teaching by cases is to be undertaken. (shrink)