The U.S. 2010 Patient Protection and Affordable Care Act exempts members of health care sharing ministries from the individual mandate to have minimum essential insurance coverage. Little is generally known about these religious organizations and even less critical attention has been brought to bear on them and their ACA exemption. Both deserve close scrutiny due to the exemption’s less than clear legislative justification, their potential influence on the ACA’s policy and ethical success, and their salience (...) to current religious liberty debates surrounding the expansion of religious exemptions from ACA responsibilities for both individuals and corporations. Analyzing documents of the United States’ three largest health care sharing ministries and related material, I examine these organizations and their ACA exemption with particular consideration of their ethical dimensions. Here a thick description of the nature and workings of health care sharing ministries precedes a similar account of the ACA exemption. From these empirical analyses, five ethical and policy concerns emerge: the charity versus insurance status of these ministries; the conflation of two ACA religious exemptions; the tension between the values of religious liberty and of justice; the potential undermining of ACA policy goals; and the questionable compliance of health care sharing ministries with ACA exemption requirements. An accurate and informed understanding of HCSMs is required for policymakers and others to justify the ACA exemption of health care sharing ministry members. A sufficient justification would address at least the five ethical and policy concerns raised here. (shrink)

This essay attempts to describe contemporary Catholic sponsored health care in the United States and to describe the purpose and structure of these particular Christian charitable organizations within the broader society. As health care has become more complex, critics claim that there is not a need for Catholic sponsored health care any longer. The author attempts to evaluate critically whether Catholic health care has a place in contemporary society. He reviews some salient (...) biblical, ecclesial, and justice teachings of the Church to demonstrate why religious institutional presence is still needed. The author reviews contemporary health care structures to show how this is accomplished. He also uncovers additional issues which need to be addressed in order for these charitable institutions to carry on the ministry of the Church, to shape social structures, and to proclaim the reign of God. (shrink)

In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out and (...) discuss a number of queries which seem to arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

In the majority of academic institutions nursing and medical students receive a traditional education, the content of which tends to be specific to their future roles as health care professionals. In essence, each curriculum design is independent of each course. Over the last decade, however, interest has been accumulating in relation to interprofessional and multiprofessional learning at student level. With the view that learning together during their student training would not only encourage and strengthen future collaboration in practice (...) settings but also enhance patient care, the University of Dundee decided to run a pilot study to explore shared teaching in ethics between medical and nursing students. This article presents a report on the reasons for selecting health care ethics as a precursor for shared teaching, the educational tool used for the sessions, and the results of student and facilitator evaluation of the short course. Overall, despite problems such as poor attendance by some students, and facilitation and timetable difficulties, most of the feedback from students and facilitators has been positive. In essence the ‘idea’ has gone from strength to strength and there are now three levels of shared teaching in ethics between nursing and medical students, with plans to include further sessions with students from other disciplines. Within the text, ‘health care ethics’ will be referred to as ‘ethics’; nursing students/nurses encompasses midwifery students/midwives. (shrink)

In the majority of academic institutions nursing and medical students receive a traditional education, the content of which tends to be specific to their future roles as health care professionals. In essence, each curriculum design is independent of each course. Over the last decade, however, interest has been accumulating in relation to interprofessional and multiprofessional learning at student level. With the view that learning together during their student training would not only encourage and strengthen future collaboration in practice (...) settings but also enhance patient care, the University of Dundee decided to run a pilot study to explore shared teaching in ethics between medical and nursing students. This article presents a report on the reasons for selecting health care ethics as a precursor for shared teaching, the educational tool used for the sessions, and the results of student and facilitator evaluation of the short course. Overall, despite problems such as poor attendance by some students, and facilitation and timetable difficulties, most of the feedback from students and facilitators has been positive. In essence the ‘idea’ has gone from strength to strength and there are now three levels of shared teaching in ethics between nursing and medical students, with plans to include further sessions with students from other disciplines. Within the text, ‘health care ethics’ will be referred to as ‘ethics’; nursing students/nurses encompasses midwifery students/midwives. (shrink)

American health care is in the process of a significant social, institutional, and economic restructuring of the manner in which health services are provided in local communities. The Catholic health care ministry is undergoing the same sort of restructuring. The history of American health care demonstrates that the ministry has experienced at least two similar major restructurings of its institutional framework. The principle of cooperation has been the customary tool to assess the moral (...) propriety of evolving social structures in which the health care ministry has been housed. A process of discernment can lead to the conclusion that the central issue is not moral agency but rather how the ministry engages the secular culture of American society and American medicine. National Catholic Bioethics Quarterly 13.2 (Summer 2013): 263–274. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that (...) threaten to drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

