Ethicists and physicians all over the world have been working on triage protocols to plan for the possibility that the Covid‐19 pandemic will result in shortages of intensive care unit beds, ventilators, blood products, or medications. In reflecting on those protocols, many health care workers have noticed that, outside the pandemic shortage situation, we routinely supply patients in the ICU with invasive and painful care that will not help the patients survive even their hospitalization. This is the kind of pointless (...) care that even the most basic protocol would triage against. Perhaps this widespread reflection on triage standards will draw our attention to our ongoing custom of supplying burdensome and inefficacious care to those near the end of life—care that most health care providers would not want for themselves. This essay argues that reflecting on triage could help us improve end‐of‐life care. (shrink)

ABSTRACT This paper explores one of the most politically sensitive and intellectually neglected issues in bioethics – the interface between the history of contemporary end‐of‐life ethics and the economics of life and death. It suggests that contrary to general belief, economic impulses have increasingly become part of the conditions in which contemporary end‐of‐life ethics continues to evolve. Although this conclusion does not refute the philosophical justifications provided by the ethics for itself, it may cast new light upon (...) its social role. (shrink)

One trend in contemporary discussions of the topic, ‘the meaning of life.’ is to emphasize what might be termed its subjective dimension. That is, it is widely recognized that ‘the meaning of life’ is not something that simply could be presented to an individual, regardless of how he/she felt about it. Thus, for example, Karl Britton has written that we could imagine ‘a featureless god who set before men some goal and somehow drove them to pursue it'; while (...) this would constitute a purpose for human life, it would hardly be sufficient to render life meaningful. ‘The goal would seem arbitrary, senseless: and its pursuit burdensome, souldestroying.’ Similarly, R. W. Hepburn has stated that meaningfulness must indispensably involve value judgment. Any set of conditions presented to us, whether by God, nature, or our fellow humans, constitutes a fact about how the world is; what provides meaningfulness to our lives, on the other hand, must be something which we affirm - something we feel ought to be the case. (shrink)

Euthanasia advocates argue that end-of-life decisions should be based on patients’ autonomous evaluations of their own quality of life. The question is whether a patient’s quality of life has deteriorated so far as to make death a benefit. Criteria for evaluating quality of life are, however, unavoidably arbitrary and unjust. The concept is difficult to define, and human autonomy has limits. This essay discusses the moral issues raised by quality-of-life judgments at the end of (...) class='Hi'>life: who makes them, what criteria they use, and what clinical actions the conclusions justify. It then looks at ways in which quality of life can be considered legitimately, in relation not to euthanasia, which is always illicit, but to specific proposed treatments. If a patient decides to forgo treatment, the decision should be based on the judgment that the treatment, its side effects, or its long-term consequences would be excessively burdensome or useless. (shrink)

The management of patients suffering from chronic disorders of consciousness inevitably raises important ethical questions about the end of life decisions. Some ethical positions claim respect of human life sacredness and the use of good medical practices require allowing DOC patients to live as long as possible, since no one can arbitrarily end either his/her or others’ life. On the other hand, some currents of thought claim respect of human life dignity, patients’ wishes, and the right (...) of free choice entail allowing the withdrawal of life sustaining therapy. This could happen when patients believe their own life to be not worth living, or if therapy is not very beneficial, excessively burdensome, or even futile. Indeed, the decision to withdraw therapies in a DOC patient should be guided by reliable information about DOC diagnosis and prognosis and on how the patient would wish to be treated in such a condition. Taking into account such issues, it would be possible to make the decision that more adequately fits a DOC patient’s best interest. This review aims to overview the range of ethical issues referring to end-of-life decisions in DOC patients, with regard to the thorny debate on the sacredness and dignity of human life. (shrink)

Critics sometimes claim that Catholic moral principles unreasonably oblige patients to adopt life-preserving medical treatments “at all costs,” even when the treatments are excessively burdensome or futile and when their adoption may badly disadvantage patients’ family members or caregivers. The author argues that this is a mischaracterization. Because of obligations arising from our relationships, not only is it sometimes licit to refuse lifesustaining medical care, but we sometimes have a duty to refuse it. This is the case when (...) the treatments are morally extraordinary and when adopting them would unfairly disadvantage someone for whom we have responsibility. The author argues that this conclusion is not inconsistent with the duty we have to properly care for our own lives or with moral principles prohibiting self-killing. National Catholic Bioethics Quarterly 12.4 (Winter 2012): 621–630. (shrink)

Untreated depression at the end of life may affect treatment and raise ethical concerns. Patients with a major depressive disorder may desire a hastened death, may refuse reasonable and beneficial medical care, or may present with cognitive distortions that hinder their ability to make decisions about care. Treating depression can avert or minimize these problems in many cases. For a patient who does not respond to antidepressant medications and other interventions, however, the unrelieved depression could tip the balance and (...) make additional medical treatments burdensome. In such cases, a proposed medical treatment might be considered extraordinary. National Catholic Bioethics Quarterly 14.4 : 697–710. (shrink)

Regulation and clinical practices regarding end of human life care differ among the nations and countries. These differences reflect the history of the development of state health systems, different societal values, and different understandings of dignity and what it means to protect or respect dignity. The result is variation in the ethical, legal, and practical approaches to end-of-life issues. The article analyzes the diversity of strategies to strengthen dignity at the end of life of terminally ill patients (...) and to highlight the legal preconditions and limitations for implementing these strategies in independent Lithuania, as a former state of the Soviet Union. It is based on the critical analysis of philosophical literature, legal national and international documents and scientific evidence related to the issue. The author argues that the legal system in Lithuania is not sufficient to ensure the patient’s dignity at the end of life and remains far behind other Western European countries. Legal regulations in Lithuania do not guarantee the right of the patient to express his or her will regarding the future treatment, including the refusal of resuscitation, do not regulate the termination of burdensome, non-viable and meaningless treatment that is undesired by the patient, and limit the accessibility of palliative care with its necessary quality and comfort. (shrink)

