Clinicians may increasingly find themselves practicing, by choice or necessity, in resource-poor or extreme environments. This often requires altering typical patterns of practice with a different set of medical and ethical considerations than are usually faced by clinicians practicing in hospitals in the United States and Europe. Practitioners may be required to alter their usual scope of practice or their standard ways of medically treating patients. Limited resources will also often place clinicians in the position of having to make decisions (...) about fairly allocating healthcare, which will alter the physician–patient relationship. This does not absolve physicians and other healthcare practitioners of providing the best quality of care that can be given under the circumstances. In addition, the lack of a well-developed healthcare infrastructure and limited resources will require working with established providers to determine the needs of the community, and what types of healthcare are feasible given these limitations. The essays in this issue of HEC Forum encourage readers to reflect on the unique ethical challenges faced in the extreme or austere environment. (shrink)

Wakefield’s harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction and a value component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder. They provide three examples of dysfunctions that, they claim, are considered disorders but are entirely harmless: mild mononucleosis, cowpox that prevents smallpox, and minor perceptual deficits. They also reject the proposal that dysfunctions (...) need only be typically harmful to qualify as disorders. We argue that the proposed counterexamples are, in fact, considered harmful; thus, they fail to disconfirm the harm requirement: incapacity for exertion is inherently harmful, whether or not exertion occurs, cowpox is directly harmful irrespective of indirect benefits, and colorblindness and anosmia are considered harmful by those who consider them disorders. We also defend the typicality qualifier as viably addressing some apparently harmless disorders and argue that a dysfunction’s harmfulness is best understood in dispositional terms. (shrink)

In The Foundations of Bioethics, former senior editor of The Journal of Medicine and Philosophy H. Tristram Engelhardt, Jr. radically reassessed the nature and scope of bioethics, as well as the possibilities for this still-young field that he helped found, in light of the prevailing sociohistorical context, which he argued had been inadequately considered by bioethicists. This issue of The Journal of Medicine and Philosophy provides a snapshot of how bioethics is developing in the wake of Engelhardt’s critique. Topics covered (...) include the relation between rule of law and US healthcare policy, the relation between autonomy and consent, the role of rights in bioethical discourse, the debate between naturalism and normativism in the theory of disease, and the question of when human individuals begin to exist. Although no single theme explicitly unites them, the papers in this issue were produced within and are fruitfully read in terms of what Engelhardt influentially characterized as a morally pluralistic postmodernity subsisting amidst the ruins of tradition. In the conclusion, I introduce a further wrinkle into this Engelhardtian picture—namely, the looming danger of a more general epistemological pluralism effected by new technologies like Deepfakes. (shrink)

This paper presents the interpersonal variability of harm challenge to Jerome Wakefield’s harmful-dysfunction account (HDA) of disorder. This challenge stems from the seeming fact that what promotes well-being or is harmful to someone varies much more across individuals than what is intuitively healthy or disordered. This makes it at least prima facie difficult to see how judgments about health and disorder could, as harm-requiring accounts of disorder like the HDA maintain, be based on, or closely linked to, judgments about well-being (...) and harm. This interpersonal variability of harm challenge is made salient by the difficulty faced by harm-requiring accounts of disorder in dealing satisfactorily with cases of intuitively disordered conditions that seem harmless because they do not deprive the individuals that they affect of anything that they value (e.g., desired infertility). I argue that this challenge is made more serious for the HDA by some clarifications Wakefield has recently made on harm. In recent publications, Wakefield dissociates himself from the sheer cultural-relativist view of harm attributed to him by some critics based on his linkage of harm to social values, and adopts a more qualified social-values-based view of harm that leaves room for criticism of the values endorsed by members of a cultural group at a given time. I show how Wakefield’s qualified view makes it more difficult for the HDA to deal with the interpersonal variability of harm challenge, at least when applied to a Western cultural context where a high value is placed on autonomy and individual choice. (shrink)

This paper criticizes Jerome Wakefield’s harmful dysfunction analysis of disorder by arguing that the conceptual linkage it establishes between the medical concepts of health and disorder and the prudential notions of well-being and harm makes the account inapplicable to nonsentient organisms, such as plants, fungi, and many invertebrate animals. Drawing on a previous formulation of this criticism by Christopher Boorse, and noting that Wakefield could avoid it if he adopted a partly biofunction-based account of interests like that often advocated in (...) the field of environmental ethics, I argue that integrating such an account of interests into the HDA would generate serious concerns. Specifically, it would make dysfunction sufficient for disorder and so reestablish between dysfunction and disorder precisely the kind of sufficiency relation that harm-requiring accounts of disorder strive to avoid; blur the line between the HDA’s dysfunction and harm components and, in so doing, deprive the HDA of its alleged main advantage over monistic dysfunction-based accounts of disorders like Boorse’s; and tie the HDA to an understanding of harm that is in itself problematic. I argue that these three concerns, and the dilemmas they generate, rob the HDA of much of its prima facie appeal, ultimately indicating that a satisfactory account of disorder should most likely eschew all references to prudential notions of well-being and harm. (shrink)