In health care, the provision of pertinent information to patients is not just a moral imperative but also a legal obligation, often articulated through the lens of obtaining informed consent. Codes of medical ethics and many national laws mandate the disclosure of basic information about diagnosis, prognosis, and treatment alternatives. However, within publicly funded health care systems, other kinds of information might also be important to patients, such as insights into the health care priorities (...) that underlie treatment offers made. While conventional perspectives do not take this as an obligatory part of the information to be shared with patients, perhaps through viewing it as clinically “non-actionable,” we advocate for a paradigm shift. Our proposition diverges from the traditional emphasis on actionability. We contend that honoring patients as equal moral agents necessitates, among other principles, a commitment to honesty. Withholding specific categories of information pertinent to patients’ comprehension of their situation is inherently incompatible with this principle. In this article, we advocate for a recalibration of the burden of proof. Rather than requiring special justifications for adding to the standard set of information items, we suggest that physicians should be able to justify excluding relevant facts about the patient’s situation and the underlying considerations shaping health care professionals’ choices. This perspective prioritizes transparency and empowers patients with a comprehensive understanding, aligning with the ethos of respect for the patient as person. (shrink)

We intuitively think and talk about health care as a human right. Moreover, we tend to talk about health in the language of basic rights or human rights without a clear sense of what such rights mean, let alone whose duty it is to fulfill them. Additionally, in the care ethics literature, we tend to think of a dividing line between care and justice. In this dissertation I aim to draw care and justice together (...) in what I call care justice. To attend to care justice requires the reconceptualization of the value and practice of health care, and of the moral communities in which we enact care and justice. First, I argue for a strong right to health care, though not to health. Second, I argue that health care includes much more than mere medical care. On this account health care is special for the practices of care it values and communicates. Third, I establish a theoretical framework for why, and importantly how, health care entails other forms of care: social, economic and political. My approach engages a complicity framework to rethink moral community formation and participation, and the rights and responsibilities of individuals as participants in a collective moral community. I argue that it is within communities of membership, which I define as ethical homes, that we have duties to and expectations from others. The moral community as complicit ethical home provides a way to reimagine individual shared responsibility within moral communities, and particularly regarding responsibility for practices of care. (shrink)

The primary objective of The Health Care Ethics Con sultant is to focus attention on an immediate practical problem: the role and responsibilities, the education and training, and the certification and accreditation of health care ethics consultants. The principal questions addressed in this book include: Who should be considered health care ethics consultants? Whom should they advise? What should be their responsi bilities and what kind of training should they have? Should there be some (...) kind of accreditation or certification program to ensure that those who call themselves ethics consultants are in fact qualified to advise, consult, research, and write in health care ethics? The distinguished authors ofthese articles are persons with diverse backgrounds, interests, presumptions, and val ues. Not surprisingly, therefore, diverse responses have emerged to the questions posed. Though the book's chapters are individually authored, they are informed by the group discussions that went on during active workshop sessions, and by knowledge of the contributions of others. All of the chapters meaningfully represent their consensus. This is not to say that there were no disagreements regarding specific details, but rather that there were no fundamental objections on the book's basic content among a panel of authors who share basic premises regarding the role, responsibilities, education, and certifica tion of health care ethics consultants. (shrink)

This study investigates how social franchises extend health care in rural areas, thus addressing vast and persistent disparities in health care access. We conducted an inductive study of Unjani, a South African organization that extended primary health services to disadvantaged rural communities through a network of 135 health clinics. Our analysis focused on the process of impact intermediation—the propagation of impact across multiple layers of the franchise network, including franchisees and downstream beneficiaries. To facilitate (...) impact intermediation, the franchisor harmonized the mission of the franchisees with its own mission and integrated community impact among franchisees. Such coordination and monitoring activity exposed franchisees to intermediation problems in the form of mission conflict and impact divergence. Our analysis reveals how Unjani nurtured network stewardship that afforded the franchisee nurses with greater support, autonomy, and ownership, thus overcoming intermediation problems in their pursuit of shared communal responsibilities to extend health care to rural communities. (shrink)

How can Christian ethics make a significant contribution to health care ethics in today's Western, pluralistic society? Robin Gill examines the 'moral gaps' in secular accounts of health care ethics and the tensions within specifically theological accounts. He explores the healing stories in the Synoptic Gospels, identifying four core virtues present within them - compassion, care, faith and humility - that might bring greater depth to a purely secular interpretation of health care ethics. (...) Each of these virtues is examined in turn, using a range of topical issues including health care rationing, genetics, HIV/AIDS, withholding/withdrawing nutrition from PVS patients, and the empirical evidence which suggests a connection between religion and health. Professor Gill also argues that these four virtues are shared by other major religious and humanistic traditions and that, together with secular principles, they can enrich health care ethics even in a pluralistic society. (shrink)