“Playing God” is the charge frequently leveled when physicians and patients agree to withdraw life-sustaining medical treatments and let the patient die. The accusation rings hollow in the context of four hundred years of moral reflection on the duty of an individual to undergo medical treatments to preserve life. From the teachings of Soto and Banez in the 16th century through the President's, Commission 1983 report ‘deciding to forego life-sustaining treatments’ there is a clear and constant teaching (...) that though life is sacred it is not an absolute and our moral duty to preserve it is limited and based on rational reflection. No patient need undergo any treatment or procedure that is “disproportionately” costly, burdensome, or painful. The assessment of whether to accept or reject a proposed treatment is in part subjective and belongs to the individual patient. The only remaining issue is how to make that judgment for those unable to speak for themselves. (shrink)

Life-support technology may become a death-prolonging horror, and some people may fear that an over-intellectualized interpretation of traditional moral teaching has led us astray from what a compassionate God wills for the dying. The author addresses this fear. Those who defend “orthodox” teaching on end-of-life issues have a serious obligation not to obscure the compassion implicit in the traditional distinction between ordinary and extraordinary means. There is no medical or moral obligation to prolong dying or make it more (...) burdensome with interventions that offer little benefit, and there is nothing immoral about pain relief. What is prohibited is killing: any action or omission that has the express or implicit purpose of ending a life. National Catholic Bioethics Quarterly 10.4 (Winter 2010): 695–705. (shrink)

Does the level of marketing activity in a country contribute to societal well-being or quality of life? Does economic efficiency also play a positive role in societal well-being? Does economic efficiency also moderate or mediate the marketing activity effect on societal well-being? Marketing activity refers to the pervasiveness of promotion expenditures and number of retail outlets per capita in a country. Economic efficiency refers to the extent to which the economy is unhampered by corruption, burdensome government regulation, and (...) a large informal economy. We used secondary data from the World Bank and other statistical sources to answer these questions. Our study findings suggest that both marketing activity and economic efficiency contribute positively to societal well-being, and that economic efficiency plays more of a mediator than moderator role between marketing activity and societal well-being. The public policy implication of this study is that increases in marketing activity and economic efficiency in countries characterized as low on both dimensions should significantly increase the quality of life in those countries. (shrink)

Human rights debates neglect social rights. This paper defends one fundamentally important, but largely unacknowledged social human right. The right is both a condition for and a constitutive part of a minimally decent human life. Indeed, protection of this right is necessary to secure many less controversial human rights. The right in question is the human right against social deprivation. In this context, ‘social deprivation’ refers not to poverty, but to genuine, interpersonal, social deprivation as a persisting lack of (...) minimally adequate opportunities for decent human contact and social inclusion. Such deprivation is endured not only in arenas of institutional segregation by prisoners and patients held in long-term solitary confinement and quarantine, but also by persons who suffer less organised forms of persistent social deprivation. The human right against social deprivation can be fleshed out both as a civil and political right and as a socio-economic right. The defence for it faces objections familiar to human rights theory such as undue burdensomeness, unclaimability, and infeasibility, as well as some less familiar objections such as illiberality, intolerability, and ideals of the family. All of these objections can be answered. (shrink)

Mill's conception of economic freedom extends his broader view of freedom to economic institutions in ways that have previously been overlooked. In his view, economic freedom involves not merely the absence of burdensome constraints on economic activities, but also the power of individuals to direct the course of their lives with respect to their economic activities and relationships. It encompasses opportunities and resources for individuals, acting independently of others, effectively to pursue their own life plans as well as (...) participation by associated individuals in governing economic enterprises. Accordingly, he is critical of the ‘restraints’ that existing capitalism imposes on the economic freedom of individuals and he favours significant reforms of existing capitalism to achieve greater economic freedom. This understanding of Mill's conception of economic freedom sheds new light on his place in the liberal tradition and on an important point of contact between the liberal and socialist traditions. (shrink)

Religion is an important element of end-of-life care on the paediatric intensive care unit with religious belief providing support for many families and for some staff. However, religious claims used by families to challenge cessation of aggressive therapies considered futile and burdensome by a wide range of medical and lay people can cause considerable problems and be very difficult to resolve. While it is vital to support families in such difficult times, we are increasingly concerned that deeply held (...) belief in religion can lead to children being potentially subjected to burdensome care in expectation of ‘miraculous’ intervention. We reviewed cases involving end-of-life decisions over a 3-year period. In 186 of 203 cases in which withdrawal or limitation of invasive therapy was recommended, agreement was achieved. However, in the 17 remaining cases extended discussions with medical teams and local support mechanisms did not lead to resolution. Of these cases, 11 (65%) involved explicit religious claims that intensive care should not be stopped due to expectation of divine intervention and complete cure together with conviction that overly pessimistic medical predictions were wrong. The distribution of the religions included Protestant, Muslim, Jewish and Roman Catholic groups. Five of the 11 cases were resolved after meeting religious community leaders; one child had intensive care withdrawn following a High Court order, and in the remaining five, all Christian, no resolution was possible due to expressed expectations that a ‘miracle’ would happen. (shrink)

Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient. We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying (...) patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care. Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients’ lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval. Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed. All data relevant to the study are included in the article. (shrink)

