Public reason demands that policies are justified to all reasonable citizens. Public health aims at protecting or improving aggregated health outcomes. Since health is not an uncontroversial value, an insurmountable chasm between public reason and public health seems to preclude any viable synthesis between the two outlooks. For any given public health policy, some reasonable citizen seems to have a reason to support ‘no policy’ over ‘some policy’, meaning that the policy cannot be justified to all. (...) The paper first spells out what exactly this conflict is about. Then, using smoking as a case, the paper outlines a model of reconciliation between public reason and public health that should give us some optimism if we want to have public health policies that are compatible with treating citizens as free and equal in the public reason sense. (shrink)

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This is lightly edited and referenced version of a presentation given at the 20th International Philosophy of Nursing conference in Quebec on 23rd August 2016. Philosophical texts are not given the same prominence in nurse education as their more valued younger sibling, primary research evidence, but they can influence practice through guidelines, codes and espoused values. John Stuart Mill’s harm principle, found in On Liberty, is not a universal law, and only a thoroughgoing libertarian would defend it as such, though (...) it, or its remnants, can be seen can be seen in policy documents. But its influence is weakening. Smoking bans in enclosed spaces were initially justified with other‐regarding considerations, but judgements from unsuccessful legal challenges from patients in UK psychiatric hospitals rely on preventing harm to the smoker, even when smoking outside, which does not harm others. In the wake of legislation, no‐smoking policies enacted by hospitals are becoming more aggressive, banning smoking both inside and outside, and extending the use of power gained through employment to prevent nurses assisting patients enjoy a lawful habit. Mill’s dictum has been subverted, and this speaks to the fundamental purpose of nursing. Should nurses collude and willingly exert their power for their version of the good of the patient? Or should they instead reaffirm values that support and facilitate life choices made by autonomous people? The paper supports the latter option, and this has wider application for nursing which can be illuminated, if not settled, by revisiting Mill and his famous dictum. (shrink)

It is axiomatic that tobacco smoking is hazardous to health. The statistics are well documented and often very grim. For example, the 2008 World Health Organization Report on the global tobacco epidemic presented the following statistics: a hundred million people died of tobacco-related diseases globally in the 20th century; there are approximately over five million tobacco-related deaths every year; and an estimated one billion could die of tobacco-related diseases in this 21st century.Significantly, no other risky, self-indulgent addictive behaviors such (...) as cocaine abuse directly endanger bystanders as much as cigarette smoking or tobacco use endangers nonsmokers through secondhand tobacco smoke or inhaled environmental tobacco smoke. Environmental tobacco smoke comprises sidestream smoke and mainstream smoke. About 85 percent of environmental tobacco smoke is sidestream smoke, while the remainder is mainstream smoke. (shrink)

Corporate social responsibility has become a potential path to legitimacy and improved public relations for both companies that produce mainstream products and those that sell vice, such as the tobacco industry. Since the early 1990s, the tobacco industry has sought to bridge the gap between the public perception it has earned as a merchant of death and its goal of gaining corporate legitimacy and normality by promoting programs, positions, and policies it hopes the general public will believe are aimed at (...) preventing or mitigating some of the societal ills that smoking causes, such as youth smoking. There is, however, an intractable problem that corporate social responsibility efforts can mask but not resolve: the tobacco industry’s products are lethal when used as directed, and no amount of public relations or funding of ineffective youth smoking prevention programs can reconcile that fundamental contradiction with ethical corporate citizenship. The focus of this study is to better understand the tobacco industry’s corporate social responsibility efforts and to assess whether there has been any substantive change in the way it does business with regard to the issue of exposure to secondhand smoke. (shrink)

ABSTRACT There is a fierce debate about nonsmokers-only hiring policies, also referred to as no-nicotine hiring policies and “tobacco free” hiring policies. The favorable outcomes of no-nicotine hiring policies include reduced health costs, improved worker productivity, enhanced organizational image, and symbolic messaging. The unfavorable consequences of such policies include violating personal liberty, risking a “slippery slope” to other health-compromising behaviors, exacerbating socio-economic disparities, and discriminating against smokers. No-nicotine hiring policies have not been adequately evaluated and a new approach is warranted. (...) The new conditional employment policy for smokers is described with stipulations for the probationary period. Autonomy and fairness are frequently cited as ethical principles to analyze no-nicotine hiring policies. An analysis of ethical principles is presented for no-nicotine hiring policies and the new conditional employment policy. The ethical principle of fairness is rooted in the effectiveness of any policy. Therefore, an evaluation plan is described for the conditional employment policy to assess effectiveness and efficiency. The proposed policy provides a powerful incentive to overcome smoking addictions, preserve the ethical principles of autonomy and fairness, as well as bridge the divide between personal liberty and personal responsibility. (shrink)

