In Britain before 1911, the vast majority of the population provided medical care for themselves and had evolved a variety of schemes that checked the power of organized medicine and encouraged a steady improvement in standards. The evidence is that at the end of the nineteenth century about 5–6 percent of the population relied on the poor law, 10–15 percent on free care from charitable institutions, 75 percent on mutual aid, and the remainder paid fees to private (...) doctors. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more modest and (...) limited topic of medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

Challenges in Medical Care Edited by Andrew Grubb School of Law and Centre of Medical Law and Ethics, King’s College, London, UK The sixth volume in the series of King’s College Studies takes a reflective view of medical law and ethics, the health care system and challenges raised by modern technology. A distinguished team of authors returns to problems and controversies that have long challenged medical law and ethics, and shows how new issues are (...) constantly arising as a result of developments in medical care. Topics such as the legal status of the frozen human embryo, medical accountability and the future of the National Health Service are discussed. The need for responsibility, accountability and respect for individual human rights forms a strong linking theme throughout the book. This thought-provoking collection constitutes a useful and informative reference source which will be of value to a wide range of professionals and students including doctors, nurses, lawyers, philosophers and medical sociologists. (shrink)

The aging of the population presents modern Western society with a variety of different challenges, especially in the areas of health and medicine. On the one hand, there is the demand of the elderly patients to receive medical treatments that are supposed to improve or preserve the existing quality of life and to prevent the extension of a life without quality, with suffering and pain. On the other hand, aging is accompanied by the appearance and exacerbation of chronic illnesses, (...) reduces the treatment benefits of medical activities and increases the risks of irreversible physical dependence. Furthermore, the lack of consensus among the physicians regarding the willingness of treatment and the proper timing of the treatment of the elderly – pose questions about the quality of the treatment for the elderly. Thus, in the opinion of different care-providers and in comparison to other age groups in modern Western society, the elderly do not enjoy the treatment advantages of medical activities proven in the treatment of other age groups in society. (shrink)

The aim of this discussion is practical; otherwise it largely repeats some very general observations, chiefly historical and philosophical. I boast no expertise in anything specifically medical, to do with either medical care or medical administration. My concern is with the system of medicine and with the ethical and social issues that it involves. Applied philosophy is a still uncharted territory. Philosophers traditionally focus more on justifying accepted solutions than on seeking new solutions to urgent or (...) interesting problems: their staple problems are those of justification. Thus, they spend less time discussing scientific problems and difficulties, and more time discussing the justification of the claims that we know. They habitually choose the simplest and most unproblematic claims for knowledge, and then try to substantiate them... (shrink)

The articles in this issue explore a number of difficult choices in medical care and research. They investigate ethical complexity in a range of decisions faced by policymakers and clinicians, and offer new evidence or normative approaches for navigating this complexity. In this issue’s feature article, Ford and colleagues engage with an ethical challenge faced by policymakers in relation to health research: should free text data contained in medical records be shared for research purposes?1 While some types (...) of data from electronic medical records are used widely in health research, privacy concerns have limited the use of free text data specifically. Ford and colleagues highlight the richness of the clinical information in free text and its centrality to some areas of healthcare such as mental health and primary care. In their view, while text analytic technology is developing rapidly, ‘policy makers routinely judge that the risk of re-identifying patients from text data is too high for these data uses’. Their citizens’ jury study in the UK found that participants were largely in favour of medical free text data being shared outside the NHS for research using an opt-out model: ‘the majority of jurors believed the benefits of sharing data for research outweighed the privacy risks’. In their commentary on this research, Largent and Morain raise some important issues about policymakers’ use of empirical findings …. (shrink)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical (...) judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated. (shrink)

Prominent among the principles put forward by Professor Bernard Williams in ‘The Idea of Equality’ were that for every difference in the way men are treated a relevant reason should be given and the proper ground of the distribution of medical care is ill health. Prominent among his conclusions was that we are confronted with an irrational state of affairs where wealth functions as a necessary condition for receiving medical care. In ‘The Idea of Equality Reconsidered’ (...) Philosophy 85–90), I argued that, on his principles alone, this conclusion though correct was one-sided. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