BackgroundThe terminal illness of late-stage Alzheimer’s and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die—which many advance directives cannot provide. Proxies/agents’ substituted judgment may not be concordant with patients’ requests. While advance directives can be patients’ last (...) resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive’s requests to cease assisted feeding.AimThis article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters’ selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are implemented. The article includes excerpts from “dementia-specific” directives or supplements that exemplify each flaw—mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests “Cease assisted feeding” but the incapacitated patient apparently expresses the desire to “Continue assisted feeding.” Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities’ additional clinical criteria as a prerequisite to honor the requests in patients directives.ConclusionThis critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients’ wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care? (shrink)

Alzheimer's disease is the most common neurodegenerative disorder in today's developed world that is also increasingly picked out as a focal theme in fictional literature. In dealing with the subjectivity of human experience, such literature enhances the reader's empathy and is able to teach about moral, emotional and philosophical issues, offering the chance to see situations from a position otherwise possibly never taken by the reader. The understanding and insight so gained may well be unscientific, but the literary approach offers (...) an insight into the whole person's perspective and the particularity and uniqueness of a situation that includes ethical conflicts. A key motif of fictional literature centred around dementia remains the burden the adult-child carer is confronted with, considering the parent's remorseless decline and personality change, the sudden demand for devoted and continuous care, and the constantly changing relationship with the declining parent. In the context of an ever increasing demand for a constructive public discussion regarding end-of-life treatment of demented patients, Christine Devars (Le Piano Désaccordé) and Andrés Barba (Ahora Tocad Música de Baile) illustrate how powerful and burdensome the impact of Alzheimer's disease is on both patient and carer and what extremes may be reached under such truly exceptional circumstances. (shrink)

Background: The parent of a child with profound cognitive disability will have complex decisions to consider throughout the life of their child. An especially complex decision is whether to place a tracheotomy to support the child’s airway. The decision may involve the parent wanting a tracheotomy and the clinician advising against this intervention or the clinician recommending a tracheotomy while the parent is opposed to the intervention. This conflict over what is best for the child may lead to a (...) bioethics consult. Objective: The study explores the conflicts that may arise around tracheotomy placements. Research design: This study is a retrospective cohort study of pediatric patients for whom a tracheotomy decision required a bioethics consult. Participants and research context: Pediatric patients aged birth to 18 years old with a bioethics consult for a tracheotomy decision conflict between April 2010 and December 2016. A standardized data collection tool was used to review notes entered by the palliative care team, social workers, primary clinical team interim summaries, and the bioethics consult service. Ethical considerations: The study was reviewed and approved by the medical center’s institutional review board. Results: There were 248 clinical bioethics consults during the identified study period. There were 31 consults involving 21 children where the word tracheotomy was mentioned in the consult, and 13 of the 21 consults were for children with profound cognitive disability. Discussion and conclusion: Clinicians need to be aware of their own biases when discussing a child’s prognosis and treatment options while also understanding the parents’ values and what the parent might consider to be burdensome in the care of their child and the acceptable burden for the child to experience. (shrink)

In 2011 the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration from a woman, M, who had been in a minimally conscious state for 8 years. It was reported as the first English legal case concerning withdrawal of artificial nutrition and hydration from a patient in a minimally conscious state who was otherwise stable. In the absence of a valid and applicable advance decision refusing treatment, of other life-limiting pathology or excessively (...) burdensome suffering, the judgement makes it clear that the obligation on health professionals falls strongly in favour of preserving life. Although the Court sought to limit the judgement as closely as possible to the facts of the case, it is likely to have a significant impact on life-sustaining treatment decisions for people in states of low awareness. This paper outlines the main legal features of the judgement. (shrink)

I defend economic and social rights as human rights, and as a feasible approach to addressing world poverty. I propose a modest conception of economic and social rights that includes rights to subsistence, basic health care and basic education. The second part of the paper defends these three rights. I begin by sketching a pluralistic justificatory framework that starts with abstract norms pertaining to life, leading a life, avoiding severely cruel treatment, and avoiding severe unfairness. I argue that (...) economic and social rights are not excessively burdensome on their addressees and that they are feasible worldwide in the appropriate sense. Severe poverty violates economic and social rights, and accordingly generates high-priority duties of many parties to work towards its elimination. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

Climate change continues to have profound impacts on people’s health, lives and life prospects. For the most part, people who are at highest risk from the impacts of climate change have contributed very little to the problem. This is the crux of the injustice. After I discuss the risks and contributions associated with the injustice of climate change, I turn to the issue of responsiveness: of why and how people should respond to this injustice. I avoid discussions of legal (...) liability and focus more attention on the need to take political action to change social structures and habits. However, I realize how political engagement can prove to be ineffective, burdensome and dangerous. So in the last section, I say more about the reasons and changes that limit the effectiveness of political engagement. I suggest how we might change both the perception and practice of politics. At the end, I note two issues that I have not addressed in this limited article. (shrink)

The financial toxicity of biotherapeutic treatments is examined. Kymriah, a new gene therapy, has a list price of $475,000 per treatment; Yescarta, from Kite Pharma, costs $373,000 per treatment. Such costs are a significant burden on patients, patients’ families, payers, health care systems, and communities. Studies have shown that financial toxicity—the effect of excessive treatment cost—diminishes patients’ quality of life, compliance, and survival. Some pharmaceutical companies promote outcomes-based pricing and other strategies to offset financial toxicity, but these approaches have (...) not been shown to reduce burdens. Catholic teaching holds that the benefits of treatment should outweigh its burdens, and that burdensome treatments are not obligatory. The financial toxicity of treatments should be included in the ethical assessment of burdens on the patient. (shrink)