Because of the development towards community care, care providers not only exchange information in a team, but increasingly also in networks. This is a challenge to confidentiality. The ethical question is how care providers can keep information about the care receiver confidential, whilst at the same time exchanging information about that care receiver in a team or network? Can shared confidentiality be extended from a team to a network? To clarify this question, the article refers (...) to the advice of an expert ethics committee in mental health care. The advice regards exchange of information in a network as a further step in enhancing collaboration among care providers. Therefore, the good and evident practice of shared confidentiality in a team can be extended to a network if the same conditions are met. First, the care providers participate in a clearly defined and identifiable team or network. Secondly, they have a shared care responsibility. Thirdly, they have a duty of confidentiality. Fourth, they dialogue with the care receiver and obtain his or her consent. Finally, they apply the filter of relevance. Hence, conditional shared confidentiality is an ethical justification for the exchange of information in a team or network. (shrink)

Book reviewed in this article: Seeking Fair Treatment: From the AIDS Epidemic to National Health Care Reform. By Norman Daniels.

Various kinds of consumer-driven reforms have been attempted over the last 20 years in an effort to rein in soaring costs of health care in the United States. Most are based on a theory of moral hazard, which holds that patients will over-utilize health care services unless they pay enough for them. Although this theory is a basic premise of conventional health insurance, it has been discredited by actual experience over the years. While ineffective in (...) containing costs, increased cost-sharing as a key element of consumer-driven health care leads to restricted access to care, underuse of necessary care, lower quality and worse outcomes of care. This paper summarizes the three major problems of U.S. health care urgently requiring reform and shows how cost-sharing fails to meet that goal. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Health Care Ethics: A Comprehensive Christian Resource by James R. ThobabenPaul D. SimmonsHealth Care Ethics: A Comprehensive Christian Resource by James R. Thobaben Downers Grove, IL: Intervarsity Press, 2009. 429pp. $28.00In recent years, a stir has been created by the vocal and aggressive involvement of evangelicals in such issues as abortion, homosexuality, and end-of-life decisions. James Thobaben, the dean of Asbury Seminary, provides what he (...) calls a [End Page 203] “comprehensive resource” for evangelicals, and promises better understandings of their perspectives and commitments for those who are baffled or frustrated by the actions and claims of those on the religious right.Thobaben casts a wide net when defining those he includes as “evangelicals”—Southern Baptists, members of Campus Crusade, Pentecostals, the Holiness movement, neoevangelicals, charismatics, and Anabaptists. These diverse groups are evangelicals because of their “consistency on moral choices,” doctrinal orientation, and styles of social advocacy (24). Although they differ in a number of ways, they all share having been influenced in some way by John and Charles Wesley, Jonathan Edwards, and the Reformation. All stress conversion in that “one must say yes to the divine Jesus Christ” and become identified with the community of faithful believers (57). And in recent decades, they have become a potent political force with regard to the issues of abortion and homosexuality.Thobaben covers a wide range of topics in this book: from a general discussion of theodicy and healing to bioethics, disability, sickness, family and congregational care, professional truthfulness, managing care, end-of-life decisions, assisted reproduction, organ donation, and death. Yet, although he claims to provide a “comprehensive resource” on evangelical Christian health care ethics, he fails to provide a thorough examination of his subject matter. For example, Thobaben pays little attention to the historic beginnings of the religious right. One misses any mention of political action groups or the coalitions formed with or by conservative Christian groups to pursue social reforms, or of why such disparate groups have cooperated for political or social goals under the same umbrella. He focuses solely on identifying and articulating the consensus among those who embrace certain moral values on the current scene. Thobaben’s uncritical approach to his subject matter leaves the impression that this book is essentially an apology for evangelical, right-wing Christian social thought. One searches in vain for any critical discussion of the beliefs and values he presents or any thoughtful engagement with those who might view the stances he presents as an assault against women’s rights or an attack on the rights of gays, lesbians, and transsexuals.Moreover, in a book like this, one would have expected a more careful assessment of biblical passages and historical precedents. Thobaben does not provide much rationale for his method for moving from the Bible to current social issues. For example, no prohibition against abortion is found in the Bible and the few passages about homosexual practices hardly add up to the fierce opposition to gays found among strident evangelicals. Moreover, Thobaben does not mention that in 1965 laws against contraceptives were declared unconstitutional by the Griswold vs. Connecticut decision, the Supreme Court’s rejection of a ban supported by an evangelical crusade led by Anthony Comstock. [End Page 204]It is interesting to note that Thobaben holds a strongly qualified commitment to religious liberty and only a “thin” version of the social contract basic to the Bill of Rights (37). He argues that in at least some situations “intolerance is not only morally understandable but strongly preferable,” as in the examples of the “abolition of slavery and prolife/antiabortion advocacy” (29) or, in another context—where he distinguishes between tolerance toward those outside the church and intolerance toward those within it—with regard to homosexuality and alcohol intoxication (30).The task of Christian ethics is to enlighten believers and the general citizenry by a careful exposition of the sources of wisdom available to those who want to think and think morally about issues of importance to human flourishing. That task is especially important in an age of demagogic hostility toward unpopular groups. Sadly, this book does not engage such critical questions. It may prove... (shrink)