In clinical research there is a tension between the role of a doctor, who must serve the best interests of the patient, and the role of the researcher, who must produce knowledge that may not have any immediate benefits for the research participant. This tension is exacerbated in HIV research in low and middle income countries, which frequently uncovers comorbidities other than the condition under study. Some bioethicists argue that as the goals of medicine and those of research are distinct, (...) it is a mistake for researchers to assume therapeutic responsibilities while engaging in research. Others propose that there is a duty of care, but disagree as to how this is limited and specified. In this qualitative study, principal investigators from HIV prevention trials discuss their experience of providing medical benefits to participants within the context of conducting research into HIV biomedical prevention technologies. They describe the limitations imposed at times by funders and at times by infrastructure constraints, and canvass the importance of ancillary care provision and capacity building in trial communities. The views of the principal investigators are compatible with the perspective that there is a duty of care, limited by the nature of the research, the depth of the relationship between research and participant, and the capacity of the research site. The therapeutic orientation in HIV prevention trial appears to be indivisible from competent research practise by making concrete and appropriate benefits available to trial participants and their communities that support rather than compete with local infrastructure. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard (...) of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. (...) For example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and (...) not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

: According to Jewish law, there is a clear obligation to try to heal, and this duty devolves upon both the physician and the society. Jewish sources make it clear that health care is not only an individual and familial responsibility, but also a communal one. This social aspect of health care manifests itself in Jewish law in two ways: first, no community is complete until it has the personnel (and, one assumes, the facilities) to provide health (...) class='Hi'>care; second, the community must pay for the health care of those who cannot afford it as part of its provision for the poor. The community, in turn, must use its resources wisely, which is the moral basis within the Jewish tradition for some system of managed care. The community must balance its commitment to provide health care with the provision of other services. (shrink)

America is aging. But even more striking than the rise in the proportion of the population over age 65 is the unprecedented number of individuals who are living into their eighties and nineties. While many people remain robust well into advanced age, the dramatic increase in the number of the oldest old has brought with it an epidemic of Alzheimer’s disease and other dementias. Dementia is a highly prevalent condition — currently 5.4 million Americans have Alzheimer’s disease, a number which (...) may rise to 16 million by 2050 if there is no breakthrough in the prevention or treatment of the disease — but it disproportionately affects those over age 85, striking between one-third and one-half of this cohort. Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. (shrink)

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act illustrate the weakening of those ideas and the institutional practices embodying them.The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted (...) in 1965, associations of American physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

The possible contribution that the figure of the veterinarian provides to a progressive clarification of the knowledge inherent in the animal subject can be highlighted by an epistemological reflection which throws into relief the distinctive modes of approach and the most suitable curative procedures. At the same time a comparison between such procedures and the methods developed by different contemporary philosophical-scientific sectors, including those of the human sciences, could prove instructive in reporting the junctions and obligatory crossings of common problems.

Walter and Ross rightfully argue that healthcare providers need to employ a less authoritarian, more empowering approach if they want to support patients’ behavioral changes. They show how motivational interviewing (MI), informed by self-determination theory, engages patients and thus may inspire enduring changes. They ground these interventions in an important, new model of relational autonomy, emphasizing the patient’s self-respect and self-cohesion as well as self-determination, and they show how patient–provider interactions influence these three aspects of autonomy. It may be surprising (...) then, that in the first part of this essay, I argue that it is problematic for them to ground their empowerment model in the .. (shrink)

The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A (...) rationing plan such as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed. (shrink)

Acid attacks on women are increasing at alarming rates in Bangladesh, but the government has failed to provide medical care to the victims. Easily available sulfuric acid, which can mutilate a human face in moments, has emerged as a weapon used to disfigure a woman’s body. By the mid-1990s, activists had documented acid attacks, and urban protests were followed by demands for better medical care. I show how the interaction between local and international-level civil society organizations (...) made international resources available to local feminist groups engaged in domestic social struggles and helped to improve medical care for acid victims of Bangladesh. (shrink)

The decisions that doctors make are formed in part through the ways in which medical care is organized. Given that the structure of a situation affects people's actions in the context of medical care, it is a matter of moral concern in any attempt to create cultures of safety in a medical environment.

Medical Officers serving with their national contingents in peacekeeping operations are faced with difficult ethical decisions in regard to their obligations to the local civilian population. Such populations may be under-resourced in regard to medical care, and vulnerable to abuse and exploitation. Though the medical officer may support the local medical services, he/she should never undermine these resources. Adopting a human rights approach and observing the requirements of ethical medicine, aids the doctor in prioritising his/her (...) duties. At times there may be conflict with one’s own military superiors. It is wise to discuss potential difficulties prior to setting out on the mission. Human rights abuses cannot be ignored. The medical officer has a duty to do his/her best to report their observations so as to prevent abuse or to bring it to an end. (shrink)