I defend economic and social rights as human rights, and as a feasible approach to addressing world poverty. I propose a modest conception of economic and social rights that includes rights to subsistence, basic health care and basic education. The second part of the paper defends these three rights. I begin by sketching a pluralistic justificatory framework that starts with abstract norms pertaining to life, leading a life, avoiding severely cruel treatment, and avoiding severe unfairness. I argue that (...) economic and social rights are not excessively burdensome on their addressees and that they are feasible worldwide in the appropriate sense. Severe poverty violates economic and social rights, and accordingly generates high-priority duties of many parties to work towards its elimination. (shrink)

Does a competent person suffering from a terminal illness or enduring an otherwise burdensome existence, who considers his life no longer of value but is incapable of ending it, have a right to be helped to die? Should someone for whom further medical treatment would be futile be allowed to die regardless of expressing a preference to be given all possible treatment? These are some of the questions that are asked and answered in this wide-ranging discussion of both (...) the morality of medically assisted death and the justifiability of making certain instances legal. A case is offered in support of the moral and legal permissibility of specified instances of medically assisted death, along with responses to the main objections that have been levelled against it. The philosophical argument is bolstered by empirical evidence from The Netherlands and Oregon where voluntary euthanasia and physician-assisted suicide are already legal. (shrink)

Aristotle’s ethical system was guided by his vision of human flourishing (also, but potentially misleadingly, translated as happiness). For Aristotle, human flourishing was a rich holistic concept about a life lived well until its ending. Both living a long life and dying well were integral to the Aristotelian ideal of human flourishing. Using Aristotle’s concept of human flourishing to inform the goals of medicine has the potential to provide guidance to clinical decision-makers regarding the provision of burdensome (...) treatments, such as intensive care treatment, where pursuing a chance of survival must be balanced against the risk of exposing patients to a negative dying experience. By conceptually uniting potentially competing goals of medicine, such as prolonging life and the promotion of peaceful deaths, Aristotle’s understanding of human flourishing creates an argument for the integration of palliative care considerations into intensive care decision-making and for advanced care planning with healthy patients. (shrink)

Our culture’s approach to dementia typically focuses on preserving the person as they once were. Mental exercises, special diets, and entire memory care facilities are designed to maintain the “previous person.” As important as this is to family and friends, it can be challenging and burdensome to the person who is living with dementia, a person who may not recall, or want to recall, their past life. This essay asserts that the emphasis on maintaining the previous person often (...) results from a belief in our innate permanence, particularly the belief in our immortal, immutable soul. Because of this insistence on innate immortality, we tend to undervalue those who fail to live up to the expectations of permanence. The author calls for a renewed emphasis on nepeš, ancient Israel’s concept of the mortal, fleeting human life. By acknowledging our impermanence, we may be able to better identify with and value those who live with dementia and design environments that honor and enable people who are becoming someone new. (shrink)

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life of (...) a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome. (shrink)

Gasping respiration in the dying patient is the last respiratory pattern prior to terminal apnoea. The duration of the gasping respiration phase varies; it may be as brief as one or two breaths to a prolonged period of gasping lasting minutes or even hours. Gasping respiration is very abnormal, easy to recognise and distinguish from other respiratory patterns and, in the dying patient who has elected to not be resuscitated, will always result in terminal apnoea.Gasping respiration is also referred to (...) as agonal respiration and the name is appropriate because the gasping breaths appear uncomfortable and raise concern that the patient is suffering and in agony. Enough uncertainty exists about the influence of gasping respiration on patient wellbeing, that it is appropriate to assume that the gasping breaths are burdensome to patients. Therefore, gasping respiration at the end of life should be treated.We propose that there is an ethical basis, in rare circumstances, for the use of neuromuscular blockade to suppress prolonged episodes of agonal respiration in the well-sedated patient in order to allow a peaceful and comfortable death. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Refusals of Treatment and Requests for DeathTom L. Beauchamp (bio)It would be hard to overestimate the importance of two decisions on physician-assisted suicide delivered recently by the Ninth and Second Circuit Courts (Compassion in Dying v. State of Washington, 79 F.3d 790 (9th Cir. 1996) (en banc), aff’g 850 F.Supp. 1454 (W.D. Wash. 1994), rev’g 49 F.3d 586 (9th Cir. 1995); Quill v. Vacco, 80 F.3d 716 (2nd Cir. (...) 1996). They are the highest courts yet to render an opinion on this subject, and their decisions have set the stage for the U.S. Supreme Court to take one of two paths: It will either say that (1) all citizens have a liberty interest in physician-assisted suicide, or that (2) each state may set its own policy on such matters. Whichever path is elected, a right to request physician-assisted suicide is a virtual certainty, at least in some states.These opinions are later segments of an evolving legal history in which courts have held that no criminal liability exists for withholding or withdrawing a life-sustaining treatment when physicians are directed to do so by a patient or an authorized surrogate (see Alan Meisel 1992). The decriminalization of suicide and the right to refuse a life-sustaining treatment now appear to be evolving into a rule that a patient has a legal right to control his or her death, or at least to obtain a lethal prescription. We are at a delicate point in this evolving history. Neither in law nor in bioethics is the justification of physician assistance in suicide the received opinion at the present time, but support for physician assistance in dying could soon become the received opinion in both disciplines.The leading edge of the wedge producing these changes has been widespread acceptance of an extensive right to refuse treatment. This right is today axiomatic in even conservative quarters of bioethics, but 20 years ago it was far from axiomatic that all patients have a right to refuse treatment. Few at that time judged that it would be both immoral and illegal for a physician not to forgo treatment in the face of a competent, authoritative refusal of any form of medical service or treatment.The justification for assistance in bringing about death in medicine is an extension of the justification for letting patients die. Letting a patient die by accepting a valid refusal to continue in life is directly analogous to helping a patient die by accepting a valid request for help. The high value we place on [End Page 371] rights of autonomy thereby spills over from the right to refuse to the underexplored right to request active assistance. 1 As the autonomy interest in this choice increases, denial of help to the patient becomes more burdensome.Those who defend the view that euthanasia and physician-assisted suicide are morally prohibited typically assume that assistance involves an act of killing, that acts of killing are impermissible, and that a defensible distinction exists between killing and letting die. However, this distinction has proved difficult to explicate, and the category of killing often seems distant from the problem at hand. For example, it is an eccentric view that a physician who prescribes a lethal medication to a patient thereby kills the patient (or, for that matter, lets the patient die) when the patient voluntarily ingests the medication and dies. So poor are the conceptual understandings of “killing” and “letting die” that conceptual confusion abounds as to which term to use in almost all morally difficult and controversial cases.A common view is that “letting die” is a matter of “ceasing useless treatments” after which patients die (Gaylin, Kass, Pellegrino, and Siegler 1988). This account is attractive, but too narrow. “Letting die” occurs in medicine under at least two circumstances: cessation of treatment because it is useless and cessation of treatment because it has been refused (which can occur even with useful treatments). Neither conceptually nor morally is “ceasing useless treatment” the proper way to state the condition under which many “letting-die” cases occur. It follows that the type of action—killing or letting... (shrink)