The implicit social contract between large companies and their employees has been recently revised to emphasize workforce flexibility and the financial responsibility of individual employees for their own employment and benefits-related decisions. The most recent aspect of this social contract to be significantly changed is health care benefits. On the basis of in-depth case studies of health benefits purchasing at 15 large United States employers, the authors found that the reported use of a purchasing technique called managed (...) competitionhas enabled firms to bring health benefits purchasing in line with other elements of the revised social contract. An important minority of companies in our study appear to have retained a different, “employer responsibility” approach toward employee health benefits, leading them to move more gradually to managed competition purchasing and refrain from instituting heavy premium cost sharing or cutting coverage for their employees. These findings are preliminary and deserve further study as to their generalizability and persistence. (shrink)

The author, a health insurance industry leader and a prominent voice in the national reform debate, shares his perspective on attempts to transform health care over nearly a decade. He advocates for a bipartisan solution to stabilize the health insurance market in the near term, and for private sector innovation in partnership with government to create sustainable long-term change. He encourages ASLME members to continue to lend their expertise to the process of transformation.

: As the twentieth century closes, marked by triumphal strides in medical advances, the American society has yet to ensure that each person has access to affordable health care. To correct this injustice, this article calls on the nation's political and corporate leaders, providers, and faith-based groups to join all Americans in a new national conversation on systemic health care reform. The Catholic faith tradition is one that compels both a proclamation to ministry values and a (...) commitment to speak out against the challenges or threats to what are essential to the well-being of individuals and society. The Catholic health ministry must therefore be both a voice for the voiceless and an agent of transformation. The nation's goal should be to "reposition" health care from its status as an important, but ultimately optional building block to one that is essential. (shrink)

There is a tendency to see the current challenges to Catholic health care ministry as unprecedented, and the particular shape they take certainly is. But there has always been pressure. The reason is simple: whatever the dominant political, economic, or medical system of a given time and place, Catholic identity must always be at an ethical angle. Catholics faithful to Jesus' words and deeds are “resident aliens” in every society.

The medicalization of risk rests on foundational assumptions shared by economics and public health. Economists, however, think in terms of pursuing an array of goods, and hence, they offer useful critiques of the irrationality involved in trying to subordinate all goods to one narrow good, like avoiding death from a particular disease. Many of our approaches to health do not appear to be fully rational, suggesting that the deeper motivation lying behind our concerns about health are to (...) be found in something other than the impulse to extend human lives as much as possible. This paper draws on the theology of St. Thomas Aquinas to sketch a richer way of thinking about the goods we pursue in health care that can help us to avoid the pitfalls associated with the medicalization of risk. (shrink)

The Affordable Care Act is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. Consistent with these (...) finding, one recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans. (shrink)

The factions debating health care reform in the United States have gravitated toward one of two positions: that just health care is an individual responsibility or that it must be regarded as a national concern. Both arguments overlook a third possibility: that justice in health care is multilayered and requires the participation of multiple and diverse communities. _Communities of Health Care Justice_ makes a powerful ethical argument for treating communities as critical moral (...) actors that play key roles in defining and upholding just health policy. Drawing together the key community dimensions of health care, and demonstrating their neglect in most prominent theories of health care justice, Charlene Galarneau postulates the ethical norms of community justice. In the process, she proposes that while the subnational communities of health care justice are defined by shared place, including those bound by culture, religion, gender, and race that together they define justice. As she constructs her innovative theorization of health care justice, Galarneau also reveals its firm grounding in the work of real-world health policy and community advocates. _Communities of Health Care Justice_ not only strives to imagine a new framework of just health care, but also to show how elements of this framework exist in current health policy, and to outline the systemic, conceptual, and structural changes required to put these justice norms into fuller practice. (shrink)

Partially because of the high cost of developing and maintaining cold chains, systems needed to keep heat-labile vaccines under adequate refrigeration from their points of manufacture to their administration in the field, the Joint WHO/FAO Expert Committee on Zoonoses (i.e., the approximately four fifths of all described human infections that people share with other vertebrate animals) recommended in 1982 operation of common cold chains by health and veterinary services in rural areas. Following this recommendation, a 1984 pilot level initiative (...) in medical-veterinary intersectoral cooperation should be regarded as a practical way to deliver human primary health care to currently neglected African pastoralists, and as a potential core program for development efforts overall within arid and semiarid areas of the African continent. (shrink)