Smoking remains the leading cause of preventable disease and death in the United States, killing approximately 480,000 people each year. This crushing health burden falls disproportionately, and recent CDC data shows that large disparities in adult cigarette smoking remain. One factor in these disparities is the use of flavors. Menthol cigarettes and other flavored tobacco products are used at higher rates by vulnerable populations including youth and young adults, African Americans, women, Hispanics and Asian Americans. This is no (...) accident; the tobacco industry has long targeted these same groups. Given FDA's failure to act to ban flavored tobacco products, states and municipalities are considering taking matters into their own hands to protect their communities from these dangerous products. The authors will explore state and local authority to restrict the sales of these products and review the evidence base indicating that removing flavored tobacco products – and menthol combustible products in particular - from the market would significantly reduce the toll of illness and death caused by these products. (shrink)

The specific purpose of this introductory paper is to explicitly introduce readers to some of the important Biblical, Talmudic, andpost-Talmudic texts which deal with business ethics. As the discussion will show, Judaism’s traditional texts treat an amazing variety of issues emphasizing responsibilities in the business context. These texts are both legalistic and aspirational in character. The theme of this study is that an authentic Jewish business ethics needs to grow out of an understanding of the needs of modern, complex economies (...) but need not accept the status quo as binding. Jewish business ethics texts provide rules of behavior, but more importantly, the texts reveal a vision encouraging us to incorporate the highest human and spiritual ideals into the common world of business.The second section of the paper emphasizes that in order to develop Jewish business ethics, especially (but not exclusively) at the levelof the organization, models of aspiration will of necessity play an integral role. A Jewish business ethics which conceptualizes Judaismas merely a set of legal rules is bound to failure. A key conclusion of this section is that Jewish business ethics needs to continue to self-consciously promote models of aspirations, as well as rely on fixed legal norms.Finally, the third section of the paper examines a specific corporate policy (no smoking) in light of a Jewish business ethics. (shrink)

Whereas smoking was once linked both to sexuality and transcendence, smoking is now correlated with medicalized death. Smoking is unhealthy because health and sex are redefined as secular rather than transcendental conduct. Freud worried about the health of civilization but did not analyse his own addiction to cigars whose smoke enveloped the practice of psychoanalysis. In the character of Zeno the paradox of the pleasure principle is reconnected to its `beyond' through the mother's complicity in the child's (...) original theft of fire. This stolen memory in turn underwrites Zeno's adult discovery of the inexhaustible pleasure of smoking each cigarette as the last cigarette, borrowing life from death. (shrink)

We use the example of the introduction of the anti-smoking legislation to model the relationship between the cultural make-up, in terms of values, of societies and the acceptance of and compliance with norms. We present two agent-based simulations and discuss the challenge of modeling sanctions and their relation to values and culture.

Smoking has long been declared a health hazard. In 1964, the U.S. Surgeon General revealed that smoking was related to lung cancer. Subsequent reports linked smoking to numerous other health problems. Recent statements by the Surgeon General indicated smokers do have the right to decide to continue or quit; however, their choice to continue cannot interfere with the nonsmoker's right to breathe smoke-free air.The full impact of adverse health consequences of involuntary smoking may not be recognized (...) yet. Smoke is now known to affect everyone who breathes it. Even when one doesn't smoke, the nonsmoker is susceptible to the ill effects because of inhaling smoke. (shrink)

One of the most unpredictable things the pandemic brought to our societies was the closure of hospitals and other health services to visitors. Preventing the spread of infection was the main reason for these decisions in the early days of the pandemic when there was no clarity about the means of transmission and the origin of the virus. However, in view of the persistence of the restrictions to date and the numerous negative consequences they have had on the professional and (...) personal quality of life of doctors, nurses, patients and carers, the aim of this article is to analyse in depth the reasons why these decisions have been and, above all, are still being applied, also considering the hypothesis that the choices made so far in the training of health professionals should be questioned. The persistence of restrictions, the constant reduction of human and economic resources in the face of an increase in the demand for care have exacerbated the distance between health professionals and users, to the point of escalating into actual acts of violence and aggression. According to the Critical Pedagogy approach, educators can play a central role in activating formative and collaborative strategies, such as maieutic groups, to rebuild an alliance between those who today find themselves on opposite sides: health professionals on the one hand, and patients and families on the other. (shrink)

Various authors have argued that in the future not only will it be technically feasible for human minds to be transferred to other substrates, but this will become, for most humans, the preferred option over the current biological limitations. It has even been claimed that such a scenario is inevitable in order to solve the challenging, but imperative, multi-agent value alignment problem. In all these considerations, it has been overlooked that, in order to create a suitable environment for a particular (...) mind – for example, a personal universe in a computational substrate – numerous other potentially sentient beings will have to be created. These range from non-player characters to subroutines. This article analyzes the additional suffering and mind crimes that these scenarios might entail. We offer a partial solution to reduce the suffering by imposing on the transferred mind the perception of indicators to measure potential suffering in non-player characters. This approach can be seen as implementing literal empathy through enhanced cognition. (shrink)

