This chapter contains sections titled: The Moral Duty to Assist Others in Their Health Care Health Care Should Be Provided by the Government The Duty to Provide Truly Universal Health Care Rejecting the Liberal Model.

This article makes a moral argument for universal access to health care and for the legitimate function of government to guarantee that access. Constructed as a reply to the libertarian argument against universal access, this article utilizes the moral and political theory of John Locke, favored by libertarianism, to develop a Lockean argument for a view contrary to the libertarian philosophy. In particular, the argument here shows how libertarianism’s neglect of a crucial element of (...) the natural-law tradition, to which Locke adhered, not only undercuts the libertarian objection to universal access to health care but also underwrites an alternative argument in favor of such. (shrink)

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free‐Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market (...) failure” in health insurance and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. -/- . (shrink)

Definition of the problem: The report supplies the national part of a European survey in which doctors that are involved in the treatment of patients in `Persistent Vegetative State' (PVS) are being interviewed. The questions concern decision-situations the doctors are frequently confronted with in the treatment of PVS-patients. The questionnaire is designed as a decisiontree in order to bring about the exact delineations that govern the decisions. Therefore the result of the survey only portrays which delineations are in fact being (...) accepted (and does not allow any conclusion concerning which norms should guide the decisions). Whether these factual delineations correspond to ethical-normative criteria that derive from guiding principles – such as human dignity – is being discussed in the part reflecting on the survey. It is crucial to an adequate interpretation of the survey results to keep in mind that the doctors were not being asked about what they actually did in the situations described; the survey was designed to bring about what the doctors' basic attitudes towards the problems are.Arguments: The reason this methodological approach to the problem was chosen is that an ethical evaluation can only take place when the action-guiding convictions of the agents concerned are known. The goal of the survey was to make a provisional orientation concerning the basic attitudes possible. Compared to other countries taking part in, the survey result in Germany confirms the hypotheses that doctors from different European countries – concerning the decisions of withdrawing treatment or withholding treatment – are guided by different basic attitudes.Conclusion: As it has become apparent that important national differences concerning the action-guided attitudes of the doctors exist, it would not be advisable to recommend that European guidelines for all countries should be set up for such cases. The decisions taken depend on the guiding ethical assumptions; they can only be decisions for the very case they were derived at. (shrink)

This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the provision of health care. Ronald Green argues that contractors in the original position would establish a basic right to health care. Green's proposal, however, requires considerable relaxation of the constraints Rawls places on the original position (...) and thus jeopardizes Rawls' arguments for the two principles of justice. Norman Daniels claims that health care is best understood as a means for helping to achieve Rawls' goal of equality of fair opportunity. Daniels acknowledges, however, that his interpretation cannot justify a basic right to health care; rather, it would at best require that certain kinds of care be made available to certain kinds of individuals. Finally, in place of the notion of health care is a human right, it is suggested that the provision of health care is a social ideal which may inspire the creation of specific legal rights. On this view, social provision of health care may properly vary significantly from culture to culture. Despite this variability, social systems may still be criticized on moral grounds. Keywords: justice, right to health care, equality, fair opportunity. (shrink)

Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect (...) for such moral integrity are extremely weak and, if taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory—which is exactly what many defenders of conscientious objection (as well as many others) do not think—the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations. (shrink)

Should blood be bought and sold is in crude terms the question asked and answered by Richard Titmuss in his recent book The Gift Relationship. Dr Raymond Plant, a lecturer in philosophy at Manchester University, analyses Titmuss' arguments in a paper which we are printing in two parts. Titmuss has taken the provision of blood as his example of the gift relationship--and by extension that of health care generally. Dr Plant considers in turn each of Titmuss' (...) class='Hi'>arguments that blood should not be a marketable commodity, the moral objections to which seem to be the erosion of freedom and of truth telling, the separation of society through the cash nexus, and its converse that the provision of health care is a means for the integration of society. Dr Plant also examines the views of other commentators on the Titmuss' theory of the value of a 'free' blood transfusion service and other medical care as a means of integration in society, and ends with his promise that in the second part of his paper he will examine Titmuss' principles not in terms of the market but rather as related to the principle of social justice. (shrink)

Approximately one in six persons in the U.S. lacks medical insurance. Legislation permits only physicians to prescribe many common medicines. This state of affairs is unjust. A just society cannot have it both ways: legislation cannot say that the expertise of physicians is so precious that only they can prescribe medicine and that not everyone is guaranteed reasonable access to their services. If there is no guarantee of reasonable access, then physicians should not have a monopoly on writing prescriptions, and (...) if there is a monopoly on writing prescriptions then people should have reasonable access to their services. To remedy this situation we must ensure that all citizens have reasonable access to medical services, or allow the uninsured to self-medicate. (shrink)

Conscience in Reproductive Health Care responds to the growing worldwide trend of health care professionals conscientiously refusing to provide abortions and similar reproductive health services in countries where these services are legal and professionally accepted. Carolyn McLeod argues that conscientious objectors in health care should prioritize the interests of patients in receiving care over their own interest in acting on their conscience. She defends this "prioritizing approach" to conscientious objection over the (...) more popular "compromise approach" without downplaying the importance of health care professionals having a conscience or the moral complexity of their conscientious refusals. McLeod's central argument is that health care professionals who are gatekeepers of services such as abortions are fiduciaries for their patients and for the public they are licensed to serve. As such, they owe a duty of loyalty to these beneficiaries and should give primacy to their beneficiaries' interests in accessing care. This conclusion is informed by what McLeod believes is morally at stake for the main parties to the conflicts generated by conscientious refusals: the objector and the patient. What is at stake, according to McLeod, depends on the relevant socio-political context, but typically includes the objector's integrity and the patient's interest in avoiding harm. (shrink)

