The sociological dimension of science is studied using the discovery of the Wasserman reaction and its accidental application as a test for syphilis as a basis, ...

An international team of four authors, led by distinguished philosopher of science, Nancy Cartwright, and leading scholar of the Vienna Circle, Thomas E. Uebel, have produced this lucid and elegant study of a much-neglected figure. The book, which depicts Neurath's science in the political, economic and intellectual milieu in which it was practised, is divided into three sections: Neurath's biographical background and the socio-political context of his economic ideas; the development of his theory of science; and his legacy as illustrated (...) by his contemporaneous involvement in academic and political debates. Coinciding with the renewal of interest in logical positivism, this is a timely publication which will redress a current imbalance in the history and philosophy of science, as well as making a major contribution to our understanding of the intellectual life of Austro-Germany in the inter-war years. (shrink)

Solidarity is a fundamental social value in many European countries, though its precise practical and theoretical meaning is disputed. In a health care context, I agree with European writers who take solidarity normatively to mean roughly equal access to effective health care for all. That is, solidarity includes a sense of justice. Given that, I will argue that precision medicine represents a potential weakening of solidarity, albeit not a unique weakening. Precision medicine includes 150 targeted cancer therapies (mostly for metastatic (...) cancer), all of which are extraordinarily expensive. Our critical question: Must a commitment to solidarity as defined mean that all these targeted cancer therapies should be guaranteed to all within each country in the European Union, no matter the cost, no matter the degree of effectiveness? Such a commitment would imply that cancer was ethically special, rightfully commandeering unlimited resources. That in itself would undermine solidarity. I offer multiple examples of how current and future dissemination of these targeted cancer drugs threaten a commitment to solidarity. An alternative is to fund more cancer prevention efforts. However, that too proves a threat to solidarity. Solidarity, with or without a sense of justice, is too abstract a notion to address these challenges. Further, we need to accept that we can only hope to achieve “rough justice” and “supple solidarity.” The precise practical meaning of these notions needs to be worked out through a fair and inclusive process of rational democratic deliberation, which is the real and practical foundation of just solidarity. (shrink)

Can Rawlsian public reason sufficiently justify public policies that regulate or restrain controversial medical and technological interventions in bioethics (and the broader social world), such as abortion, physician aid-in-dying, CRISPER-cas9 gene editing of embryos, surrogate mothers, pre-implantation genetic diagnosis of eight-cell embryos, and so on? The first part of this essay briefly explicates the central concepts that define Rawlsian political liberalism. The latter half of this essay then demonstrates how a commitment to Rawlsian public reason can ameliorate (not completely resolve) (...) many of the policy disagreements related to bioethically controversial medical interventions today. The goal of public reason is to reduce the size of the disagreement by eliminating features of the disagreement that violate the norms of public reason. The norms of public reason are those norms that are politically necessary to preserve the liberal, pluralistic, democratic character of this society. What remains is reasonable disagreement to be addressed through normal democratic deliberative processes. Specific issues addressed from a public reason perspective include personal responsibility for excessive health costs, the utility of a metaphysical definition of death for organ transplantation, and the moral status of excess embryos generated through IVF and/or their use in medical research. (shrink)

Four distinguished authors have been brought together to produce this elegant study of a much-neglected figure. The book is divided into three sections: Neurath's biographical background and the economic and social context of his ideas; his theory of science; and the development of his role in debates on Marxist concepts of history and his own conception of science. Coinciding with the emerging serious interest in logical positivism, this timely publication will redress a current imbalance in the history and philosophy of (...) science. (shrink)

The annual cost of healthcare in the United States reached $2.5 trillion in 2009 (about 17.6% of GDP) with projections to 2019 of about $4.5 trillion (about 20% of likely GDP).

De Bie et al. (2023) call attention at the conclusion of their essay to the “novel questions” generated by complete ectogenesis. The question I explore is how complete ectogenesis from conception t...