There is controversy in the Catholic medical ethics community surrounding assisted nutrition and hydration (ANH). Recently, the Ethical and Religious Directives for Catholic Health Care Services were amended to make ANH “obligatory.” The persistent vegetative state is cited specifically in the document, and the sentence following its mention states that ANH is “optional” when it cannot be expected to “prolong life” or when it would be “excessively burdensome.” For patients suffering from other medical conditions, such as dementia and (...) frailty, ANH may be excessively burdensome and may not prolong life. For these patients, ANH may be of no real benefit and may even have significant morbidity and mortality. Competent individuals with these conditions can ethically elect to forgo ANH. National Catholic Bioethics Quarterly 10.3 (Autumn 2010): 481–488. (shrink)

When it comes to how to hold people responsible for wrongdoing, much of the African philosophical tradition focuses on reconciliation as a final aim. This essay expounds an interpretation of reconciliation meant to have broad appeal, and then draws out its implications for responsibility in respect to three matters. First, when it comes to criminal justice, prizing reconciliation entails that offenders should be held responsible to “clean up their own mess,” i.e., to reform their characters and compensate victims in ways (...) they find burdensome, an approach to punishment that differs from deterrence and desert theories. Second, regarding civil justice, reconciliation means that holding responsible to compensate wrongful harm means improving victims’ quality of life in ways they accept, which contrasts with a common prescription to put victims in the condition they would have been in had the wrong not occurred. Third, reconciliation can involve putting on trial more than just the direct offender, for instance family members who had been able to influence his behavior and were allied with him. The chapter provides reason to take the reconciliatory approaches seriously that will be found prima facie attractive by those from a variety of backgrounds. (shrink)

The advent of COVID-19 has been the occasion for a renewed interest in the principles governing triage when the number of critically ill patients exceeds the healthcare infrastructure’s capacity in a given location. Some scholars advocate that it would be morally acceptable in a crisis to withdraw resources like life support and ICU beds from one patient in favor of another, if, in the judgment of medical personnel, the other patient has a significantly better prognosis. The paper examines the (...) arguments for and against this approach from the point of view of natural law theory, especially using the principle of double effect. We conclude that it is inadmissible to withdraw life-saving medical interventions from patients who are still benefiting from them, on the sole grounds that other patients might benefit more. Those who are currently using such technology should only interrupt their treatment if, in the judgment of medical personnel and, if possible, taking into account the wishes and needs of the patient and his family, the treatment is deemed futile, burdensome, or disproportionate. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Breaking the Readmission CycleBrian HattenI want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could (...) recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today.CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital.Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills.During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her.Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the... (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33. (shrink)

Through an analysis of policy texts, population statistics and a targeted sample from the popular press, this paper both furthers knowledge about changing meanings of working motherhood in the contemporary US, and proposes a refinement to existing conceptual work relating to how wage-work and care-work are combined. I focus analysis on recent US social policy which grants new rights and protections for women seeking to combine lactation and wage-work (the Patient Protection and Affordable Care Act of 2011). I critique this (...) policy through Bernise Hausman’s work on the politics of motherhood, arguing that it represents a form of work-life integration that is particularly burdensome for working mothers. I further argue that maternal practice as well as well as expectations of working motherhood in the contemporary US are being reshaped around the demands of neoliberalism, producing what I term ‘neoliberal motherhood’. I assert that this policy represents a way of combining wage-work and care-work that is not captured within existing feminist theory, and suggest that a re-working of theory in this area is needed in order to address cases in which embodied care-work is enfolded within the time and space of wage-work. (shrink)

Recent interpretations of Michel Foucault's work have leaned heavily on a reading that can be traced back to the 'vital ist/mechanist' debate in the philosophy of science from earlier in this century. Friends (Gilles Deleuze) and enemies (Jürgen Habermas) both read Foucault as a kind of vitalist, championing repressed and unrealized life-forces against a burdensome facticity. This reading of Foucault, however, comes with a prohibitively high cost: the giving up of Foucault's most trenchant insights regarding the nature of (...) power. In fact, Foucault has a quite different relation to the history and philosophy of science than the one ascribed to him by critics. Key Words: Bergson • Canguilhem • Foucault • opposition • vitalism. (shrink)