Imagine that an American physician volunteered to treat wounded children through the Ministry of Health in Gaza, controlled by Hamas. Or that a Palestinian nurse attending to injured fighters in Gaza spoke out against the firing of rockets into Israel, was threatened with arrest, and sought asylum in the United States. Under U.S. law, the doctor could be subject to prosecution, and the nurse could be denied asylum—in the first case, because she provided medical care under the direction (...) or control of a designated terrorist organization; in the second, because he knowingly provided care to a member of a terrorist organization. The question of whether a terrorist is entitled to medical care, though largely theoretical, has generated considerable discussion, with near unanimity that there is no moral basis to refuse to treat. But whether a health professional can be punished for providing medical care either to terrorists or under the auspices of a terrorist organization has received little attention from either a moral or legal perspective, although such situations arise throughout the world. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of (...) health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

This paper will examine the topic of identity in Roman Catholicism from the perspective of topics contained in or absent from mission statements of 25 Catholic health care institutions. In particular, I will look at these from the perspective of social justice as well as how this and other topics such as human dignity, the sanctity of life, stewardship, pastoral care and the likelihood of mergers with other institutions will affect the healing ministry of Catholic health (...) care providers. The article will conclude that there are three key dimensions to Catholic health care: leadership in advocating reform of the current health care system, care for the marginalized and under-insured, and the provision of pastoral care in all institutions. (shrink)

One of the arguments that is often advanced in defence of the public health care system in Canada appeals to the idea that medical care should not be treated as a “commodity.” The recent Romanow Report on the Future of Health Care in Canada, for instance, says that, “Canadians view medicare as a moral enterprise, not a business venture.”1 Public provision is then urged on the grounds that this is the only mode of delivery compatible (...) with this constraint. This argument has received surprisingly little scrutiny, despite the important role that it plays in structuring the recommendations of the report, not to mention the broader public debate. This is unfortunate, since not only is it, in my view, a bad argument, but it is one that actually obscures the rationale for the current public system. It encourages the widely shared misperception that health care is a pure public good in our society (financed through taxation, then provided “for free” to all citizens). Provincial governments in Canada do not, for the most part, deliver health care services directly to the population. What they provide instead is health insurance. They rely primarily upon the private sector to deliver care. Thus the Canadian health care system more closely resembles what is often described as a quasi-market, or a “public market.” The justification for the role of the public sector in health care can be traced back to market failure in the insurance sector, and not in the market for health care services. (shrink)