The past decade has seen a burgeoning of scholarly interest in conscientious objection in health care. Specifically, several commentators have discussed the implications that conscientious objection has for the delivery of timely, efficient, and nondiscriminatory medical care. In this paper, I discuss the main argument put forward by the most prominent critics of conscientious objection—what I call the Professional Duty Argument or PDA. According to proponents of PDA, doctors should place patients’ well-being and rights at the center (...) of their professional practice. Doctors should be prepared to set their personal moral or religious beliefs aside where these beliefs conflict with what is legal and considered good medical practice by relevant professional associations. Conscientious objection, on this account, should be heavily restricted, if even allowed at all. I discuss two powerful objections against PDA. The first objection, which I call the fallibility objection, notes that law and professional codes of conduct are fallible guides for ethical conduct and that conscientious objection has in the past and continues today to provide a check on aberrations in law and professional convention. The second, which I call the professional discretion objection, states that restrictions on conscientious objection undermine one of the cornerstones of good medical practice, namely, a practitioner’s right to independent professional judgment. I argue that these two objections give us reason to retain conscience clauses in professional codes of conduct. (shrink)

The argument for children's rights in health care has been long in the making. The success of this position is reflected in the 1995 American Academy of Pediatrics recommendations for the role of children in health care decisionmaking, which suggest that children be given greater voice as they mature. But there are good moral and practical reasons for exercising caution in these health care situations, especially when the child and parents disagree. Parents need (...) the moral and legal space within which to make decisions that will facilitate their child's long‐term autonomy, not only her present‐day autonomy. Moreover, third‐party intrusion, by physicians or the state, should be resisted unless negligent and abusive decisions are in the making. (shrink)

This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, and (...) freedom–where freedom is understood as independence and self-determination–justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and–although this is arguable–government action to guarantee access to health care does not itself undermine freedom. (shrink)

This article discusses what arguments best support universal health care (UHC), with a focus on Norman Daniels’ equality of opportunity account. This justification for UHC hinges on the assumption of a close relationship between health care and health. But in light of empirical research that suggests that health outcomes are shaped to a large extent by factors other than health care, such as income, education, housing, and working conditions, the question (...) arises to what extent health care is really necessary to protect and promote health, and thereby opportunity. The author argues that, although this challenge to the equality of opportunity rationale is legitimate, it is not sufficiently specified to allow us to adequately assess the extent to which universal health succeeds in protecting equality of opportunity. The article concludes by outlining a more promising strategy for developing a viable rationale for UHC. (shrink)

The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care, the issue of (...) who provides health care has evolved as individual rights have trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a ‘negative right to health care’, to various forms of a ‘positive right to health care’. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a ‘right’, which is unconditional, a ‘privilege’ has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one’s health must for elevated. To have access to health care in the future will mean some loss of personal rights and an increase in personal responsibility for gaining or maintaining one’s health. (shrink)

In recent literature, there has been much debate about whether and how luck egalitarianism, given its focus on personal responsibility, can justify universal health care. In this paper we argue that, whether or not this is so, and in fact whether or not egalitarianism should be sensitive to responsibility at all, the question of personal responsibilization for health is not settled. This is the case because whether or not individuals are responsible for their own health (...) condition is not all that is relevant when considering whether we should somehow hold them responsible for their own health condition, e.g. cost-wise. There may also be efficiency-based reasons to hold them responsible, and there may even be egalitarian reasons. Defining universal health care as an insurance system where everyone’s deductible and premium is 0, we will argue that efficiency-based reasons for cost-responsibilization are not convincing, but that there are egalitarian reasons for cost-responsibilization. Luck egalitarianism, therefore, cannot, at least not on its own term, justify universal health care. (shrink)

Temkin asks how we should distribute resources between the social determinants of health and health care; Sreenivasan argues that if our goal is fair opportunity, funding universal health coverage is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly than he claims: it applies to any (...) argument for UHC based on health equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given what Sen calls the multidimensional nature of health equity and the role of UHC in cost containment, UHC may not be a threat to health equity. I also argue against Sreenivasan's claim that the data he discusses should not trouble sufficientists and prioritarians. The worst-off are not simply lagging in improvement; rather, their health status is stagnating or worsening. (shrink)

American adults currently enjoy a widely accepted and legally well-settled right to refuse health care, including life sustaining treatment. Joel Feinberg provides a moral foundation for this right in liberal political theory. Feinberg's theory grounds the right to refuse in a broad right to self-determination, and it implements the right through a variable conception of voluntariness. This theory provides a plausible account that comports with the widely accepted right to refuse, commonsense, and ordinary practice. -/- Allen Buchanan (...) and Dan Brock contend, however, that Feinberg's priority for the right to self-determination is inconsistent with his variable scale of voluntariness. Although Feinberg presents his theory as one that grants categorical priority to self-determination over individual well-being, Buchanan and Brock argue that Feinberg's variable scale of voluntariness involves a balancing of self-determination and well-being. This balancing approach, which Buchanan and Brock endorse, seems to undermine the competent patient's right to refuse care because it allows concern for the patient's well-being to override that person's right to self-determination in some circumstances. Taken together, these arguments seem to suggest that we must give up either the competent patient's right to refuse treatment or the intuitively sensible variable scale. -/- In this paper, I argue that one can reconcile a categorical priority for self-determination with legal rules that incorporate a variable scale of competence. This integration requires careful examination of the practical and expressive functions of legal rules as well as of the manner in which these rules embody moral priorities. This analysis pursues specific and general projects. Specifically, it addresses the moral foundations of the legal right to refuse treatment, identifying a substantive difference between the balancing approach and the priority for self-determination that characterizes Feinberg's liberalism. Generally, it examines the types of priorities embodied by legal rules as practical decision guides and as expressions of the conventional morality represented by the law. This general project extends beyond the right to refuse treatment to the analysis of the manner in which legal rules express and apply moral priorities. (shrink)