Against the common understanding that the Ethics promotes a "radical anti-emotion program," I claim that Spinoza describes an immanent transformation of love from a form of madness to an expression of wisdom. Love as madness produces the affects that another tradition unites in the seven deadly sins, such as lust, gluttony, envy, greed, and pride. Spinoza, however, never condemns these affects as such. Within each affect one can find its "correct use" (E5p10schol), which enables us to love and to live (...) otherwise. As we come to understand our beloveds as determinate expressions both of nature's power and of our own ability to persevere in being, we find conditions for our liberation within these most burdensome of passions. More specifically, as we diminish our tendency to imagine what we love in terms of its finitude and susceptibility to loss, we are determined to love and to know both others and ourselves by the joyful passions. Ultimately, Spinoza's portrait of love suggests ways of life that generate the satisfaction of our possessive desire with the collective and inclusive love of, certainly, the eternal and immutable thing, but also the eternal and immutable in things, in each other, and above all, in ourselves. In other words, Spinoza's economics of love and possession point up the desire to appropriate our own power in and of community, and in of nature. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Managing the Transition from Patient-Centered Care to ProtocolDavid SlakterI learned that I would need a kidney transplant in the summer of 2015. This was not a complete surprise to me, as I had been subjected to a number of tests and invasive procedures to investigate nephritis since I was a child. I had heard similar stories of clinicians performing repeated tests on my father for similar reasons without any (...) conclusions. Following my recommendation for transplant and consultation with genomics specialists, the cause of my kidney failure was determined to be Alport syndrome. What made Alport syndrome so difficult to diagnose in my case was that the associated mutation is a rare, autosomal-dominant one that has only recently been associated with the condition.After reviewing the data on survival rates for transitioning to dialysis versus a transplant, my family and I then considered the success rates for living versus cadaver donors, and the success rates at various transplant centers. The current data favor the long-term outcomes of transplant over dialysis and living over cadaver donors. Since we had decided to focus on searching for a live donor, my nephrologist recommended contacting Renewal, an organization that specializes in connecting those in need of a kidney transplant with live donors and providing support for donors to make the donation process less burdensome.On Renewal’s recommendation, my family and friends reached out across their social networks to search for potential donors. Many of those tested for compatibility were eliminated on basic matching criteria, others due to previously undiagnosed medical problems. Finally, the wife of a childhood friend came forward as an eligible donor and was also an incredibly close match on the antigens tested for kidney transplants.Having a living donor who was also a friend made the transplant experience somewhat less intimidating than it might have been. It meant the transformation of an existing relationship with someone already close to me, with fewer open questions about what may have motivated them to be so generous than if the donor had been someone I did not know. It also meant our families could be together in the waiting room, and that we shared in each other’s recoveries.Life post-transplant has been a significant improvement from what it was like immediately beforehand. Before my transplant, I regularly weighed food and consulted nutrition charts to gauge how much potassium I was consuming. To prevent too much potassium from building up in my bloodstream, I had to take sodium polystyrene [End Page 111] regularly. As one might guess from the name, it tastes much like burnt Styrofoam, and I could only ingest it with copious amounts of fruit-flavored syrup (strawberry covered up the awful flavor the best). There are other potassium binders on the market now, so fewer people with kidney failure will likely need to engage in such gustatory experimentation.I was also able to engage in more activities than what was possible even years before my transplant. I had long experienced difficulty with aerobic exercises, but assumed the reason was merely being out of shape. Though I have always walked regularly, even the one-mile walk from my office to my apartment had become a chore by the end. Within a few months after my transplant, I was riding a bicycle all over NYC, from Harlem to Brooklyn and back regularly, and hiking trails in nearby state parks. I began sessions with a personal trainer and attained a level of fitness I had not reached since I played soccer as a child.The transition from personalized care to one more driven by protocol has been a surprising and challenging aspect of the transplant process. While my previous experience with medical treatment has been individual meetings with physicians, my post-transplant care is managed by a team of nephrologists and other specialists in transplant care. My initial transplant nephrologist was automatically assigned to me. Because the standard of care for transplant patients is often driven by protocol, my assigned nephrologist recommended a biopsy on my transplanted kidney due to results in my recent lab tests. When pressed on the necessity of a biopsy in my case versus... (shrink)

The majority of workplace incivility research has focused on implications of such acts for victims and observers. We extend this work in meaningful ways by proposing that, due to its norm-violating nature, incivility may have important implications for perpetrators as well. Integrating social norms theory and research on guilt with the behavioral concordance model, we take an actor-centric approach to argue that enacted incivility will lead to feelings of guilt, particularly for prosocially-motivated employees. In addition, given the interpersonally burdensome (...) _as well as_ the reparative nature of guilt, we submit that incivility-induced guilt will be associated with complex behavioral outcomes for the actor across both home and work domains. Through an experience sampling study (Study 1) and two experiments (Studies 2a and 2b), we found that enacting incivility led to increased feelings of guilt, especially for those higher in prosocial motivation (Studies 1 and 2a). In addition, supporting our expectations, Study 1 revealed that enacted incivility—via guilt—led to increased venting to one’s spouse that evening at home, increased performance the next day at work, as well as decreased enacted incivility the next day at work. Our findings demonstrate that enacted incivility has complex effects for actors that span the home and work domains. We discuss the theoretical and practical implications of our results. (shrink)