There is no more striking public health triumph than the demise of the “brown plague.” The cigarette was once the accoutrement of a good life, but smoking is now a tragic habit of the poor. By the mid‐1960s, half of all men and a third of women in the United States smoked. Today the national prevalence is 18 percent, with rates in major cities below 15 percent. A suite of policies drove down smoking rates—antismoking campaigns, taxation, clean air (...) laws, package labeling, and marketing curbs. These policies, and the resultant behavior changes, however, have diminishing returns. Is it possible that tobacco rates will remain relatively stagnant? If so, what “endgame” strategies might drive rates to negligible levels, say, lower than 5 percent? And if society does achieve such an audacious goal, how attentive should it be to the problems of social justice? (shrink)

This paper offers a relatively comprehensive assessment of government anti-smoking policies (both taxation and other regulatory measures). I conclude that interventions to engender in smokers and prospective smokers an accurate perception of tobacco's health risks are justified, that except in the case of adolescents addiction by itself does not justify intervention beyond providing adequate information, that the proper goal of tobacco taxation policy should be to recoup only the extra costs that smokers place on others (at most a (...) $1/pack tax on cigarettes), and that passive smoke's imposition of harm on unconsenting others strongly supports at least the development of a safe-to-others smokeless cigarette, if not direct intervention. (shrink)

Commemorating the life and work of Dr John Bennett; his lifelong contribution to Early Childhood Education and Care, and his ongoing influence on policy, research and practice in this field, In Search of Social Justice is a tribute to a preeminent scholar and his vision for an equitable and high-quality start for all children. Working tirelessly to raise the profile of Early Childhood Education and Care, and prioritise the rights and well-being of children and families in national and international (...) policy, John Bennet played an invaluable role in improving the position of young children globally. In Search of Social Justice takes John's legacy as a starting point for critical examination of the changing discourse on Early Childhood Education, and argues for the continued relevance of his approach. Drawing on personal reflections, vignettes and testimonials from eminent authors who shared their professional lives with him, the book foregrounds John's insistence that we must continue to shape policy and provision through inquiry, high-quality evidence, passion and persistence, improving the early experiences of all young children. As much a celebration of John's work and achievements, as a call to collective action towards achieving his vision for equitable, quality early childhood education and care, this is a fascinating read for students, researchers and activists in the field of Early Childhood Education and Care. (shrink)

Generating an account that can sidestep the disagreement among substantive theories of well-being, while at the same time still providing useful guidance for well-being public policy, would be a significant achievement. Unfortunately, the various attempts to remain agnostic regarding what constitutes well-being fail to either be an account of well-being, provide useful guidance for well-being policy, or avoid relying on a substantive well-being theory. There are no theory-free lunches in well-being policy. Instead, I propose an intermediate account, (...) according to which well-being is constituted by endorsed veridical experiences. This account refers back to theories of well-being but does so as agnostically as possible. An intermediate account of well-being is meant as a policy guiding compromise between the different theories of well-being that make claims regarding what constitutes well-being. An intermediate account does as well as can be hoped for in providing a basis for well-being policy. (shrink)

