The intensity of the opposition to health reform in the United States continues to shock and perplex proponents of the Patient Protection and Affordable Care Act. The emotion and the apocalyptic rhetoric, render civil and evidence-based debate over the implications and alternatives to specific provisions in the law difficult if not problematic. The public debate has largely barreled down two non-parallel yet non-intersecting paths: opponents focus on their fear of government expansion in the future if PPACA is implemented now, (...) while proponents focus on the urgency and specifics of our health care market problems and the limited number of tools we have to address them. Frustration on both sides has led opponents to deny the seriousness of our health system’s problems and proponents to ignore the risk of governmental overreach. These non-intersecting lines of argument are not moving us closer to a desired and necessary resolution. (shrink)

This essay makes the affirmative case for health reform by expounding on three fundamental points: one moral case for expanding access to coverage and care to all is grounded in scriptural concepts of community and mutual obligation which continue to inform the American pursuit of justice; the structure of PPACA springs from an appreciation of and approach to channeling market forces that was developed and proposed by a coalition of moderate and conservative Republican U.S. senators almost 20 years (...) ago; the most humane path to a better and more sustainable health system lies in implementing PPACA as fast and fully as we can. The purpose of this essay is to articulate why it is not possible to make our health system better, sustainable and serve us all without government playing specific and limited but absolutely crucial catalytic roles. (shrink)

In order to reflect on the morality of the health care market this paper critiques some of H. T. Engelhardt's presuppositions. Engelhardt has created the vivid term ‘moral stranger’ and suggested that there can be a ‘morality of moral strangers’. However his position relies either on certain necessary presuppositions which he leaves unmentioned or on presuppositions that are—in a strict sense—not moral ones. Engelhardt advocates the market economy as the guiding principle of health care, and claims (...) that the market needs no moral presuppositions. But when the preconditions of a functioning market are examined it turns out that a functioning market requires property and ownership, and that property and ownership are moral institutions. Therefore the application of the idea of the market to health care undoubtedly has morally serious consequences: most important, the difference between commodities and human beings is obscured. (shrink)

The marketing of health care services raises the prospect that an ethic of strangers will govern relations between providers and patients. A fiduciary model that emphasizes honesty and public accountability, as well as the patient's good and avoiding unnecessary services, can keep marketing consistent with the ethical tradition of medicine.

USING QUALITATIVE INTERVIEWS AT CATHOLIC AND JEWISH HOSPITAL organizations, this essay contrasts the market-driven reforms of consumer-directed health care and physician entrepreneurship with the mission-driven structures of religious nonprofits. A structural analysis of values in health care makes a convoluted system more transparent. It also demonstrates the limitations of market reforms to the extent that they erode organizational structures of solidarity, which are needed to pool risks, shift costs, and maintain safety nets in a complex and (...) expensive health economy. (shrink)

The free market theory has as its basis the assumption of equity. This equity is ascribed to both purchasers and providers in a perfectly balanced system so that there are seen to be no 'winners' or 'losers' in the market-place. The health system that is developing in the UK is structured as a managed market, but agency relationships between GPs and health authorities buffer the costing process of goods and therefore may be described as distorting the price. (...) This could also be distorting the ability of the users, who are the real purchasers, from exercising their economic freedom. They may also lose the autonomy to choose goods that suit their particular needs, and equally not to choose those services that they do not want or wish to pay for vicariously (i.e. that the common good is respected by both providers and purchasers). This assumes that users of the service know the level of choice that they have and that not only are providers protected at present by the practices of the purchasers but also entry into the market for new providers is severely curtailed. The exercise of true freedom of the market in economic terms is one of moral obliga tion to provide services that not only have a market value that is affordable and a require ment of the 'common good' but also are historically acceptable for social requirements (i.e. that the services are valued as fundamental tenets of the rights of individuals in soci ety). The expression of this need will therefore be utilitarian (i.e. the users of the services should benefit from them rather than the providers). (shrink)