Accelerated approval of aducanumab for mild Alzheimer's by the U.S. Food and Drug Administration on June 7, 2021, has generated substantial medical, scientific, and ethical controversy. That approval was contrary to the nearly unanimous judgment of the FDA's Advisory Committee that little reliable evidence existed of significant benefit, even though the drug did reduce β‐amyloid. Three major ethical problems were created by this approval: (1) Medicare resources would be unjustly squandered, given the drug's $56,000 annual price and the 3.1 million (...) older potential American patients needing the drug; (2) physicians will feel ethically compelled to provide the drug to desperate, insistent patients, given FDA approval and in spite of side effects of brain bleeds and brain swelling; (3) and false hopes are generated for patients. A needed corrective by the federal government would reduce reimbursement to the bare cost of producing the drug (plus only a modest profit) until a phase IV trial has been successfully completed. (shrink)

I fundamentally agree with Childress et al. (2023) in the scenario they have constructed with Mr. J. None of the arguments they critically assess are ethically persuasive enough to justify removing...

The phrase "personalized medicine" has a built-in positive spin. Simple genetic tests can sometimes predict whether a particular individual will have a positive response to a particular drug or, alternatively, suffer costly and debilitating side effects. But little attention has been given to some challenging issues of justice raised by personalized medicine. How should we determine who would have a just claim to access particular treatments, especially very expensive ones? How effective do those treatments need to be?If there were a (...) thick, bright line separating minimal responders from maximal responders, then we could allocate these treatments in a fair and cost-effective way. But there is no bright line. The .. (shrink)

The annual cost of healthcare in the United States reached $2.5 trillion in 2009 (about 17.6% of GDP) with projections to 2019 of about $4.5 trillion (about 20% of likely GDP).

In the following interview, philosophers Leonard Fleck and Arthur Ward discuss the latter’s recent experience of being a nondirected kidney donor. The interview took place in the Center for Bioethics and Social Justice at Michigan State University.

John Rawls has held up as a model of public reason the U.S. Supreme Court. I argue that the Dobbs Court is justifiably criticized for failing to respect public reason. First, the entire opinion is governed by an originalist ideological logic almost entirely incongruent with public reason in a liberal, pluralistic, democratic society. Second, Alito’s emphasis on “ordered liberty” seems completely at odds with the “disordered liberty” regarding abortion already evident among the states. Third, describing the embryo/fetus from conception until (...) birth as an “unborn human being” begs the question of the legal status of the embryo/fetus, as if an obiter dictum settled the matter. Fourth, Alito accuses the Roe court of failing to exercise judicial restraint, although Alito argued to overturn Roe in its entirety. In brief, the Dobbs opinion is an illiberal, disingenuous, ideological swamp that swallows up public reason and the reproductive rights of women. (shrink)

Abstract:Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, (...) and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes. (shrink)

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, but it is mostly hidden (...) rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

: New genetic technologies continue to emerge that allow us to control the genetic endowment of future children. Increasingly the claim is made that it is morally "irresponsible" for parents to fail to use such technologies when they know their possible children are at risk for a serious genetic disorder. We believe such charges are often unwarranted. Our goal in this article is to offer a careful conceptual analysis of the language of irresponsibility in an effort to encourage more care (...) in its use. Two of our more important sub-claims are: A fair judgment of genetic irresponsibility necessarily requires a thick background description of the specific reproductive choice; and there is no necessary connection between an act's being morally wrong and its being irresponsible. These are distinct judgments requiring distinct justifications. (shrink)

It's not only necessary, but possible, if the public can be educated.

Abstract:The American College of Physicians in its ethics manual endorsed the idea that physicians ought to improve their ability to provide care to their patients more parsimoniously. This elicited a critical backlash; critics essentially claimed that what was being endorsed was a renamed form of rationing. In a recent article, Tilburt and Cassel argued that parsimonious care and rationing are ethically distinct practices. In this essay I critically assess that claim. I argue that in practice there is considerable overlap between (...) what they term parsimonious care and what they define as rationing. The same is true of the Choosing Wisely campaign endorsed by the American Board of Internal Medicine. In both cases, if the goal is to control healthcare costs by reducing the use of marginally beneficial care that is not cost effective, then a public conversation about the justness of specific choices is essential. (shrink)