Euthanasia and physician-assisted suicide are controversial issues in medical ethics and medical law. In the debate, several arguments against the moral acceptability and legal feasibility of active involvement of physicians in bringing about a patient’s death can be found.One argument refers back to the Ten Commandments: “Thou shall not kill”. Killing another human being is morally abject. According to the argument, this is certainly so for medical doctors, as can be seen in the Hippocratic Oath, which explicitly (...) forbids abortion and euthanasia. A less apodictic argument refers to the slippery slope: if euthanasia would be permitted, a downhill movement is set in motion. The end of this movement would be, on the one hand, that physicians will feel forced to assist people who ask for termination of life on whatever grounds. On the other hand, it might lead to a situation in which it becomes normal to kill people who are no longer useful for society.In the literature and in the public debate, there are also arguments in favour of euthanasia and physician-assisted suicide. One such argument invokes the right to die. According to this argument, decisions concerning life and death should be up to the individual who is concerned. In many countries, suicide is morally and legally accepted. If people are allowed to kill themselves, why should they be without rights when they are no longer able to perform the act themselves?In medical ethics and medical law, patient autonomy is a central pivot. Patients have the right to refuse treatment even if this leads to their death. Shouldn’t people also have the right to determine the moment of dying, if they are in a situation which is unbearable, and without prospect of improvement? Another argument focuses on the duty of the physician to alleviate pain and suffering. If there is no other option, the doctor, in fulfilling this duty, should be allowed to actively end the patient’s life. This argument is not based on autonomy, but on beneficence.The debate concerning euthanasia involves fundamentally different moral principles. This makes the debate interesting, if not central to medical ethics and medical law. Yet, the principles are normally presented in an abstract way. Discussants stick to very general ideas, which lack reference to specific social and historical conditions, and are not related to concrete experiences. To invoke the Ten Commandments, or plea for a right to die, implies the use of universal standards, which tend to be general and empty.From a philosophical perspective, this type of argumentation can be criticized. Following Aristotle, ethics should be based upon experience. Ethical knowledge requires participation in concrete practices. Central to ethics is a feeling for the concrete situation, which is always contingent and historical. From this perspective, it makes sense to consider how practitioners in specific situations deal with moral issues, for instance concerning euthanasia. What role do they give to notions such as autonomy and beneficence, how do they interpret them and apply them to the concrete situation?In this paper I will present the Dutch experience with euthanasia. I will focus upon the way in which during the past thirty years the arguments in favour of euthanasia have been developed, in interaction with euthanasia practice. I will show that patient autonomy has been a crucial pivot. Yet, the Dutch interpretation of autonomy is not purely liberal. It does not only involve rights, but also obligations. Next, I will make clear that the physician plays a central role, in that the moral and legal basis of euthanasia is a conflict of duties on the side of the physician.This brings in the issue of beneficence. Yet the Dutch interpretation of the duty to help is not simply paternalistic. In Dutch health care, the physician-patient relationship is based upon deliberation and mutual agreement. Therefore, my conclusion will be that the Dutch practice of euthanasia has a moral ground, which goes beyond the traditional opposition between autonomy and beneficence. (shrink)

Solidarity is commonly invoked in the justification of public health care. This is understandable, as calls for and appeals to solidarity are effective in the mobilization of unison action and the willing- ness to incur sacrifices for others. However, the reference to solidarity as a moral notion requires caution, as there is no agreement on the meaning of solidarity. The article argues that the refer- ence to solidarity as a normative notion is relevant to health-related (...) class='Hi'>moral claims, but that it does not provide a convincing foundation of claims to universal health care. References to universal soli- darity obliterate an important distinction between those moral demands that are founded on principles like justice, recognition, or humanity, and those demands that stem from partisan rela- tions in communities. While there is no ‘separate essence’ of solidarity that could be referred to in order to argue for the conceptual necessity of solidarity’s partiality, some features may reasonably be stipulated as being essential to solidarity with a view to its systematic function within moral phi- losophy. The normative and motivational force of the ties invoked by solidarity is particularly relevant when basic moral demands are not met, and societies are in need of significant forms of communal relatedness. (shrink)