:Academic Medical Centers offer patient care and perform research. Increasingly, AMCs advertise to the public in order to garner income that can support these dual missions. In what follows, we raise concerns about the ways that advertising blurs important distinctions between them. Such blurring is detrimental to AMC efforts to fulfill critically important ethical responsibilities pertaining both to science communication and clinical research, because marketing campaigns can employ hype that weakens research integrity and contributes to therapeutic misconception and misestimation, (...) undermining the informed consent process that is essential to the ethical conduct of research. We offer ethical analysis of common advertising practices that justify these concerns. We also suggest the need for a deliberative body convened by the Association of American Medical Colleges and others to develop a set of voluntary guidelines that AMCs can use to avoid in the future, the problems found in many current AMC advertising practices. (shrink)

In this paper I argue that the free-market provision of health care is both practical and morally sound, and is superior in both respects to its provision by the State. The State provision of health care will be inefficient compared to its free-market alternative. It will thus provide less health care to persons for the same amount of expenditure, and so save fewer lives and alleviate less suffering for two reasons: state actors have no incentive (...) to husband their resources effectively, and that in a non-market setting, special interest groups can capture resources through lobbying, perverting them away from their efficient allocation. Given these considerations of efficiency a utilitarian should morally prefer the free-market provision of health care to its State-based rival. Furthermore, even if one is not a utilitarian, the free-market provision of health care will be more morally sound than its State-based alternative because it will likely better respect the autonomy of persons, and will better refrain from imposing values upon persons. With these points in hand, I address two prominent objections to a free market system of health care. (shrink)

In this paper we explore the intersection of three topics which have historically been singled out for ethical consideration in advertising and marketing: the use of fear appeals, marketing to the elderly, and the marketing of health care services and products. Issues relevant to using fear appeals in promoting health care issues to the elderly are explored with a consumer psychologist's theoretical view of fear appeals. Next the assumption of the elderly market's vulnerability and indicants of social (...) or psychological function which would differentiate the elderly recipients of marketing communications are examined both in terms of function and ethical concerns.Overall, our review of the theoretical underpinnings of fear-based communication and the psychological characteristics does not indicate that the elderly of today are particularlyvulnerable. While the elderly are probably somewhat more dogmatic than younger consumers and perhaps view outcomes from the perspective of their age, there are no indications that their psychological responses to fear-based appeals differ significantly from those of younger consumers. (shrink)

Markets have long had a whiff of sulphur about them. Plato condemned innkeepers, whose pursuit of profit he believed led them to take advantage of their customers, Aristotle believed that the pursuit of profit was indicative of moral debasement, and Cicero held that retailers are typically dishonest as this was the only path to gain. And even those who are more favorably disposed towards markets in general are frequently inclined to be suspicious of markets in medical goods and services. For (...) example, Margaret Thatcher supported the legal prohibition of markets in kidneys despite being arguably the most pro-market Prime Minister the United Kingdom saw in the 20th century. (shrink)

Many Western countries have introduced market principles in healthcare. The newly introduced financial instrument of “care-intensity packages” in the Dutch long-term care sector fit this development since they have some characteristics of a market device. However, policy makers and care providers positioned these instruments as explicitly not belonging to the general trend of marketisation in healthcare. Using a qualitative case study approach, we study the work that the two providers have done to fit these instruments (...) to their organisations and how that enables and legitimatises market development. Both providers have done various types of work that could be classified as market development, including creating accounting systems suitable for markets, redefining public values in the context of markets, and starting commercial initiatives. Paradoxically, denying the existence of markets for long-term care and thus avoiding ideological debates on the marketisation of healthcare has made the use of market devices all the more likely. Making the market invisible seems to be an operative element in making the market work. Our findings suggest that Dutch long-term care reform points to the need to study the ‘making’ rather than the ‘liberalising’ of markets and that the study of healthcare markets should not be confined to those practices that explicitly label themselves as such. (shrink)

Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating scarce health care (...) resources.The market in health care has increased administration, fragmented services, eroded local accountability, and decreased choice.This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need.The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly.The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care. (shrink)