As web instruction becomes more and more prevalent at universities across the country, instructors of ethics are being encouraged to develop online courses to meet the needs of a diverse array of students. Web instruction is often viewed as a cost-saving technique, where large numbers of students can be reached by distance education in an effort to conserve classroom and instructor resources. In practice, however, the reverse is often true: online courses require more of faculty time and effort than do (...) many traditional classes. Based on personal experience teaching an online course in health care ethics for students in the Allied Health Professions, it is evident that there are both benefits and challenges in teaching online courses, particularly in ethics. Examples of benefits are (1) the asynchronous nature of web instruction allows students to progress through the course at their own pace and at times that are convenient given their clinical responsibilities; (2) web courses allow for a standardization of content and quality of instruction over a diversity of programs; and (3) examples can be tailored to the differing experiences of students in the course. Some challenges to teaching online ethics courses include (1) the fact that online instruction benefits visual learners and disadvantages those lacking good reading comprehension or strong writing skills; (2) developing meaningful student-student and student-instructor interaction; and (3) teaching ethics involves teaching a process rather than a product. Allowing students to apply their knowledge to real-world cases in their disciplines and encouraging them to share experiences from clinical practice is an effective way to meet several of these challenges. Building an online community is another good way to increase the interaction of students and their engagement with the material. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:In Search of the Good: A Life in Bioethics by Daniel Callahan, and: Why the Church Needs Bioethics: A Guide to the Wise Engagement with Life’s Challenges ed. by John F. Kilner, and: Respecting Life: Theology and Bioethics by Neil MesserAndrea Vicini SJIn Search of the Good: A Life in Bioethics By Daniel Callahan (edited by Arthur Caplan) CAMBRIDGE, MA: MIT PRESS, 2012. XVII + 206 PP. $29.00Why (...) the Church Needs Bioethics: A Guide to the Wise Engagement with Life’s Challenges Edited by John F. Kilner GRAND RAPIDS: ZONDERVAN, 2011. 304 PP. $26.99Respecting Life: Theology and Bioethics By Neil Messer LONDON: SCM PRESS, 2011. XI + 236 PP. $36.20With their specific styles, targeted readerships, and overall goals, these three volumes provide diverse but synergic ways to articulate and expand bioethical reflection in today’s society. Daniel Callahan is undoubtedly one of the founders of the field of bioethics. In Search of the Good: A Life in Bioethics is a fascinating memoir where, in a very engaging and personal way, Callahan unveils his intellectual development, career, and major interests. At the same time, he provides a critical lens to examine the history of bioethics in the United States. It shows his “abiding fascination with the human nature, scope, and validity of ethics as part of human life, and a similar strong interest in the ways that the scientific knowledge of medicine influences how we think about our health and mortality and shapes the ways we live our lives” (xvi). In particular, he describes how his philosophical training, and philosophical mind, led him to address the burgeoning ethical questions in biology and medicine and, thereby, to contribute to the founding of today’s bioethics.By sharing his intellectual journey with great honesty and transparency, Callahan guides his readers from his initial philosophical questioning to the later critical developments that have shaped bioethics as a theoretical and practical discipline in the last forty years. The list of topics that he has studied is impressive—from birth control to heart transplants, from end-of-life issues to embryonic stem cell research, and from market-driven health care to medical rationing. Drawing on his time as editor of the famous liberal Catholic magazine Commonweal in the 1960s, Callahan narrates his 1969 founding of the Hastings Center in cooperation with the author and psychiatrist Willard Gaylin. He describes the [End Page 196] stages in the life of this first bioethics research institution in the world, focusing on the years of its success (1980–86) and then on the routinization of its charisma (1986–96). More recent years have seen Callahan questioning medical progress and stressing the urgency of critically examining the goals of today’s medicine, even including discussion topics that are often avoided.Bioethics scholars and students will enjoy In Search of the Good. They will be able to integrate their own historical study of this discipline with Callahan’s personal memoir, which gives a human face to issues and debates. Moreover, bioethicists will be stimulated to reassess their own intellectual engagement and reflect on the future developments of this interdisciplinary discipline whose “roots lie in the humanities” (167).John Kilner, director of bioethics programs and professor of bioethics and contemporary culture at Trinity Evangelical Divinity School, takes a broader approach in Why the Church Needs Bioethics. The volume includes contributions from an interdisciplinary group of thirty-one Christian leaders with diverse expertise, ranging from medicine, business, and law to biblical studies, theology, counseling, and intercultural and pastoral ministry. Nineteen leaders contributed essays, and twelve offered their critiques to earlier drafts. This collaborative effort is praiseworthy, but at the same time it leaves readers desiring more cohesive reflections and a synthetic theological voice.The volume considers three cases emblematic of major human quests: reproductive technologies for a better birth; enhancing drugs for a better life; and end-of-life care for a better death. Each case is discussed by experts from three different disciplines—biblical theology, practical theology, and other secular professions (business, law, or health care)—followed by a specifically bioethical essay. The volume ends with two conclusive contributions discussing how preaching and wisdom... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Death and Dying in JapanRihito Kimura (bio)A majority of Japanese, at present, feel that the modern biomedical and technological innovations pertaining to human life and death have been forcing a change in our common understanding of what, historically, was simply the natural event and process of death and dying. The meaning of death and the dying process in our lives is changing as have the traditional criteria for determining (...) death, namely, cessation of heartbeat and respiration.An individual’s death should be a personal and private matter as well as a familial, communal, and social matter. It has been regarded as such for many thousands of years in our Japanese society and culture. It is well understood that our traditional socio-cultural understanding of human life positively admits the natural process of death as the final event of life. The ideas expressed in Zen-Buddhist phrases such as “accept death as it is” and “life-death as one phenomenon” have been key motifs totally integrated into our traditional understanding of life (Tomomatsu 1939).However, the traditional perception of death as an acceptable process has [End Page 374] been vanishing as the Japanese have applied modern biomedical technologies more frequently in well-equipped hospital settings. Although the involvement of family members in the process of dying and particularly in the death event continues in a variety of ways, the care of dying patients in Japan is becoming much more similar to that delivered in advanced hospital settings in many countries of the world, than it is different. Now, in Japan, a majority of people end their lives in the hospital, surrounded by high-technology machines. Yet, in a survey by the Yomiuri Shimbun of 15 June 1991, half of the respondents said they would prefer to die at home.In addition, there has been a tradition of not explaining to terminally ill people the true nature of their condition, on the ground that this is most appropriate way to proceed (Kashiwagi 1994, pp. 78–85). However, views on this matter are changing. There is a gradual move toward telling patients the truth, and the notion of informed consent has been widely publicized in the clinical setting (Leflar 1996, pp. 96–107). In the 1991 nationwide opinion poll by the Yomiuri Shimbun, 65 percent of the participants said that they would like to be given full diagnostic information about themselves even if they were terminally ill. Nevertheless, only 22 percent of the people questioned said they themselves would definitely be prepared to disclose such information to a family member.The same survey indicated that 78 percent of people considered palliative care desirable, even though it might shorten life, while 16 percent thought life should be sustained as long as possible, irrespective of the pain that patients might be suffering.Challenges of Care for the DyingA special task force on terminal care, set up by the Ministry of Health and Welfare, issued a report in 1989 that encouraged the disclosure of diagnostic information to patients, provided that consideration was given to patients’ life histories, personalities, relationships with family members, and other factors. The report favored the use of drugs for pain control; it also dealt with matters such as spiritual requirements and the care of the family members.Traditionally, the physician-patient relationship in Japan is based on a complete and unquestioning trust of the physician by the patient, such that the physician acts to make health care decisions on behalf of the patient (Kimura 1991). However, increasingly it is believed that people should not have to accept without question the authority of doctors in the treatment of disease. Responsibility for the care of the dying should be shared between family members and all health professionals, not only physicians. Changes are needed in the mentalities of health care providers, patients, and family members, and it must be recognized that the medical system and institutions are not immutable (Annas and Miller 1994, pp. 374–76). [End Page 375]To complicate matters even further, although a patient’s family is informed of the incurable nature of the disease affecting their family member, the patient, as noted above, usually is not told of... (shrink)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government (...) regulations tend to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government (...) regulations tend to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