Health reform must include health care rationing, both for reasons of fairness and efficiency. Few politicians are willing to accept this claim, including the Clinton Administration. Brown and others have argued that enormous waste and inefficiency must be wrung out of our health care system before morally problematic cost constraining options, such as rationing, can be justifiably adopted. However, I argue that most of the policies and practices that would diminish waste and inefficiency include implicit (and therefore morally problematic) rationing. (...) Critics of rationing see as its most morally and psychologically troubling feature that an identified individual is denied potentially beneficial care. That psychic anguish may not be eliminable, and perhaps ought not be eliminated. But if rationing protocols are fairly adopted through a process of free and informed rational democratic deliberation to which all have access, the moral objections are largely overcome. Such a process is possible only if implicit rationing is recognized and rejected. Keywords: Justice, health care rationing, health reform, democratic decision-making CiteULike Connotea Del.icio.us What's this? (shrink)

What should be the content of a package of health care services that we would want to guarantee to all Americans? This question cannot be answered adequately apart from also addressing the issue of fair health care rationing. Consequently, as I argue in this essay, appeal to the language of "basic," "essential," "adequate," "minimally decent," or "medically necessary" for purposes of answering our question is unhelpful. All these notions are too vague to be useful. Cost matters. Effectiveness matters. The clinical (...) circumstances of a patient matters. But what we must ultimately determine is what we mutually agree are the just claims to needed health care of each American in a relatively complex range of clinical circumstances. Answering this question will require a public moral conversation, a fair process of rational democratic deliberation aimed at defining both just claims to needed health care and just limits. (shrink)

I agree with Professor ter Meulen that there is no need to make a forced choice between “justice” and “solidarity” when it comes to determining what should count as fair access to needed health care. But he also asserts that solidarity is more fundamental than justice. That claim needs critical assessment. Ter Meulen recognizes that the concept of solidarity has been criticized for being excessively vague. He addresses this criticism by introducing the more precise notion of “humanitarian solidarity.” However, I (...) argue that these notions are still not precise enough and are in need of behavioral translation, especially in relation to the problem of fair health care rationing. More specifically, I argue that translation ought to take the form of a well-ordered process of rational democratic deliberation, which I describe and defend in this essay. Such a process is what is required to construct a working model of just solidarity as opposed to a merely abstract idealization of just solidarity. (shrink)

The debate around age-based healthcare rationing was precipitated by two books in the late 1980s, one by Daniel Callahan and the other by Norman Daniels. These books ignited a firestorm of criticism, best captured in the claim that any form of age-based healthcare rationing was fundamentally ageist, discriminatory in a morally objectionable sense. That is, the elderly had equal moral worth and an equal right to life as the nonelderly. If an elderly and nonelderly person each had essentially the same (...) medical problem requiring the same medical treatment, then they had an equal right to receive that treatment no matter what the cost of that treatment. Alternatively, if cost was an issue because the benefits of the treatment were too marginal, then both the elderly and nonelderly patients requiring that treatment ought to be denied it. If there were something absolutely scarce about the treatment, then some fair process would have to be used to make an allocation decision. (shrink)

It's not only necessary, but possible, if the public can be educated.

My task is to provide some critical commentary on the preceding essays. My unfortunate conclusion will be that the issues that are their primary focus are more likely to become more ethically intractable over the next several years as medicine progresses. I do not see any easy or obvious way to avoid this conclusion.

Galasso calls for “the actualization of the public health potential of precision medicine….as the best realistic contribution to health equity” (Galasso 2024, 83). Unfortunately, this is wishful th...

Bioethicists appearing in the media have been accused of "shooting from the hip" (Rachels, 1991). The criticism is sometimes justified. We identify some reasons our interactions with the press can have bad results and suggest remedies. In particular we describe a target (fostering better public dialogue), obstacles to hitting the target (such as intrinsic and accidental defects in our knowledge) and suggest some practical ways to surmont those obstacles (including seeking out ways to write or speak at length, rather than (...) in sound bites). We make use of our own research into the way journalists quote bioethicists. We end by suggesting that the profession as a whole look into this question more fully. (shrink)