The World Health Organisation (WHO) is leading a global effort to deliver improved diagnostic testing to people living in low‐resource settings. A reliance on the healthcare technologies marketplace and industry, shapes many aspects of the WHO project, and in this situation normative guidance comes by way of the ASSURED criteria — Affordable, Sensitive, Specific, User‐friendly, Rapid and robust, Equipment‐free, and Delivered. While generally improving access to diagnostics, I argue that the ASSURED approach to distributive justice — efficiency — and assessment (...) of worth — productivity — may constrain efforts to deliver timely and accurate diagnosis in the developing world equitably by holding back new and innovative diagnostics and indirectly encouraging program and device design that may unfairly discriminate against certain groups. Even as we try to overcome the problem of global healthcare injustice, we may be entrenching disadvantage. I present my critique of ASSURED by 1) referencing Boltanski and Thévenot's theory of orders of worth to highlight the industrial and market foundations of the ASSURED guidelines; 2) comparing ASSURED with other normative guides that elevate the importance of civic responsibility in evaluations of distributive justice; 3) presenting a case study of the failed promise of microfluidic diagnostic devices. I conclude that a new approach to normative guidance is required to assess the value of developing world diagnostics, preferably, one that does not force global public goods into the marketplace. (shrink)

: Many activities formerly not in the market are being "marketized," and women's labor is increasingly in the market. I consider the grounds on which to decide what should and what should not be "in" the market. I distinguish work that is paid from work done under "market norms," and argue that market values should not have priority in education, childcare, healthcare, and many other activities. I suggest that a feminist ethics of care is (...) more promising than Kantian ethics or utilitarianism for recommending social decisions concerning limits on markets. (shrink)

Many activities formerly not in the market are being “marketized,” and women's labor is increasingly in the market. I consider the grounds on which to decide what should and what should not be “in” the market. I distinguish work that is paid from work done under “market norms,” and argue that market values should not have priority in education, childcare, healthcare, and many other activities. I suggest that a feminist ethics of care is more (...) promising than Kantian ethics or utilitarianism for recommending social decisions concerning limits on markets. (shrink)

The unfortunately vast history of paternalism in both medicine and clinical research has resulted in perpetually increasing respect for patient autonomy and free choice in Western health care systems. Beginning with the negative right to informed consent, the principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation. This evolution of patient autonomy has mirrored a more general social attitude of market liberalism where increasing numbers of patients have (...) come to embody the role of the “consumer.” This paper explores this transformation and critiques the current way in which respect for patient autonomy is put into practice. Ultimately, this paper concludes that the consumer view of patient autonomy is dysfunctional. Moreover, this paper argues that, based on the inherent goals of medicine, some form of paternalism is required in any meaningfully therapeutic relationship. (shrink)

Although the impact of market reforms in Swedish health care stands out as not very far-reaching in an international comparison, it represents a route away from the features and basic values normally associated with the Swedish or Scandinavian model. Summarizing the development over the last decades, we may identify signs of sustainability as well as change. Popular support for public provision and a robust institutional structure make far-reaching alterations of existing structures less feasible, although most visible changes this (...) far—incremental though they may be—represent a change in which the normative foundations of the Swedish model are challenged. (shrink)

It is generally agreed that the current methods of providing health care in the West need to be reformed. Such reforms must operate within the practical limitations to which any future system of health care will be subject. These limitations include an increase in the demand for costly end-of-life health care coupled with a reduction in the proportion of the population who are working taxpayers (and hence a reduction in the proportionate amount of health care funding (...) that can be secured through taxation) and the fact that the imposition of bureaucratic regulations on health care systems is costly. Recognizing these limitations should naturally lead one to consider market-based reforms. Yet despite the practical impetus for such reforms, there is still widespread concern that market-based health care is unethical. The purpose of this paper is to address this concern and, in so doing, to pave the way for the market-based reform of health care to proceed. (shrink)

In the current global care regime, care shortages in wealthy nations such as the United States, Canada, Italy, and Hong Kong are being addressed through the global supply of cheap migrant care labor from less wealthy nations. This paper argues that Feminist Care Ethics has a great deal to offer in the analysis of this global care regime. Joan Tronto's own critiques of the migration of care workers have focused on analogies between workers and (...) imported slaves: both are intrinsically exploited, vulnerable, excluded, and stigmatized. She argues that this situation undermines human virtue and the possibility of adequate care, and she advocates instead a model wherein caregiving is seen as a basis for .. (shrink)

This article explores the ethics and economics of a market in donated kidneys in the United States. With the impending changes in the health care system, the author argues that a full turn to the market for distribution of kidneys is not appropriate. However, he would sanction a regulated market, as outlined in the article.