: Widespread collection and use of identifiable information can promote social goods while, at the same time, infringing on personal privacy. Information systems are developing within the context of a fundamental transformation in the organization, delivery, and financing of health care. Changes in the health care system include rapid development of employer-sponsored health coverage, managed care organizations, and integrated delivery systems. These complex, multifaceted arrangements for delivering and paying for health care require (...) ever-more-sophisticated information systems that facilitate extensive sharing of personal data. Systemic flows of sensitive health information occur both vertically and horizontally among employers, hospitals, insurers, laboratories, and suppliers. Beyond this complex web of vertical and horizontal sharing are the multiple demands for information management, quality assurance, research, governmental regulation, and public health. Theoretical problems exist with the law and ethics of informational privacy. The traditional method of exercising control over personal health information is through informed consent. Informed consent, however, within a modern health information infrastructure becomes highly complex. In this kind of environment, the doctrine of informed consent is flawed and does not provide sufficient control over personal information to assure adequate protection of privacy. (shrink)

This paper draws on findings from qualitative interviews with queer and trans patients and with physicians providing care to queer and trans patients in Halifax, Nova Scotia, Canada, to explore how routine practices of health care can perpetuate or challenge the marginalization of queers. One of the most common “measures” of improved cultural competence in health care practice is self-reported increases in confidence and comfort, though it seems unlikely that an increase in physician comfort levels (...) with queer and trans patients will necessarily mean better health care for queers. More attention to current felt discomfort in patient–provider encounters is required. Policies and practices that avoid discomfort at all costs are not always helpful for care, and experiences of shared discomfort in queer health contexts are not always harmful. (shrink)

Because health care professions exist to provide a good for society, ethical questions are inherently part of them. Such professions and their members can be assessed based on how effective they are in developing knowledge and enacting practices that further the health and well‐being of individuals and society. The complexity of contemporary health care environments makes it important to prepare clinicians who can anticipate, recognize, and address problems that arise in practice or that prevent a (...) profession from fulfilling its service goals and obligations. Different health care professions have evolved distinct perspectives about appropriate goals for, and the purposes of, their clinicians, even when the goal of improving health and well‐being for society is shared across professions. While medicine and nursing goals are shared in principle, they differ in the particulars. Given the centrality to nursing of ethical questions, the profession has a collective responsibility to help clinicians at all levels of practice become ethically savvy and to reinforce their moral agency as needed. Both knowledge of nursing ethics and knowledge of the interdisciplinary field of bioethics are critical to nursing work. (shrink)

The relationship of religion and health is often misunderstood owing to a tendency to concentrate on the medical model and to ignore the wider context of heath care. A conceptual--as opposed to a historical--examination of this context reveals nine central religious ideas or categories which provide an ethical foundation and heritage for medical practice and health care delivery. These include doctrines of creation; dominion or stewardship; freedom and responsibility; human dignity or sanctity of life; love or (...) compassion; covenant; justice; vocation; and finitude. A discussion of the complementarity of religion and medicine is necessary and should proceed from these shared values and common concerns. (shrink)

Political philosophers often formulate the problem of distributive justice as the problem of how the government ought to distribute different types of goods—for example, income or health care—to its citizens. They therefore presuppose that the government is a unitary agent that governs its citizens directly. However, although a number of governments are unitary in this way, many are federations, exhibiting a division of sovereignty between two or more levels of government having independent grounds of authority. In contrast to (...) unitary states, therefore, within a federation, two or more levels of government directly govern their citizens and are directly accountable to them. Because of the way in which different levels of government in a federation can separately affect the distribution of goods in society, federations face resource allocation problems that are far more complex than those of unitary states. In addition to determining what a just distribution of goods is, federations must also determine (1) whether distributive justice is a shared responsibility amongst different levels of government, and, if so, (2) how this shared responsibility should be allocated between them. (shrink)