Analysts have generally offered two explanations for China's no-devaluation policy during the Asian financial crisis. The first is China's good economic fundamentals and the renminbi is not fully convertible. The second is China's foreign relations' imperative. China was endeavouring to seek favourable entry conditions into the WTO and improve relations with its Asian neighbours. At the same time it sought to exploit the undercurrent of resentment in Asia towards the role played by the US during the crisis. Policy (...) making in China has become more institutionalized in the post-Deng era, but these explanations ignore the role of China's domestic bureaucratic actors in exchange rate policy making. This paper examines the exchange rate regime preferences of China's key economic ministries and their influences in exchange rate policy making and argues that Party leaders were able to adopt a no-devaluation policy throughout the crisis because China's key economic ministries actively supported or acquiesced to that policy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:594 Feminist Studies 41, no. 3. © 2015 by Feminist Studies, Inc. Liberty Walther Barnes and Christin L. Munsch The Paradoxical Privilege of Men and Masculinity in Institutional Review Boards In the 1939 Hollywood classic The Wizard of Oz, the great wizard admonishes Dorothy and her friends to “pay no attention to that man behind the curtain.” Dorothy and company turn to see a man standing before a large (...) control panel operating the smoke, holographic image, and voice of the great wizard. Realizing he has been discovered, the man gives up manipulating the switches and the nebulous wizard vanishes.1 Hegemonic masculinity is analogous to the “all-powerful” wizard.2 In order to maintain its grandeur, power, and mystique, the mechanics of masculine ideology—as well as the social actors who participate in its reproduction —must be kept hidden.3 A crucial aim of feminist research is to 1. The Wizard of Oz, directed by Victor Fleming (Culver City, CA: Metro-Goldwyn -Mayer, 1939). 2. See R. W. Connell, Masculinities: Knowledge, Power and Social Change (Berkeley : University of California Press, 1995); R. W. Connell and James W. Messerschmidt, “Hegemonic Masculinity: Rethinking the Concept,” Gender & Society 19 (2005): 829–61; Michael Kaufman, “Me, Feminism, and Men’s Contradictory Experiences of Power,” in Theorizing Masculinities, ed. Harry Brod and Michael Kaufman (Thousand Oaks, CA: Sage Publications, 1994), 142– 63; and Michael S. Kimmel, “Masculinity as Homophobia: Fear, Shame, and Silence in the Construction of Gender Identity” in Brod and Kaufman, Theorizing Masculinities, 119–42. 3. Michael Flood and Bob Pease, “Undoing Men’s Privilege and Advancing Gender Equality in Public Sector Institutions,” Policy and Society 24, no. 4 (2005): 119–38; Allan G. Johnson, The Gender Knot: Unraveling Liberty Walther Barnes and Christin L. Munsch 595 pull back the curtain on men’s lives and masculine institutions in order to demystify socially constructed masculinities, particularly in their most powerful forms. As early feminist scholars note, male privilege renders women’s lives invisible.4 But male privilege renders aspects of men’s lives invisible, too. In this article we highlight how institutional review boards (IRBs) in universities and hospitals erect barriers to research that render particular aspects of men’s lives invisible. We draw on our experiences of submitting ten applications for a series of methodologically diverse studies of masculinity to eight IRBs. First, we argue that, despite their original function of protecting subordinated groups, IRBs are gendered institutions in which members base their decisions on culturally dominant, normative images of women and men. We show how this results in the stringent protection of male research participants, the safeguarding of participants’ personal masculinity, and the shielding of men’s lives from social inquiry. Second, we argue that IRBs are gendering institutions. Our experiences reveal how the privileging and protection of masculinity results in mandatory protocol modifications that idealize hegemonic masculinity. These modifications require researcher-participant interactions that socialize men to engage in gender “appropriate” behavior and reify gendered expectations. Third, our experiences reveal the ways in which IRBs protect the institution itself and privilege the universities, hospitals, and (predominantly male) medical doctors they represent. Consequently, the ways they reproduce social inequality remain impervious to academic inquiry. IRBS AS GENDERED AND GENDERING INSTITUTIONS Every university and hospital in the United States where human research is conducted houses a human research protections program, or IRB, to oversee academic research. Universities with hospitals typically our Patriarchal Legacy (Philadelphia, PA: Temple University Press, 1997); Michael Kimmel, Guyland: The Perilous World Where Boys Become Men (New York: Harper Collins, 2008). 4. Simone de Beauvoir, The Second Sex, trans. Howard M. Parshley (New York: Knopf, 1951); Sandra Harding, The Science Question in Feminism (Ithaca, NY: Cornell University Press, 1986); Dorothy E. Smith, “Women’s Perspective as a Radical Critique of Sociology,” in Feminist Perspectives on Social Research, ed. Sharlene N. Hesse-Biber and Michelle L. Yaiser (New York: Oxford University Press, 2004), 84–96. 596 Liberty Walther Barnes and Christin L. Munsch maintain two types of IRB committees: a social-behavioral committee that oversees studies in the social sciences, and a biomedical committee to supervise clinical drug trials, experimental medical treatments, and tissue and blood research. The duty of the... (shrink)

Reviews the book, Animal models of human psychology: Critique of science, ethics, and policy by Kenneth J. Shapiro . The principle focus of most of this text is on the present-day use of animals in psychological research. In particular, Shapiro examines contemporary animal models of eating disorders, showing how psychology came to rely so heavily on animal models in the first place and how prevalent scientific attitudes about the use of animals in the laboratory have taken shape over the (...) past several decades. In addition, he traces the recent rise of the animal rights movement and highlights the several philosophies upon which it is based. Drawing upon certain historical and empirical analyses, as well as certain themes in contemporary sociology of knowledge, Shapiro attempts to navigate his reader through the twin minefields of impassioned rhetoric and insufficiently examined conceptual commitment to a better understanding of the core issues surrounding the role of animals in scientific psychological investigation. 2012 APA, all rights reserved). (shrink)