The truth about health care policy lies between two exaggerated views: a market view in which individuals purchase their own health care from profit maximizing health-care firms and a control view in which costs are controlled by regulations limiting which treatments health insurance will pay for. This essay suggests a way to avoid on the one hand the suffering, unfairness, and abandonment of solidarity entailed by the market view and, on the other hand, to diminish (...) the inflexibility and inefficiency of the control view. It suggests that the way to mitigate these problems is to recognize the malleability of motivation and the range of factors, in addition to financial incentives, that may influence the behavior of patients and especially physicians. (shrink)

Recent developments in organ procurement have revived the much-debated role of markets in our health care system. The unique American health care system, with its presumption of universality alongside private health insurance and relatively limited federal and state programs, is in many ways consumer-driven today. We certainly tolerate more broad disparities in availability of care and in outcomes of care largely based on socioeconomic status than do many other developed countries, where notions of universal access are (...) supported by broader public financing. (shrink)

Feminist Care Ethics has much to offer in an analysis of the international migration of care workers. This paper argues, however, that Joan Tronto’s analysis of this international care regime is incomplete insofar as it overlooks the ways in which the current global care market is progressive for the workers and the significant harms this market is inflicting on care receivers in source countries. In order for Feminist Care Ethics to fulfill its (...) potential, it must be developed beyond a visionary tool for revaluing care—it must also produce analytic tools for evaluating real alternatives under pressing, real-time constraints. (shrink)

Images of the future are usually only caricatures of the present. Perhaps this picture of the future of medical care will also prove to be a caricature. Whether it does depends on choices that Americans have still to make. —Paul Starr The Social Transformation of American Medicine.

Health care reform in the United States and United Kingdom has resulted in the cross-fertilization of policy. The “new” health care models adopted by the two jurisdictions utilize free market principles for reasons of quality, efficiency, and cost, but also feature characteristics of a state-run model, through the provision of a safety net for citizens and a buffer against the commodification of health. In this sense, the health care systems of the US and UK are more (...) congruent than they were. Here we identify two distinct narratives that emerge from health care reform undertaken in these jurisdictions. The “revolutionary” narrative views the reforms as fundamental change whilst the “evolutionary” narrative accepts them as natural development. We argue that neither the revolutionary nor the evolutionary narrative adequately characterizes the reforms undertaken in health care because neither takes sufficient account of the broader setting in which reform has occurred. In seeking to examine and explain the jurisdictions' apparent drive to the middle, we propose a distinctive evolutionary narrative, that of “convergence,” which, as well as adopting a less parochial perspective on developments in health care policy and provision, also situates the reforms politically, constitutionally, and comparatively. (shrink)

This article examines the recent transformations of the Italian welfare state from a familist welfare model to what I term transnational market familism. In this model, families buy in care labour, commonly provided by migrant workers. There is now a growing literature exploring both the transformations of the Italian welfare model and the experiences of migrant workers providing care in Italy. However, what has been overlooked in the current literature is the ethical aspect of this model of (...) welfare provision, which is part of the transnational political economy of care. The article analyses the ethical implications of the migrant-in-the-family model, which transforms the care relationship between the caregiver and care receiver into a complex relationship between the family member organising care, the migrant caregiver and the dependent care receiver. The context of such welfare provision is transnational. Examining this care triangle, I draw on care ethics and individualization perspective for an analysis of how social policies safeguard, or overlook, human interaction and care relationships in the context of global hierarchies. The article draws on ethnographic data gathered in Naples, Italy, during 2004–2005, including interviews with Neapolitan employers and elderly care-receivers, interviews with migrant workers, as well as participant observations. (shrink)