The Dobbs decision has precipitated renewed medical, political, and professional interest in the issue of abortion. Because this decision handed responsibility for regulation of abortion back to the states, and because the states are enacting or have enacted policies that tend to be very permissive or very restrictive, the result has been legal and professional confusion for physicians and their patients. Medical education cannot resolve either the legal or ethical issues regarding abortion. However, medical education must prepare future physicians for (...) caring for patients seeking abortion-related services. Physicians must be prepared to interact appropriately (sensitively and with integrity) with patients or colleagues whose views on abortion differ significantly from their own. This essay describes our educational effort to achieve that objective. The motto that governed this exercise was “No Easy Answers.”. (shrink)

What exactly is a “wicked problem”? It is a social or economic problem that is so complex and so interconnected with other issues that it is extraordinarily difficult or impossible to resolve. This is because all proposed resolutions generate equally complex, equally wicked problems. In this essay, I argue that precision medicine, especially in the context of the U.S. healthcare system, generates numerous wicked problems related to distributive justice. Further, I argue that there are no easy solutions to these wicked (...) problems. The need for trade-offs is inescapable. Rough justice is the best outcome we can hope for, and that outcome requires a commitment to processes of public reason that are fair and inclusive. (shrink)

Are DRGs just? This is the primary question which this essay will answer. But there is a prior methodological question that also needs to be addressed: How do we go about rationally (non-arbitrarily) assessing whether DRGs are just or not? I would suggest that grand, ideal theories of justice (Rawls, Nozick) have only very limited utility for answering this question. What we really need is a theory of “interstitial justice,” that is, an approach to making justice judgments that is suitable (...) to assessing the social practices and institutions that comprise the interstices of our social life as opposed to its basic structure. Rawls's appeal to “our considered moral judgments” provides us with a useful starting point for this task, which we shall discuss in the first part of this essay. In the second part, we shall actually assess DRGs from the perspective of interstitial justice. What we shall show is that DRGs violate a large number of our considered judgments regarding a just approach to financing health care for the elderly in a cost-effective manner. This is true to such an extent that efforts to reform DRGs and make them fairer, such as the recent effort by Robert Veatch, should be abandoned. In the concluding section of the essay we discuss one especially pernicious feature of DRGs, namely, that they represent an invisible approach to rationing access to health care. In the minds of many this is one of the virtues of DRGs. That claim needs critical examination. (shrink)

If we accept the premise that some sort of rationing of access to health care resources is necessary to contain escalating health care costs effectively, then we need to ask how that rationing might be accomplished most fairly. Calabresi and Bobbitt have argued in their book Tragic Choices that there is no 'perfectly fair' or even 'reasonably fair' way to bring this about.

Four distinguished authors have been brought together to produce this elegant study of a much-neglected figure. The book is divided into three sections: Neurath's biographical background and the economic and social context of his ideas; his theory of science; and the development of his role in debates on Marxist concepts of history and his own conception of science. Coinciding with the emerging serious interest in logical positivism, this timely publication will redress a current imbalance in the history and philosophy of (...) science. (shrink)

Park and Davies (2024) address the question of whether vaccine status can be an ethically legitimate criterion for the allocation of scarce medical resources, such as access to an ICU bed and venti...

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance (...) assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols. (shrink)

In this paper, I argue for the following points. First, all of us have a presumptive moral obligation to be organ donors if we are in the relevant medical circumstances at the time of death. Second, family members should not have the right to interfere with the fulfillment of that obligation. Third, the ethical basis for that obligation is reciprocity. If we want a sufficient number of organs available for transplantation, then all must be willing donors. Fourth, that likelihood is (...) diminished if individuals are entirely free to refuse to be organ donors but still would demand to be organ recipients. Fifth, although individuals would be ethically obligated to be organ donors, we still need to permit them to refuse to be organ donors. Sixth, to encourage individuals to stay within the organ donation system, we should have as a just and ethically justified policy denying individuals an organ transplant in the relevant medical circumstances if they have chosen to exit the organ donation system. Individuals would not be permitted to be organ recipients if they were unwilling to be organ donors. This is what it means to be part of what Rawls in Political liberalism (15-22) would refer to as a “fair system of social cooperation.” We refer to this as the “reciprocity requirement.”. (shrink)