This study addresses whether businesses discriminate against employees who smoke, which for the purposes of this study is called smokism. It began with a description of the employers' costs which led to the development of these smoking bans and examined several company policies as a result of these costs. The viewpoints from several perspectives toward these policies and their perceptions about smokers were also reviewed. This was followed by surveying the corporate smoking policies of 76 companies representing 287 (...) employees in the New York City metropolitan, as well as the viewpoints of these employees on these smoking policies. Several laws regarding the rights of smokers and nonsmokers were discussed and along with the company smoking policies described earlier were compared to those firms surveyed. Next, the philosophies of Locke, Kant, Rawls, and Nozick were examined to determine whether the current smoking policies would be deemed just or discriminatory. Conclusions and implications of this research then followed the analysis of these philosophical and legislative findings. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Environmental Genome Project and BioethicsRichard R. Sharp (bio) and J. Carl Barrett (bio)Eight years ago, the Kennedy Institute of Ethics Journal published a brief selection by Eric Juengst (1991) entitled “The Human Genome Project and Bioethics.” That essay introduced and described the Ethical, Legal, and Social Implications (ELSI) Program at the National Center for Human Genome Research. 1 Since that time, the ELSI program has grown to become (...) one of the largest and most well regarded bioethics programs in the country, sponsoring the work of hundreds of researchers and coordinating bioethics activities both nationally and internationally (Marshall 1996; Meslin, Thomson, and Boyer 1997). In 1991, however, Juengst, the first director of the ELSI program, had no way of anticipating these developments. Juengst’s goal in his essay was simply to highlight some of the moral and social issues that were emerging as focal points for the ELSI program. Looking back, the issues he outlined may seem vague and overly broad. At the time, however, the essay served an important purpose, to identify areas requiring additional study and thereby to serve as a guide to others interested in joining in these discussions.In many ways, Juengst’s article serves as an inspiration to those of us working on a new bioethics project. The National Institute of Environmental Health Sciences (NIEHS) recently launched a multi-year project aimed at better understanding genetic influences on environmentally associated diseases (Albers 1997; Brown and Hartwell 1998; Cannon 1997; Kaiser 1997). This project, known as the Environmental Genome Project (EGP), plans to identify and study a number of common genetic variants that may play an important role in determining how individuals respond to environmental exposures. NIEHS hopes that the information learned through the EGP will be instrumental in developing more effective disease-prevention strategies and intervention programs. Following the precedent developed in connection with the Human Genome Project, NIEHS also plans to address the moral and social implications of the EGP. Efforts in this regard include sponsoring workshops and conferences to address such issues, as well as supporting research on the ethical, legal, and social implications of the EGP. Through this work, NIEHS hopes to anticipate potential problems before [End Page 175] they arise and to develop policies that maximize the benefits of the research while avoiding potential misuses of the information learned.In exploring the social implications of the EGP, we at NIEHS are very fortunate to be able to draw upon the work being done by the ELSI program at the National Human Genome Research Institute (NHGRI), as well as the ever-expanding bioethics literature that has been sparked by the ELSI program. Still, there is much to be done and this is an exciting time for those of us involved with the EGP. Many of the ethical, legal, and social implications of the project are only beginning to become clearer, and several of these issues appear quite different from the sorts of concerns that have previously been discussed in connection with other types of genetic research.This essay highlights some of the ethical, legal, and social implications that are emerging as important focal points for the Environmental Genome Project. Like Juengst’s 1991 paper, the goal of this article is to provide an overview of current areas of interest and to encourage others to join us in thinking about these difficult issues.The Environmental Genome ProjectIndividuals differ greatly in their responses to chemicals, drugs, radiation, smoking, alcohol, and other environmental exposures. These differential responses are the result of complex interactions between many factors, including an individual’s genetic make-up, age, sex, nutritional status, and overall health. The EGP aims to better understand the genetic basis of differential responses to environmental exposures. The vast majority of diseases, many forms of cancer, for example, are the consequence of both environmental and genetic contributions (Perera 1997). Hence, understanding the relationships between genetic variation and response to environmental exposure is important for understanding the causes of human disease and is crucial for the development of effective disease-prevention strategies.The EGP and projects like it represent a new stage of genomic research. It is expected that the Human Genome Project will complete... (shrink)

Most experts would agree that the current medical malpractice system in the United States does not work effectively either to compensate victims fairly or prevent injuries caused by medical errors. Policy responses to a series of medical malpractice crises have not resulted in effective reform and have not altered the fundamental incentives of the stakeholders. In Medical Malpractice, economist Frank Sloan and lawyer Lindsey Chepke examine the U.S. medical malpractice process from legal, medical, economic, and insurance perspectives, analyze past (...) efforts at reform, and offer realistic, achievable policy recommendations. They review the considerable empirical evidence in a balanced fashion and assess objectively what works in the current system and what does not. Sloan and Chepke argue that the complexity of medical malpractice stems largely from the interaction of the four discrete markets that determine outcomes--legal, medical malpractice insurance, medical care, and government activity. After describing what the evidence shows about the functioning of medical malpractice, types of defensive medicine, and the effects of past reforms, they examine such topics as scheduling damages as an alternative to flat caps, jury behavior, health courts, incentives to prevent medical errors, insurance regulation, reinsurance, no-fault insurance, and suggestions for future reforms. Medical Malpractice is the most comprehensive treatment of malpractice available, integrating findings from several different areas of research and describing them accessibly in nontechnical language. It will be an essential reference for anyone interested in medical malpractice.Frank A. Sloan is J. Alexander McMahon Professor of Health Policy and Management and Professor of Economics at Duke University. He is the coauthor of The Price of Smoking and author or editor of many other books on health economics. Lindsey M. Chepke, an attorney, is a Research Associate at the Center for Health Policy at Duke University. (shrink)