Efficient markets are alienating if they inhibit us from recognizably caring about one another in our productive activities. I argue that efficient market behaviour is both exclusionary and fetishistic. As exclusionary, the efficient marketeer cannot manifest care alongside their market behaviour. As fetishistic, the efficient marketeer cannot manifest care in their market behaviour. The conjunction entails that efficient market behavior inhibits care. It doesn’t follow that efficient market behavior is vicious: individuals might (...) justifiably commit to efficiency because doing so serves the common good. But efficient market systems nevertheless have significant opportunity costs. The discussion yields a range of desiderata for non-alienated economic organization. (shrink)

Public interest theory has argued that lack of trust in companies may reduce support for free markets. The literature did not address, however, the underlying causes of lack of trust and support of free markets in customer’s perceptions of virtuousness in economic actors. Combining public interest theory with virtue theory and stakeholder trust theory of organizations, we surmise that if customers perceive that employees of companies have insufficient due care for customers’ interests, the perceived trustworthiness of those companies will (...) be low. Customers will then be more inclined to support government regulation in that particular sector or industry. In this paper, we test the relevance of these relationships for the banking sector using a representative sample of 5844 respondents in the Netherlands. We find that if bankers are perceived as persistent in their due care for customers, this encourages a perception that banks are trustworthy, which in turn induces support for free markets in banking and reduces the call for government regulation. An important management implication of our research is that banks should foster due care by means of employee-virtue training programs to enhance trust, thus generating more support for free market operations in the banking sector. (shrink)

This paper examines nurses’ international migration within the broader context of female migration, particularly against more studied groups of women who have migrated for employment in care‐giving roles. We analyze the similarities and differences between skilled professional female migrants (nurses) and domestic workers (nannies and in‐home caretakers) and how societal expectations, meanings, and values of care and ‘women's work’, together with myriad social, cultural, economic and political processes, construct the female migrant care‐giver experience. We argue that, as (...) the recruitment of foreign workers gains visibility, strategies are introduced to better prepare female migrant care‐givers for the marketplace. Language, specifically command of English and accent modification, is highlighted as one means to assimilate migrant care‐givers to host communities. (shrink)

This paper uses the recent history of marketization and privatization in the UK National Health Service as a case study through which to explore the relationship between health-care organization and health-care goods. Phases and processes of marketization are briefly reviewed in order to show that, although the scope of both marketization and privatization reforms have, until recently, been very heavily circumscribed (and can only be understood in the context of the rise of managerialism), they have nonetheless had a (...) major impact on the “value field” of UK health services. The second half of the paper draws upon the concerns of the critics of market-style reforms to set out and explore the ways in which organizational reform and the shifts in institutional norms consequent upon it construct health-care goods and argues that the investigation of this organization-goods axis ought to have a central place in health-care ethics. (shrink)

This essay argues for two conclusions. First, clinical decision-making is not best thought of as analogous to the purchase of other services, such as car repair. Health-care decision-making is far more difficult, collaborative, emotionally fraught, and subject to cognitive distortions. Second, the provision of health care should not be delegated to unregulated markets. Unlike other markets, there is no reason to expect health-care market outcomes to be efficient or fair or to promote individual freedom, properly conceived. (...) Markets may play an important role in implementing an allocation of healthcare, but they are not an ethically acceptable alternative to determining what that allocation should be. (shrink)

Trust in the nurse—patient relationship is maintained not by how professionals perceive their actions but rather by how the public perceives them. However, little is known about the public's view of nurses and other health care professionals who participate in pharmaceutical marketing. Our study describes public perceptions of health care providers' role in pharmaceutical marketing and compares their responses with those of a random sample of licensed family nurse practitioners. The family nurse practitioners perceived their participation in marketing (...) activities as significantly more ethically appropriate than did the public responders. Further research is warranted before conclusions can be drawn, but these early findings suggest that nurse practitioners should consider a conservative approach to participating in pharmaceutical marketing. (shrink)