Books have their origins in conversations and seek to extend and expand those conversations over time and with different audiences. The conversations that have culminated in this book were initially stimulated through a research project at The Hastings Center on the role of religious voices in the professional fields of bioethical inquiry. Those professional conversations have continued throughout my academic career as a member of various institutional ethics committees, organizational ethics task forces, and in local, state, and national public policy (...) settings. The professional context of bioethics conversations can sometimes miss the richness of conversations that occur in the classroom and with various communities, including family members, friends, and religious and civic communities. These conversations provide an experiential depth, a groundedness in the lives and stories of persons, which augments and corrects the professionalized perspectives. I have been particularly fortunate and appreciative of opportunities to bridge the academic and professional with the personalized and communal through conversations about the ethical commitments and moral culture cultivated by The Church of Jesus Christ of Latter-day Saints (LDS or Mormon). I was invited to develop an overview essay on "Bioethics in Mormonism" for the professional reference work, Encyclopedia of Bioethics (3rd ed., 2004), and some years later received my first invitation to make a presentation on "LDS Ethics" in an academic setting at the University of Virginia. This book is the outgrowth of these many conversations and seeks to advance my communal bridging. My aim in this book is to begin bridging these various intersections between the LDS religious community and its moral culture, the professional fields of bioethics, and practical decision-making. This work seeks to be a catalyst for expanding discourse within the interdisciplinary field of Mormon studies to include ethics and bioethics. Ethics has not been a well-developed area in Mormon studies, in contrast to studies in LDS history, theology, or literature. To remedy this oversight, I present a substantive interpretation of the sources, theological background, and moral principles of LDS ethics. The historical narratives and conceptual intertwining I offer of both bioethics and of LDS moral culture is intended to complement and expand the realm of Mormon studies. A further objective is to create opportunities for reciprocal dialogues between the bioethics community and LDS scholarship. This conversation has yet to occur within academic disciplines, professional communities, or in public policy deliberations. My exposition, analysis, and critiques will intertwine and contextualize LDS moral values and health care practices within the ethical inquiry undertaken in the broader professional scholarship of bioethics. My arguments will disclose some points of common ground as well as areas of divergence towards the end of establishing the LDS faith tradition as a community of moral discourse for the bioethics field and the healing professions (medicine, nursing, pharmacy, etc.) it informs. My claim is that given its emerging cultural prominence, LDS ethical scholarship should engage in bioethical literacy and bioethics should be LDS-literate. I am also engaged in an effort to initiate more reflective dialogues regarding LDS ethics and moral culture among LDS scholars, LDS health care professionals, and the interested general LDS reader. The focus of the book on the interrelationship of religion, ethics, medicine, and health care should present for these various audiences new opportunities for mindful reflection and creative scholarship on the ethical implications of faith commitments, the responsibilities of the healing professions, and religious dimensions of public policy and public bioethics. A religious community that is formed through narratives and practices of covenantal commitments of love of neighbor needs to have a robust discourse about its ethical character. I have understood my scholarship in biomedical ethics and in religious ethics through a linking metaphor of my moral culture, of medicine, and the law, of bearing witness. The witness offers moral realities, moral truths about the way things are, vocalizes and embodies moral experience, and prophetically critiques the hypocrisies of the powerful and their oppression of the vulnerable by offering a new story, a re-storying, of tradition and conventional practice. (shrink)

In this article, it is argued that an appropriate starting point for an analysis of ethical issues in health care is the consideration of the role obligation of health care professionals. These obligations have customary, legal, and moral elements. By appreciating the different kinds of health care roles and their purposes, one can begin to understand some of the role conflicts which arise in the health care community. Moreover, one can (...) see that some criticisms of health care professionals are mistaken. Nonetheless, there are internal conflicts with the roles of persons engaged in health care and historically some role obligations have violated fundamental universal norms. Whereas the latter inadequacy of health care role obligations can be eliminated, the former will, to at least some extent, always be with us. In short, it may be argued that some of the so-called "moral dilemmas" in health care can be resolved by taking the perspective of role morality. As will be shown, this does not suggest that there are no limitations of role morality. CiteULike Connotea Del.icio.us What's this? (shrink)

This book proposes a new, rationally-justified, evidence-based theory concerning values. It discusses practical applications of these universally-applicable values, especially to morality, society, education and upbringing. In doing so, it discusses sexism, sexuality, racism, freedom, politics, law, animal rights, environmental ethics, health-care, war, economics, psychology, science, literature, religion, and much more.

Dilemma discussions have been proven to be one of the most effective methods to enhance students’ moral reasoning in ethics education. Dilemma discussions are increasingly arranged online, but research on the topic has remained sparse, especially in the context of continuing professional education. The aim of the present paper was to develop a method of dilemma discussions for professional ethics. The method was based on asynchronous discussions in small groups. Health and social care students raised work-related dilemmas (...) from their experiences and discussed them in terms of professional values, ethical guidelines and theories. Participants in this quasi-experimental study were 87 first-term graduate students at a Finnish university of applied sciences. Health and social care students in two consecutive ethics courses constituted two experiment groups, whereas health and social care students and business students in other programmes served as control groups. Students filled in a Defining Issues Test (DIT2) at the beginning of their studies and three months apart. Statically significant increase in moral reasoning was evidenced for experiment group 2, when discussion groups were purportedly composed to maximise differences in initial levels of moral reasoning. Findings suggest that online dilemma discussions can advance students’ moral reasoning development, especially when students’ exposure to higher-level arguments is ensured through complementary means, such as instructions, examples and plenary discussions. Online real-life dilemma discussions may also serve other important goals of ethics education, especially acquiring ethical concepts, and they can promote other components of ethical decision making: ethical sensitivity and motivation, and acquisition of implementation skills. (shrink)