Most experts would agree that the current medical malpractice system in the United States does not work effectively either to compensate victims fairly or prevent injuries caused by medical errors. Policy responses to a series of medical malpractice crises have not resulted in effective reform and have not altered the fundamental incentives of the stakeholders. In Medical Malpractice, economist Frank Sloan and lawyer Lindsey Chepke examine the U.S. medical malpractice process from legal, medical, economic, and insurance perspectives, analyze past (...) efforts at reform, and offer realistic, achievable policy recommendations. They review the considerable empirical evidence in a balanced fashion and assess objectively what works in the current system and what does not. Sloan and Chepke argue that the complexity of medical malpractice stems largely from the interaction of the four discrete markets that determine outcomes--legal, medical malpractice insurance, medical care, and government activity. After describing what the evidence shows about the functioning of medical malpractice, types of defensive medicine, and the effects of past reforms, they examine such topics as scheduling damages as an alternative to flat caps, jury behavior, health courts, incentives to prevent medical errors, insurance regulation, reinsurance, no-fault insurance, and suggestions for future reforms. Medical Malpractice is the most comprehensive treatment of malpractice available, integrating findings from several different areas of research and describing them accessibly in nontechnical language. It will be an essential reference for anyone interested in medical malpractice.Frank A. Sloan is J. Alexander McMahon Professor of Health Policy and Management and Professor of Economics at Duke University. He is the coauthor of The Price of Smoking and author or editor of many other books on health economics. Lindsey M. Chepke, an attorney, is a Research Associate at the Center for Health Policy at Duke University. (shrink)

