There are in two assumptions inherent in this issue's theme, both inimical to the traditional goals of medicine and to the standards of care it proposed. First, the idea that treatment must be limited for some (but not others) on the basis of cost was born in the early literature of bioethics. Second, that there is a quantifiable and diagnostically predictable period at the “end-of-life” where treatment is “futile,” and therefore not worth supporting in a context of scarcity grew out (...) of bioethics's construction of allocative protocols in the 1990s. This paper traces the history of these ideas as constructs grounded in neither natural scarcity nor in firm diagnostic categories. Their relation to issues of care is therefore suspect. (shrink)

Early announcements of this special journal issue solicited authors interested in contributing articles on the subject of “costs at the end of life.” Those who replied were then informed the title was being changed, on the basis of early subscriber interest, in “rational end-of-life treatment.” Because that seemed a still inadequate reflection of the authorial concerns of responding potential contributors, the editors again changed the title, two months later, to “Making Treatments More Rational and Compassionate for the Chronically Critically Ill.” (...) At that point the editors gave up and decided this issue’s final title would be determined only after the papers were submitted and reviewed. (shrink)

In recent years geographic interest has focused increasingly on the moral and ethical dimensions of social constructions. Much of this work has followed the direction taken by moral philosophers whose principled approach has been applied to a range of ethically or morally problematic contexts. The challenge has been to apply a geographic perspective to an ethical dilemma that seems intractable at the level of ethical principle. This paper uses a geographic perspective to consider in a concrete fashion a current bioethical (...) concern: defining who will or will not be eligible for an organ transplant. Methodologically, it uses the analytic hierarchy process, a multicriterion decision making approach, and Q-analysis to analyze the resulting data. Long known by geographers, Q-analysis presents a methodology for the analysis of relations between two sets of criteria, in this case focus groups and their responses to a hierarchy of criteria. The result is a topology that not only presents but also explains the moral reasoning of members of a diverse set of focus groups constituted at a Canadian hospital to consider the question of organ transplant eligibility. (shrink)

In recent years geographic interest has focused increasingly on the moral and ethical dimensions of social constructions. Much of this work has followed the direction taken by moral philosophers whose principled approach has been applied to a range of ethically or morally problematic contexts. The challenge has been to apply a geographic perspective to an ethical dilemma that seems intractable at the level of ethical principle. This paper uses a geographic perspective to consider in a concrete fashion a current bioethical (...) concern: defining who will or will not be eligible for an organ transplant. Methodologically, it uses the analytic hierarchy process, a multicriterion decision making approach, and Q-analysis to analyze the resulting data. Long known by geographers, Q-analysis presents a methodology for the analysis of relations between two sets of criteria, in this case focus groups and their responses to a hierarchy of criteria. The result is a topology that not only presents but also explains the moral reasoning of members of a diverse set of focus groups constituted at a Canadian hospital to consider the question of organ transplant eligibility. (shrink)