An incisive examination of bioethics and American healthcare, and their profound affects on American culture over the last sixty years, from two eminent scholars. An eye-opening look at the inevitable moral choices that come along with tremendous medical progress, Everybody Wants to Go to Heaven but Nobody Wants to Die is a primer for all Americans to talk more honestly about health care. Beginning in the 1950s when doctors still paid house calls but regularly withheld the truth (...) from their patients, Amy Gutmann and Jonathan D. Moreno explore an unprecedented revolution in health care and explain the problem with America’s wanting everything that medical science has to offer without debating its merits and its limits. The result: Americans today pay far more for health care while having among the lowest life expectancies and highest infant mortality of any affluent nation. Gutmann and Moreno—“incisive, influential, and pragmatic thinkers” (Arthur Caplan)—demonstrate that the stakes have never been higher for prolonging and improving life. From health care reform and death-with-dignity to child vaccinations and gene editing, they explain how bioethics came to dominate the national spotlight, leading and responding to a revolution in doctor-patient relations, a burgeoning world of organ transplants, and new reproductive technologies that benefit millions but create a host of legal and ethical challenges. With striking examples, the authors show how breakthroughs in cancer research, infectious disease, and drug development provide Americans with exciting new alternatives, yet often painful choices. They address head-on the most fundamental challenges in American health care: Why do we pay so much for health care while still lacking universal coverage? How can medical studies adequately protect individuals who volunteer for them? What’s fair when it comes to allocating organs for transplants in truly life-and-death situations? A lucid and provocative blend of history and public policy, this urgent work exposes the American paradox of wanting to have it all without paying the price. (shrink)

Health care ethics is a sensitive domain, which if ignored, can lead to patient dissatisfaction, weakened doctor–patient interaction and episodes of violence. Little importance has been paid to medical ethics within undergraduate medical education in developing countries such as Pakistan. Three doctors in Pakistan are currently facing an official police complaint and arrest charges, following the death of a sanitary worker, who fell unconscious while cleaning a drain and was allegedly refused treatment as he was covered in sewage (...) filth. The medical license of the doctors in question should be cancelled, if found guilty following a thorough investigation into the case. The ‘right to life’ has been universally assured by all moral, cultural and legal codes and no society can ever argue against the sacredness of a human life. It is quite clear that the aforesaid doctors’ actions are not only against the core principles of the physicians’ code, but also go against the doctrine of human rights. If serious efforts on an urgent basis are not made by the regulatory and governing bodies, one can definitely expect similar incidents for at least a few more decades before any noticeable change is seen. (shrink)

In addressing issues of access to health care and rationing, Jewish and Roman Catholic writers identify similar guiding values and specific concerns. Moral thinkers in each tradition tend to support the guarantee of universal access to at least a basic level of health care for all members of society, based on such values as human dignity, justice, and healing. Catholic writers are more likely to frame their arguments in terms of the common good (...) and to be more accepting of rationing that denies beneficial and needed health care to some persons. Jewish writers are more likely to consider individual responsibility for illness in allocation decisions and to accept differences in the health care that different members of society receive. The article considers the relevance of both shared and complementary perspectives for deliberations in nations such as the United States. (shrink)

Problem An estimated 100,000–500,000 migrant care workers provide live-in care in German households, many of them caring for older people with dementia. Social research has identified a wide range of structural social problems associated with live-in care. However, a systematic ethical analysis and discussion is still missing. Arguments This article explores the moral conflicts that arise in the microsetting of live-in arrangements for people with dementia. For this purpose, we conduct an ethical analysis of the (...) expectations of relatives towards live-in care for people with dementia based on a qualitative content analysis of 182 contributions from three German-language online forums. These expectations address live-ins as service providers, professional nurses, moral agents, and family members. Conclusion The diverse and often disappointed expectations of relatives are an expression of problematic and partly contradictory claims regarding live-in care for people with dementia. An ethical analysis of their legitimacy and coherence can help to improve the individual arrangement, the institutional organisation, and the moral framing and legal regulation of live-in care. (shrink)

Background Moral courage means courage to act according to individual’s own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower. Objective To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care. Research design Was a descriptive-correlational study using a questionnaire, containing Nurses (...) Moral Courage Scale©, a video vignette of the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives. Participants and research context Nurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses’ Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette. Ethical considerations Good scientific inquiry guidelines were followed. Permission to use the Nurses’ Moral Courage Scale© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses’ Association. Findings The mean value of potential whistle-blowers’ moral courage on a Visual Analogue Scale (0–10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers’ moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables. Discussion and conclusion In health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing. (shrink)

This book provides an analysis of the debate surrounding cultural diversity, and attempts to reconcile the seemingly opposing views of "ethical imperialism," the belief that each individual is entitled to fundamental human rights, and cultural relativism, the belief that ethics must be relative to particular cultures and societies. The author examines the role of cultural tradition, often used as a defense against critical ethical judgments. Key issues in health and medicine are explored in the context of cultural diversity: the (...) physician-patient relationship, disclosing a diagnosis of a fatal illness, informed consent, brain death and organ transplantation, rituals surrounding birth and death, female genital mutilation, sex selection of offspring, fertility regulation, and biomedical research involving human subjects. Among the conclusions the author reaches are that ethical universals exist, but must not be confused with ethical absolutes. The existence of ethical universals is compatible with a variety of culturally relative interpretations, and some rights related to medicine and health care should be considered human rights. Illustrative examples are drawn from the author's experiences serving on international ethical review committees and her travels to countries in Africa, Asia, and Latin America, where she conducted educational workshops and carried out out her own research. (shrink)

Human beings working in fields involving life, death, and morality are going to have fundamental and occasionally irreconcilable differences of opinion regarding goals, values, and actions. This has been true from the beginning of civilization. Along the way, civilized peoples have created laws that accommodate these differences so that a diverse population can coexist peaceably in one pluralistic society. As such, the Law is the practical, inchoate expression of that society's combined morals.For more than a decade, scholarly articles about conscientious (...) objection in medical care have tended to involve one group of people telling other groups what they must value and how they must behave in order to be good... (shrink)