Joaquin Segura. Untitled (fig. 40) . 2007 continent. 1.2 (2011): 117-124. The interview that follows is a dialogue between artist and gallerist with the intent of unearthing the artist’s working strategies for a general public. Joaquin Segura is at once an anomaly in Mexico’s contemporary art scene at the same time as he is one of the most emblematic representatives of a larger shift toward a post-national identity among its youngest generation of artists. If Mexico looks increasingly like a foreclosed (...) home burning to the ground, Segura could likely be the one walking away, charred matchstick between thumb and forefinger and shit-eating grin on his face. His corrosive attacks on institutions, ideologies, and power reflect a deep general distrust of authority, increasingly evident within the work of younger Mexican artists. It is perhaps most directly the result of President Calderon’s deeply unpopular war against the cartels but no doubt equally the product of decades upon decades of rampant corruption and errant policy within Mexico. Brett W Schultz (BWS): A recurring—if not dominant—theme within your current work and investigation explores ideological extremism in reaction to some perceived political and economic disenfranchisement, especially that espoused and practiced by right-wing groups in United States. That's exactly why I thought of you when I was approached to contribute a piece to an issue on the subject of the moraine—taken metaphorically here to signify a certain set of beliefs that have resurfaced within mainstream American culture in the wake of a probably over-exaggerated political sea-change, marked by Obama's election. You're a Mexican artist who now lives and works in Guadalajara, far from the border cities where such concerns would seem more likely to be relevant to a contemporary artist; of course, you're even farther from the culture that birthed this nature of extremism. What interests you so intensely about this movement, if we can call it that? Joaquin Segura (JS): I think there are several seminal points that you touch on in this particular question. There's a very specific set of interests that make me address the socio-political issues I've been dissecting through my practice in the last few years. First of all, I don't really consider myself a 'mexican' artist. As I've made clear in the past, I don't really believe in the notion of 'identity' or the idea of 'nation', which I find totally laughable and heartwarmingly passé. I'm convinced that these are totally outdated models of understanding our differences and similarities, expanding our already immense and irreconcilable cultural abysses instead of bringing them together, thus resulting in their total dispersion among the complex and extremely arbitrary weaving of contemporary social nucleii. Pretty much a frankly bad joke, if I may say so. The fact that I live and work in Mexico is a completely random geographical and temporal factor, which of course affects what I think and what I do, but I've chosen not to be limited by this specific circumstance. In the past, while working abroad, I've taken advantage of this preconception of Mexico—to be more exact, pretty much all of Latin America—as one of the last barbaric bastions of western civilization. Totally amusing, if you ask me about it. I consider my practice to be, among other things, a gonzo strategy of deceit: there are quite a few roles you can adopt in this approach that may actually reveal themselves to be a privileged vantage point. In my experience, the gentle savage is one of the most effective ones to establish my standing position. Thus, I'm a mexican artist if I need it to prove my point. If it's not necessary in a specific circumstance, I'm not. Quite simple, I think. Said in other words, it's just an ace I can play to win a particular match. It has worked so far, at least for me. L: Hey, America… , 2009. R: The Inaugural Address , 2009. I am interested in the nature of power and the rise and fall of totalitarian ideological and political apparatuses nowadays. But I guess, going even further, I'm essentially fascinated by the fissures and contradictions that have made these structures spectacularly crumble to the ground. I do believe extreme ideologies have played a crucial role in the globalization of socio-political crisis. In the end, our world is nothing more than a fading monument to all things gone wrong—the inspiring triumph of failure, in every sense. I see this as an exciting parable. And of course, it is an undeniable fact that the US, through their influence in world economy, international policies and general attitude towards the rest of the planet is the largest structure waiting to collapse. I think we are all secretly awaiting that moment of splendor, even americans. It'll be disastrous and as nasty as it can get, but it will also be liberating and incredibly inspirational. Not just because it’s the US but because it'll prove that absolutely everything is susceptible to fall. And not only that, most importantly, it would confirm that radical change may actually be possible and not just one more of the unfulfilled promises modernity has left us to struggle with on our own. BWS: I want to talk first about two of your works in particular: Hey, America... and The Inaugural Address . I feel like your more recent work has a subtle —or even hidden—sinisterness, but these two works are perfect examples of how brutally confrontational your earlier work has been. When we showed Hey, America... at Mexico City's Zona Maco art fair in 2010, there were at least a couple visitors to our stand who were absolutely ready to punch me in my gringo face for having done so. Certainly the shock value of these works is crucial to their central ideas, but can you tell me more about your intentions and how these works relate to your general oeuvre? JS: So funny. Perhaps we do deserve to be punched in the face. I think that's what I'm sometimes looking for, but I hardly ever get it. I do think of such works as some sort of logical trap, a somewhat perverse ambush waiting for someone to walk into head-on. I think what I tried to do with those two specific works, as well as some other past projects, is just emphasize issues or themes that do disturb or make me uneasy and restless. I consider my essential intention a need to make clear that we do not have to look the other way, ignore or forget. We must address, understand and solve these manifestations of senseless violence and absurdity because if we don't confront them this way, they'll end up consuming us. In other words, I do consider these works as a personal need of coming to terms with the nonsense of the world we all are living in. I don't particularly consider myself to be someone with a clear set of beliefs. Perhaps my only certainty would be that everything is there to be denied, demolished and obliterated—even my supposed unquestionability of that particular 'dogma.' My practice is a reflection of that paradox, and I do think that's how these two pieces relate to a wider body of work. Every democratic system and so-called developed contemporary society is deeply flawed on the inside, and that is because each has swept things under the rug. Of course, there's tolerance, good will and eagerness to make a difference but there's also hatred, pain and fear lingering all around. We must learn to relate to both sides of the spectrum. In a way, I approach the themes behind these particular works in what I think to be a non-biased, somewhat 'neutral' way. I do think there's an encryption process going on in the way I work, some sort of formal refinement of this somewhat outrageous content. A digest of infamy, if we can refer to it that way. It is up to the individual experiencing the work to decide which way these pieces lean. They can easily be seen from both positions and I'm ok with that. If you look closely at these works, there's nothing that establishes an unrelenting position—neither support nor rejection. I don't want my personal political views to directly set an agenda for the spectator as that’s essentially propaganda, which is one of the things I absolutely despise. To sum it up, I strive for the spectator to complete the piece in that sense. The work then becomes a reflection of his or her own contradictions, a playground of the mind. I'm interested in achieving a deadpan and deadlock state in the observer. So, in a way, those visitors threatening to beat the shit out of you unconsciously became that particular issue the work is alluding to. Just blind and senseless reaction to god knows what people feel must be defended, the overwhelming virtue of ambiguity. Beautiful. Perhaps you can also think of my practice as a uber-sophisticated and snobbish version of Punk'd. And you wouldn't be far from what I'm trying to convey. Untitled (Disturbance Scenarios #2) . 