The Liverpool Care Pathway is intended as a palliative care regime at the end of life. Even its critics agree that certain of its recommendations may be useful and appropriate. Additionally, critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. There is no suggestion that critics of the Pathway (...) adhere irrationally to what is known in medical ethics as the error of vitalism, the commitment to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. However, to ask whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago. The independent inquiry ordered in response to Freedom of Information Act requests performed in 2012 demonstrating a staggering increase in the number of people dying on the Pathway once it was financially incentivised needs to ensure certain investigations take place. What is needed, however, is not a whitewash but an independent inquiry with all interests declared and data sets interrogated and collated. These will cover a time-series medical history of each anonymised patient on the Pathway, duration until death, information about interventions provided during the period, monthly raw data from each trust, hospice or care home, medical histories, removals from the Pathway, information about journals that were corrected once a patient recovered, demographic data, location information and an audit trail of all data management. (shrink)

In this article we consider some of the implications of the UK Human Rights Act 1998 for nurses in practice. The Act has implications for all aspects of social life in Britain, particularly for health care. We provide an introduction to the discourse of rights in health care and discuss some aspects of four articles from the Act. The reciprocal relationship between rights and obligations prompted us to consider also the relationship between guidelines in the United Kingdom Central Council’s (...) Code of professional conduct and the requirements of the Human Rights Act 1998. We conclude with the recommendation that the new legislation should be welcomed for its potential to support good practice and to urge critical and reflective practice rather than as yet another burdensome bureaucratic imposition. (shrink)

Background Sickle cell anemia is a major genetic disease with the greatest burden in sub-Saharan Africa. To try to help reduce this burden, some churches in Nigeria conduct premarital sickle cell hemoglobin screening and refuse to conduct weddings when both individuals are identified as carriers of sickle cell trait. Main body This paper explores the ethical challenges involved in such denials. We assess whether churches have the right to decline to marry adults who understand the risks and still prefer to (...) get married, and whether couples should be denied church weddings based on the risk that their child may suffer from sickle cell anemia. We examine the moral and ethical dimensions of such denials and explore the underlying socio-cultural context involving the purpose of marriage and the meaning of the wedding ceremony in societies where premarital screening is one of the few tools available to reduce the risk of having children with SCA. The potential role of the church is also examined against the background of church beliefs, the duty of the church to its members and its role in reducing the suffering of its members and /or their children. Conclusion We argue that the church should impose these burdens on couples only if doing so promotes a sufficiently compelling goal and there is no less burdensome way to achieve it. We then argue that the goal of reducing the number of individuals in Nigeria who have SCA is compelling. However, testing earlier in life offers a less burdensome and potentially even more effective means of achieving this goal. This suggests that, advocating for earlier screening and helping to support these programs, would likely better promote the church’s own goals of helping its parishioners, increasing the number of church weddings, and reducing the burden of SCA in Nigeria. (shrink)

Sickle cell anemia is a major genetic disease with the greatest burden in sub-Saharan Africa. To try to help reduce this burden, some churches in Nigeria conduct premarital sickle cell hemoglobin screening and refuse to conduct weddings when both individuals are identified as carriers of sickle cell trait. This paper explores the ethical challenges involved in such denials. We assess whether churches have the right to decline to marry adults who understand the risks and still prefer to get married, and (...) whether couples should be denied church weddings based on the risk that their child may suffer from sickle cell anemia. We examine the moral and ethical dimensions of such denials and explore the underlying socio-cultural context involving the purpose of marriage and the meaning of the wedding ceremony in societies where premarital screening is one of the few tools available to reduce the risk of having children with SCA. The potential role of the church is also examined against the background of church beliefs, the duty of the church to its members and its role in reducing the suffering of its members and /or their children. We argue that the church should impose these burdens on couples only if doing so promotes a sufficiently compelling goal and there is no less burdensome way to achieve it. We then argue that the goal of reducing the number of individuals in Nigeria who have SCA is compelling. However, testing earlier in life offers a less burdensome and potentially even more effective means of achieving this goal. This suggests that, advocating for earlier screening and helping to support these programs, would likely better promote the church’s own goals of helping its parishioners, increasing the number of church weddings, and reducing the burden of SCA in Nigeria. (shrink)