In the United States, judicialrulings that unrealistically addressed the complexityof cases and demonstrated limited understanding ofprinciples, helped to create a legal quagmire whichlegislatures had to confront. Moreover, thelegislative response was often slow and inadequate interms of both the scope and clarity of the laws. However, since the 1970s, progress has been made onmany fronts, particularly in regard to advancedirectives dealing with end-of-life decisions. Thedebate over physician-assisted suicide has spawned arepetition of moral and legal arguments. Thoseagainst legalization (...) have failed to make a realisticappraisal of the dilemmas facing patients and theirfamilies in an age of technological medicine deliveredin the context of the marketplace. The underlyingproblem is a system in dire need of reform that willno longer treat health care as a commodity of themarketplace and provide universal health care. Terminal care as an integral part of health care willsubstantially benefit from such reforms because amajor obstacle to comprehensive palliative care is thecondition of the present system. (shrink)

The concept of solidarity has achieved relatively little attention from philosophers, in spite of its signal importance in a variety of social movements over the past 150 years. This means that there is a certain amount of preliminary philosophical work concerning the concept itself that must be undertaken before one can ask about its potential use in arguments concerning the provision of health care. In this paper, I begin with this work through a survey of some of (...) the most prominent bioethical, political philosophical and intellectual historical literature concerned with the project of determining a philosophically specific and historically perspicacious meaning of the term ‘solidarity’. This provides a conceptual foundation for a sketch of a four-tiered picture of social competition and cooperation within the nation-state. Corresponding to this picture is a four-tiered account of health care provision. These two models, taken together, provide a framework for articulating the conclusion that, while there are myriad examples of solidarity in claiming health care for some, or even many, the concept does not provide a basis for claiming health care for all. (shrink)

Environmental pollution and greenhouse gas emissions that contribute to climate change have adverse impacts on global health. Somewhat paradoxically, health care systems that aim to prevent and cure disease are themselves major emitters and polluters. In this paper we develop a justification for the claim that solidaristic health care systems should include sustainability as one of the criteria for determining which health interventions are made available or reimbursed – and which not. There is however (...) a complication: most adverse health effects due to climate change do occur elsewhere in the world. If solidarity would commit us to take care of everyone’s health, worldwide, it might imply that solidaristic health system cannot justifiably restrict universal access to their own national populations. In response we explain health solidarity is to be considered as a moral ideal. Such an ideal does not specify what societies owe to whom, but it does have moral implications. We argue that ignoring sustainability in political decision making about what health care is to be offered, would amount to betrayal of the ideal of solidarity. (shrink)

Patient autonomy has a critical role in making decisions in medical practice and it is accepted by international conventions on health care and various national medical codes. However, pertaining to terminally ill patients, this right becomes very problematic in regards to end of life decisions. Utilitarian ethicists motivated by materialistic worldview and individualism have made patient autonomy based arguments for the permissibility of active euthanasia. An appraisal of pro-euthanasia arguments that include the best interest, golden rule, (...) and autonomy is made in this paper. The best interest and golden rule arguments are based on subjective moral judgment thus failing the universalization test. The argument from autonomy is unconvincing because of the confounded autonomy of the terminally ill patients. (shrink)

Books have their origins in conversations and seek to extend and expand those conversations over time and with different audiences. The conversations that have culminated in this book were initially stimulated through a research project at The Hastings Center on the role of religious voices in the professional fields of bioethical inquiry. Those professional conversations have continued throughout my academic career as a member of various institutional ethics committees, organizational ethics task forces, and in local, state, and national public policy (...) settings. The professional context of bioethics conversations can sometimes miss the richness of conversations that occur in the classroom and with various communities, including family members, friends, and religious and civic communities. These conversations provide an experiential depth, a groundedness in the lives and stories of persons, which augments and corrects the professionalized perspectives. I have been particularly fortunate and appreciative of opportunities to bridge the academic and professional with the personalized and communal through conversations about the ethical commitments and moral culture cultivated by The Church of Jesus Christ of Latter-day Saints (LDS or Mormon). I was invited to develop an overview essay on "Bioethics in Mormonism" for the professional reference work, Encyclopedia of Bioethics (3rd ed., 2004), and some years later received my first invitation to make a presentation on "LDS Ethics" in an academic setting at the University of Virginia. This book is the outgrowth of these many conversations and seeks to advance my communal bridging. My aim in this book is to begin bridging these various intersections between the LDS religious community and its moral culture, the professional fields of bioethics, and practical decision-making. This work seeks to be a catalyst for expanding discourse within the interdisciplinary field of Mormon studies to include ethics and bioethics. Ethics has not been a well-developed area in Mormon studies, in contrast to studies in LDS history, theology, or literature. To remedy this oversight, I present a substantive interpretation of the sources, theological background, and moral principles of LDS ethics. The historical narratives and conceptual intertwining I offer of both bioethics and of LDS moral culture is intended to complement and expand the realm of Mormon studies. A further objective is to create opportunities for reciprocal dialogues between the bioethics community and LDS scholarship. This conversation has yet to occur within academic disciplines, professional communities, or in public policy deliberations. My exposition, analysis, and critiques will intertwine and contextualize LDS moral values and health care practices within the ethical inquiry undertaken in the broader professional scholarship of bioethics. My arguments will disclose some points of common ground as well as areas of divergence towards the end of establishing the LDS faith tradition as a community of moral discourse for the bioethics field and the healing professions (medicine, nursing, pharmacy, etc.) it informs. My claim is that given its emerging cultural prominence, LDS ethical scholarship should engage in bioethical literacy and bioethics should be LDS-literate. I am also engaged in an effort to initiate more reflective dialogues regarding LDS ethics and moral culture among LDS scholars, LDS health care professionals, and the interested general LDS reader. The focus of the book on the interrelationship of religion, ethics, medicine, and health care should present for these various audiences new opportunities for mindful reflection and creative scholarship on the ethical implications of faith commitments, the responsibilities of the healing professions, and religious dimensions of public policy and public bioethics. A religious community that is formed through narratives and practices of covenantal commitments of love of neighbor needs to have a robust discourse about its ethical character. I have understood my scholarship in biomedical ethics and in religious ethics through a linking metaphor of my moral culture, of medicine, and the law, of bearing witness. The witness offers moral realities, moral truths about the way things are, vocalizes and embodies moral experience, and prophetically critiques the hypocrisies of the powerful and their oppression of the vulnerable by offering a new story, a re-storying, of tradition and conventional practice. (shrink)