The substantive center of Christian ethics is Jesus’s ministry of the kingdom or reign of God, and its preferential inclusion of the poor, the outcast, and the sinner. What defines a gospel-based bioethics is a hopeful, practical commitment to improve the health of those who are most vulnerable to illness and early death because they lack basic needs. This commitment is distinctive of Christian bioethics, if not “unique” in the sense that no other bioethical approaches or traditions share it. (...) To succeed in reducing disparities in access to health care requires cooperative social action with members of multiple moral and political communities, meaning that there is no strict boundary between secular and Christian bioethics at the practical, political level, the level of applied Christian social ethics. (shrink)

Economic competition threatens equity in the delivery of health care. This essay examines four of the various ways in which it does that: the reduction of charity care, increased patient cost-sharing, "cream-skimming" of healthy subscribers, and lack of information to patients about rationed care that is not prescribed. In all four cases, society must guard against distinct inequities and injustices, but also in all four, either the particular problem is not inherent in competition or, though (...) inherent, it is not irremediable. Competition therefore cannot be finally morally accepted or rejected as an economic structure for delivering health care without knowing what among a wide range of supplementary things our society is actually going to do with it. Keywords: for-profit medicine, competition, patient-physician relationship, informed consent CiteULike Connotea Del.icio.us What's this? (shrink)

The problem of providing mandated medical care has become commonplace as correctional systems in the United States struggle to manage unprecedented increases in its aging prison population. This study explores older incarcerated women’s perceptions of prison health care policies and their day-to-day survival experiences. Aggregate data obtained from a sample of 327 older women residing in prison facilities in five Southern states were used to identify a baseline of health conditions and needs for this vulnerable group. (...) With an average of 4.2 chronic health conditions, frequently histories of victimization, and high rates of mental health issues, the women’s experiences of negotiating health care was particularly challenging. By incorporating the voices of older women, we expose the contradictions, dilemmas, and obstacles they experience in their attempts to obtain health care. It is clear from the personal accounts shared that, despite court mandates, penal harm practices such as delaying or denying medical treatment as well as occasional staff indifferences are common in women’s prisons. With older women having the greatest need for health care, an age- and gender-sensitive approach is recommended. (shrink)

This paper presents a systematic account of ethical issues actualised in different areas, as well as at different levels and stages of health care, by introducing organisational and other procedures that embody a shift towards person centred care and shared decision-making (PCC/SDM). The analysis builds on general ethical theory and earlier work on aspects of PCC/SDM relevant from an ethics perspective. This account leads up to a number of theoretical as well as empirical and practice oriented issues (...) that, in view of broad advancements towards PCC/SDM, need to be considered by health care ethics researchers. Given a PCC/SDM-based reorientation of health care practice, such ethics research is essential from a quality assurance perspective. (shrink)

This article challenges a key tacit assumption underpinning legal and ethical instruments in health care, namely, that people are ideally bounded, independent, and often also strategically rational individuals. Such an understanding of personhood has been criticized within feminist and other critical scholarship as being unfit to capture the deeply relational nature of human beings. In the field of medicine, however, it also causes tangible problems. I propose that a solidarity-based perspective entails a relational approach and as such helps (...) to formulate new solutions to complex ethical and regulatory questions, ranging from caring for people at the end of their lives to improving policies for organ donation and better governance of health data. It also underscores the importance of universal health care. Although a solidarity-based perspective does not require health to be seen as an individually enforceable right, it does influence our understanding of individual rights: it draws attention to how their meaning is shaped by shared social practices. I conclude by arguing that, in light of current pressures for medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much needed endeavor. (shrink)

The organisation of health care is rapidly changing. There is a trend to move away from individual health care institutions towards transmural integrated care and interorganizational collaboration in networks. However, within such collaboration and network there is often likely to be a pluralism of values as different health care institutions often have very different values. For this paper, we examine three different models of how we believe institutions can come to collaborate in networks, (...) and thus reap the potential benefits of such collaboration, despite having different moral beliefs or values. A first way is the pragmatic way in which the different health care institutions avoid ethical reflection and focus on solutions. A second possible route is that of consensus where health care institutions base their collaboration on values that they all share. The third, and final, approach is that of compromise. Although moral compromise is often seen in a negative light, we argue that in many cases compromise might be necessary and ethically justified. In a final section, we will shift our focus from discussing various theoretical methods to allow collaboration to the potential content of consensus or compromise. (shrink)