In this article we consider some of the implications of the UK Human Rights Act 1998 for nurses in practice. The Act has implications for all aspects of social life in Britain, particularly for health care. We provide an introduction to the discourse of rights in health care and discuss some aspects of four articles from the Act. The reciprocal relationship between rights and obligations prompted us to consider also the relationship between guidelines in the United Kingdom Central Council’s (...) Code of professional conduct and the requirements of the Human Rights Act 1998. We conclude with the recommendation that the new legislation should be welcomed for its potential to support good practice and to urge critical and reflective practice rather than as yet another burdensome bureaucratic imposition. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:498 BOOK REVIEWS generations of theologians across denominational lines. Both Placher and Hunsinger at the end of their essays choose quotations from within Frei's own writings to give a synoptic portrait of the man and his work. Placher chooses a remark about Niebuhr's sense of vocation as a theologian (20), and Hunsinger one about knowledge of that seemingly elusive reality, a person's identity (257). However one might come away (...) from this challenging collection of essays, further confused or more enlightened, more in agreement or disagreement, I think every reader will recognize the coincidence of intellectual perspicuity and generosity with passionate faith. Regis College, Toronto School of Theology Toronto, Ontario, Canada GEORGE P. SCHNER, S.J. Reasoned Faith. Edited by ELEONORE STUMP. Ithaca, N.Y.: Cornell University Press, 1993. Pp. x + 364. As the editor remarks in her "Introduction," it is not so long ago that the analytical philosophy of religion consisted very largely of discussions of the meaningfulness of religious language, and of arguments about the existence of God. Nowadays it is more adventurous, ranging over such topics as creation, providence, and God's responsibility for sin. According to Robert Merrihew Adams, the statement "truth is subjectivity," though one of the most famous, is also one of the most misunderstood in Kierkegaard's writings. He argues that, taken in context within the Concluding Unscientifu: Postscript, the statement is by no means incompatible with the objective truth of religious belief. From the point of view of the Postscript, a member of an idolatrous community who prays to her God with "the entire passion of the infinite" has more of the truth than one who prays in a false spirit from within Christendom; but this implies that the latter does have some truth. Whatever the deficiencies in her faith, she is clearly admitted to be in possession of the true concept of God objectively speaking (223 ). Adams maintains, quite rightly in the reviewer's opinion, that the Postscript is excessively pessimistic about the integration of the ideals of subjectivity and objectivity, of passionate commitment on the one side and rational assessment of evidence on the other, in religious faith (21). A useful distinction is made by Scott MacDonald between "occurrent" and "dispositional" belief; this seems to resolve some of the more puzzling paradoxes about the relation of the more cognitive and propositional side of faith to other aspects which may be thought essential to it. The demons alluded to by St. James (2:19) might believe dispositionally that their highest fulfillment BOOK REVIEWS 499 was to be found in obeying the divine will, and so performing acts of charity and service to other creatures. But to avoid the inconvenience of acting in such a way, they could think of God occurrently as just a powerful being who makes burdensome demands (55). For MacDonald, the cognitive component of faith has only two elements, belief that certain propositions are true, and belief that the kind of response of the will which is also essential to faith may be grounded on these (56). "We can make sense of Christian faith if we think of it simply as belief that Christianity is true plus an appropriate volitional response to that truth" (69). Against mainline Christian accounts like those of Augustine and Aquinas, he sees no good reason to suppose that one cannot have faith in propositions for which one has conclusive proof, but only in those for which one's justification is relatively weak. He provides interesting grounds for contradiction of a view which has been expounded by both Robert Adams and John Hick, that only such uncertainty can ground the trust which is essential to the relationship which human beings ought to have to God (59). "My ability to love and trust my wife, to commit myself without reservation to her well-being and to the goals and purposes we have chosen as definitive of our common life seem in no way dependent on my being uncertain about what she is like or what she will do" (60). On the question of how faith ought to be related to the demands of reason, Robert Audi remarks that, up to the middle 1970s... (shrink)

The prevailing orthodoxy for competency assessment is to test for the presence of certain abilities. This article argues that the presence of certain abilities is not enough when a patient refuses a life-sustaining/lifesaving measure that promises to work and does not present obviously onerous burdens. In such cases, we need to know whether the patient has rendered a competent refusal of such measures. Whereas the former refers us to test for certain abilities, the latter refers us to assess the (...) quality of one’s judgment. Although such a thesis has been entertained previously (for example, Freedman), I reformulate the argument by applying two well-accepted epistemological criteria for justified belief. I argue that a competent refusal of such measures requires that the judgment be based on reasons. This basing condition turns on (or kicks in) in what I refer to as high-stakes contexts—contexts in which the patient’s life will end by respecting the refusal, and, by not respecting it, the patient undergoes a lifesaving and minimally burdensome treatment. (shrink)

Genes dance. They dance with culture. Theydance with environment. Genes act on the world through the brain, mind and behavior. Historically, psychologists, therapists,educators and most lay people have understoodgenes in the context of Gregor Mendel'sexperiments, which were only partiallyexplained to us. While many studies show thatbrain structures and behaviors have quiterobust influences from inheritance, mostbehavior is not influenced in the classic waywe were taught in our introduction to genetics– which has been revolutionized by molecularstudies and understandings that most of theimportant (...) genes of everyday life arequantitative, or polygenic.Popular culture and naïve theory has a verysimplistic view of genes. They are bad,impolite and vaguely anti-democratic if notsinister. A very simple truth exists, however.Were it not for the genes of our grandparents,no one would be reading this article.This article introduces the reader to an ideathat emerges from evolutionary psychology andbehavior genetics, which may turn our thinkinginside out. For the most part, genes are giftsof nature to solve problems, and to hedge a beton the future. Most true genetic diseases,regulated by the classic processes that Mendelobserved, are extremely rare – typically belowone in several hundred. Most of the behaviorsthat cause us grief or joy in our homes,schools and communities and with some form ofgenetic contribution happen far more often –3%, 5%, 10% or more of the time in thepopulation. If such behaviors were ``defects''harming our reproductive success, Mother Naturewould have quickly made short work of thosegenes in a handful of generations. The factthat many of the genes related to thesebehaviors and subtle changes in the brain seemto have been recent changes (pejorativelycalled by some ``mutations'') in the past fewthousand years implies that these changes are insome sense Nature's Gifts.Gifts are to be treasured, saved and perhapspassed on. Sometimes a gift may be burdensome. This paper is about reframing and explainingadvances in science in the past 10 years or so,parallel to the brain imaging studies. Themolecular studies, explored in the context ofevolutionary psychology and behavioral geneticsprovide a new model for human development,enhancing our understanding of more traditionalviews of human phylogeny and ontogeny. Thesame molecular studies, when framed in thecontext of twin, adoption and longitudinalstudies, provide new insights for parenting,schools, community and therapy. (shrink)

This chapter contains sections titled: The Vance Conception of Economic and Social Rights Justifying Economic and Social Rights Implementing Economic and Social Rights The Widespread Acceptance of Economic and Social Rights Note References.