This paper argues for the necessity of universal health care (as well as universal free education) using a different argument than most that have been made heretofore. It is not meant to conflict with but to strengthen the arguments previously made by others. Using the second paragraph of the Declaration of Independence and the Preamble to the Constitution we argue that universal health care in this day and age has become a necessary (...) condition if the ideals of life, liberty and the pursuit of happiness are to be more than an empty promise and if the discussion of “promoting of general welfare” in the preamble is to have any meaning. (shrink)

The United Nations Educational, Scientific, and Cultural Organization's (UNESCO) Universal Declaration on Bioethics and Human Rights announces a significant array of welfare entitlements—to personal health and health care, medicine, nutrition, water, improved living conditions, environmental protection, and so forth—as well as corresponding governmental duties to provide for such public health measures, though the simple expedient of announcing that such entitlements are “basic human rights.” The Universal Declaration provides no argument for the legitimacy of the (...) sweeping governmental authority, taxation, and regulation to create and impose such “rights.” As this paper explores that some action promotes a purported good, such as “health,” does not thereby make the action morally permissible. Just as there are moral limits on legitimate personal actions, there are also moral limits on legitimate governmental actions to promote purported goods, including health. A core question of any governmental regulation, therefore, is whether it is a legitimate application of moral political authority or an unauthorized act of state coercion. Pace UNESCO's wide-ranging assertions, this paper argues that promoting health only falls within the legitimate authority of governments in very narrowly defined circumstances. As the paper critically explores, at stake are foundational moral and political questions concerning the limits of governmental authority to intervene in the consensual interaction of persons. Imposing such duties on others, including citizens of a state through regulatory activity and taxation, must be justified, nonarbitrary, and demonstrably within the limits of moral political authority. UNESCO's assertions do not meet this burden of proof. (shrink)

There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient’s actual situation (...) is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients’ needs and legal rights to healthcare and on nurses’ codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients’ needs in different settings and may thus be different in different contexts and countries. (shrink)

This article discusses cosmopolitanism as the moral foundation for access to health care for migrants. The focus is on countries with sufficiently adequate universal health care for their citizens. The article argues for equal access to this kind of health care for citizens and migrants alike—including migrants at special risk such as asylum seekers or undocumented migrants. Several objections against equal access are raised, such as the cosmopolitan approach being too restrictive or (...) too permissive, or the consequences being undesirable; but the objections are largely refuted. Some special cases in which a restriction of equal access to health care might be justified are described: humanitarian crisis, short term tourism, and the case of a migrant or refugee who will stay only very briefly on a state's territory. (shrink)

Is the science of moral cognition usefully modelled on aspects of Universal Grammar? Are human beings born with an innate 'moral grammar' that causes them to analyse human action in terms of its moral structure, with just as little awareness as they analyse human speech in terms of its grammatical structure? Questions like these have been at the forefront of moral psychology ever since John Mikhail revived them in his influential work on the linguistic analogy (...) and its implications for jurisprudence and moral theory. In this seminal book, Mikhail offers a careful and sustained analysis of the moral grammar hypothesis, showing how some of John Rawls' original ideas about the linguistic analogy, together with famous thought experiments like the trolley problem, can be used to improve our understanding of moral and legal judgement. (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)

Discussions concerning whether there is a natural right to health care may occur in various forms, resulting in policy recommendations for how to implement any such right in a given society. But health care policies may be judged by international standards including the UN Universal Declaration of Human Rights. The rights enumerated in the UDHR are grounded in traditions of moral theory, a philosophical analysis of which is necessary in order to adjudicate the value (...) of specific policies designed to enshrine rights such as a right to health care. We begin with an overview of the drafting of the UDHR and highlight the primary influence of natural law theory in validating the rights contained therein. We then provide an explication of natural law theory by reference to the writings of Thomas Aquinas, as well as elucidate the complementary “capabilities approach” of Martha Nussbaum. We conclude that a right to health care ought to be guaranteed by the state. (shrink)

Proposed solutions to the problems of this country's health care system range along a spectrum from central planning to free market. Central planners and free market advocates provide various ethical justifications for the policies they propose. The crucial flaw in the philosophical rationale of central planning is failure to distinguish between normative and metanormative principles, which leads to mistaken understanding of the nature of rights. Natural rights, based on the principle of noninterference, provide the link between individual morality (...) and social order. Free markets, the practical expression of natural rights, are uniquely capable of achieving the goals that central planners seek but find beyond their grasp. The history of this country's health care system and the experiences of other nations provide evidence of the superiority of free markets in reaching for the goals of universal access, control of costs, and sustaining the quality of health care. (shrink)

Artificial intelligence systems advising healthcare professionals will be widely introduced into healthcare settings within the next 5–10 years. This paper considers how this will sit with tort/negligence based legal approaches to compensation for medical error. It argues that the introduction of AI systems will provide an additional argument pointing towards no-fault compensation as the better legal solution to compensation for medical error in modern health care systems. The paper falls into four parts. The first part rehearses (...) the main arguments for and against no-fault compensation. The second explains why it is likely that AI systems will be widely introduced. The third part analyses why it is difficult to fit AI systems into fault-based compensation systems while the final part suggests how no-fault compensation could provide a possible solution to such challenges. (shrink)

The principles of equality and equity, respectively in the Bill of Rights and the white paper on health, provide the moral and legal foundations for future health care for children in South Africa. However, given extreme health care need and scarce resources, the government faces formidable obstacles if it hopes to achieve a just allocation of public health care resources, especially among children in need of highly specialised health care. (...) In this regard, there is a dearth of moral analysis which is practically useful in the South African situation. We offer a set of moral considerations to guide the macro-allocation of highly specialised public health care services among South Africa's children. We also mention moral considerations which should inform micro-allocation. (shrink)

Beginning my third year with the Kansas City Chiefs and being also a medical student at McGill University, I was at first a little reluctant to comment on Glenn Cohen et al.’s critique of the National Football League's structure involving player health and team doctors, but the opportunity to provide a perspective as both a football player and a medical student was too much to forgo. Because of my athletic and academic background, I am often asked what I think (...) about injuries in professional sports and about the role of sports medicine physicians, and Cohen et al.’s article demands a thoughtful reaction. I want to suggest that the fundamental principles concerning the medical profession and the doctor-patient relationship provide additional arguments for some of the solutions that Cohen et al. discuss. The professional self-regulation that the proposed medical committee could provide and the reliance on a doctor who was not hired by the player's employer—the club—for a second opinion are both good ways to minimize conflicts of interest. (shrink)

This book provides the reader with a theoretical and practical understanding of two health care delivery models: the patient/child centred care and family-centred care. Both are fundamental to caring for children in healthcare organizations. The authors address their application in a variety of paediatric healthcare contexts, as well as the ethical and legal issues they raise. Each model is increasingly pursued as a vehicle for guiding the delivery of health care in the best (...) interests of children. Such models of health care delivery shape health care policies, programs, facility design, resource allocation decisions and day-to-day interactions among patients, families, physicians and other health care professionals. To maximize the health and ethical benefits these models offer, there must be shared understanding of what the models entail, as well as the ethical and legal synergies and tensions they can create. This book is a valuable resource for paediatricians, nurses, trainees, graduate students, practitioners of ethics and health policy. (shrink)

Because the goal of military medicine is salvaging the wounded who can return to duty, military medical ethics cannot easily defend devoting scarce resources to those so badly injured that they cannot return to duty. Instead, arguments turn to morale and political obligation to justify care for the seriously wounded. Neither argument is satisfactory. Care for the wounded is not necessary to maintain an army's morale. Nor is there any moral or logical connection between the right (...) to health care (a universal human right) and the duty to defend one's nation (a local political duty). Once badly wounded, soldiers enjoy the same right to medical care as any similarly ill or injured individual. National health care systems grasp this point and offer few additional health care benefits to veterans. In the United States, however, lack of universal health coverage skews the debate to focus on special entitlements for veterans without considering the health care rights that other citizens enjoy. (shrink)

Doctors’ strikes are legally permissible in the UK, with the situation differing in other countries. But are they morally permissible? Doug McConnell and Darren Mann have systematically attempted to dismiss the arguments for the moral impermissibility of doctors’ strikes and creatively attempted to provide further moral justification for them. Unfortunately for striking doctors, they fail to achieve this. Meanwhile, junior doctors’ strikes have continued in the UK through 2023 and have now extended into 2024. In this response, (...) which focuses on the UK situation and specifically junior doctors’ strikes in the National Health Service (NHS) in England, I will demonstrate a central problem with their arguments—namely that they underplay the harms caused by prolonged doctors’ strikes by ignoring the harms to patients with cancer. This weakens their conclusion that strikes are morally permissible in terms of the conditions and thresholds they set. I then provide a psychological critique of their justification for strikes in terms of the interests of the public. It follows that invoking the controversial concept of supererogatory action is ungrounded but also absurd when you consider time-critical cancer care. If those representing striking doctors wish to maintain a modicum of moral respectability, they should mitigate for patients with cancer and negotiate reasonably and with urgency. (shrink)

Ethical issues about children’s rights in respect of matters concerning resource allocation or treatment opportunities are now a matter for public consumption and concern. Alongside this exists a long-frustrated desire by children’s nurses to promote children’s health. Long-held assumptions about the legal and moral status of children within the health care system in this country are now rightly scrutinized and challenged. Those of us who claim to represent children now possess an opportunity to exploit public (...) attention for the benefit of these children. This article will explore selected major relevant legal and moral concepts that relate to children with the aim of making transparent some of the important and often confusing information available. It is anticipated that debates about the legal and ethical status of children may be stimulated and fuelled from the following discussion. It is strongly recommended that entering into dialogue with families and children about their perceived needs will go a long way towards advancing thoughtful nursing care of individual children, their families and the general population. (shrink)