2010. BWS: To me, an important transitional marker in the overall trajectory of your work is the series, Disturbance Scenarios , which evokes a similar generalized state of panic, paranoia, and impending doom through its incorporation of sensationalist newspaper headlines, yet also suggests this slyly mysterious meta-narrative via the context in which the newspaper itself is placed. How did you arrive at this series and why did you choose photorealistic painting as the medium for it? JS: I consider this series to be a by-product of the process I follow when making work. I spend an important part of my time just doing research, going through documentation and accumulating visual or historical references for the themes or episodes I'm interested in, in that particular moment. These are, of course, valuable assets that connect among themselves in a mysterious and almost undetectable manner, sometimes a few years between one and the other. I've employed similar production strategies in the past, in ongoing series like Random Moments of Urban Decay , in which I document what I consider to be physical traces of ethnic, religious or ideological violence in the form of text graffiti, invisibly scattered in different cities of the world, mostly in the US. Disturbance Scenarios was started in early 2010, following a particularly intense period of traveling here and there that lasted for most of the year. I've always felt compelled by text, as I find quite intriguing the idea of how words can create equally intense evocations of what I call a mental panorama of uneasiness than those produced by aesthetically-charged imagery; of course, if handled right. I have a close relationship to print media—due both to my academic background and to my attraction to its ubiquity and almost unlimited influence, which in the end, is nothing else but power—so I found myself with a growing archive of newspaper headlines snapshots from cities like Melbourne, Auckland, London, and LA. Going through them, I noticed that they had in common a very specific thematic slant: they were all about some sort of conflict: energy crisis, political unrest, local episodes of domestic violence, you name it. So as you very well put it, I felt they all connected through this feeling of anxiety and anguish and I decided to start thinking of them as a body of work. Basically, I felt an interest in creating what I think of as my personal fragmented prefigurements of the end of civilization. There were few elements on the shots that could give away its actual location, geographically speaking, and I liked that. I find this sensation of vagueness and uncertainty quite alluring. The more subtle, the more perverse. The formal resolution of the series—as photo-realistic painting—is linked to my intention of creating distance between me as the artist and the themes I work with. I rarely execute my own work, and that is more a personal choice as I'm more interested in the ideas I mingle with than in the actual outcome of that process, understood as an "art-object" with certain market value. I did some tests with light-jet prints of those snapshots and I found them devoid of that nightmarish, disturbing indistinctness that I felt was so important for them to be able to project the turmoil I experienced upon encountering them and in conceiving of them as a series. So I thought that photorealistic painting would be an interesting resource to play with, as I hardly had worked with that medium before because of my lenient animosity toward painters and their craft. So they were executed like that and I think it turned out to be just right. Homemade (Napalm #2) . 2010. BWS: Though Disturbance Scenarios remains ongoing, it's an interesting contrast to another series of yours, Homemade, which are these beautifully banal photographs of the ingredients used to make improvised explosives. Whereas Disturbance Scenarios still confronts the viewer aggressively with its visual emphasis on loaded texts, in Homemade , you've dropped the surface-level bravado entirely. They're pieces that require explanation to someone not already versed in the fine art of amateur explosive-making. You weren't known for subtlety in your past work; why this change in direction? JS: I'm personally convinced that these are just two angles of the same conceptual preoccupation. I mentioned before my obsession with the idea of encryption. I'm quite enticed by how these processes of translation can politically and semantically alter and deviate purportedly subversive materials such as the ones these works allude to. I do think subversion is futile. I was really troubled by that thought for some time, but I think now I understand that it's not really that important. What is really significant is to elaborate on these alternate views, to envision and refine possible escape routes. It doesn't really matter if they go nowhere, but that is because nothing really matters. A "mute" artwork is a notion that captivates me. When you look at the works you mention, you know there's something off, but it's not fully clear how and why that is. I rely on that insecurity—on that moment of hesitation. And that can also be achieved through an approach like the one I'm now interested in. Let's just call it a smoke screen, a surrogate ruse to get to the same point: to talk about impotence and defeat in contemporary life. The notion that readily accessible information is actually a weapon is a double-edged fallacy: sure, you can make use of whatever resources you can lay your hands on, but that doesn't set you free because freedom is impossible. Still, that doesn't mean you can't blow up stuff during the process, metaphorically or not. I didn't understand the nature of subtlety before. I used to think that you needed to be loud and manifest anger and unconformity in the most aggressive manner possible. Then I finally realized that you can actually permeate and rarify a battleground—because after all, this is low-intensity war—if you actually aim at silently building up the contradictions and making the symbolic value of ideas and acts clash within themselves. Or perhaps it is that I am just getting old. I guess I used to be an angry kid until recently. Now I think of myself as a disenchanted post-teenager, and of course that reflects in my work and my approach to art-making. Kind of a rite of passage and I laugh at it because, overall, it has been overwhelmingly fun. And that doesn't mean that I'm not ready to stick it in someone or something's face again if I feel like it. BWS: You're now taking the subtlety of the Homemade series even further with your newest series, Definitive Reader For a Botched Revolution , in which you photograph a series of politically-charged books side-on, negating their content entirely—essentially reducing them to purely aesthetic objects in which the subject matter is only revealed in the title of the work. Can you talk about the ideas behind this series? Furthermore, is your recent interest in this idea of the "botched revolution" an indication of a general attitudinal or philosophical shift you've since adopted? JS: This new series of works is the logical outcome of a brief period I went through. Probably the last couple years, in which due to a number of circumstances that don't really have to do with my art-making, I was forced to renegotiate my ideas, my beliefs and practically everything that surrounds me. It was quite distressful and turbulent, but in the end, I think it was also almost epiphanic. I came to terms with myself and now I'm calm and serene. That is, of course, my personal take on it but I mention it because I do think it's important to address this shift you mention. The idea of an artwork as a container for latent revelations enthralls me quite a bit. That's how I see these particular works: art as an incendiary agent. It's up to the artist and the spectator to do whatever they please with it. I think the detachment and almost surgical cleanliness from the Definitive Reader series is also my take at poking fun of the way some art is totally innocuous and uncompromising. These images may be pleasing to the eye, but there's something twisted and rotten within them, well hidden beneath. You'll either see it or not, but without a doubt, it will not cancel its presence. This series is intrinsically linked to Homemade . I'm pretty much horsing around with similar ideas and statements here. And well, yes, I do think any revolution is a botched one. There's nothing too heavy about their own downfall. Decay and breakdown are here and will not go away. Perhaps we must learn to embrace them in one way or another, for our own sake. L: Untitled (T.A.Z.). R: Untitled (United States Marine Guidebook of Essential Subjects) . 2011. BWS: Finally, let's discuss the near future. You've got an upcoming solo show at the Sala de Arte Público Siqueiros [SAPS] in Mexico City this summer. What can we expect from that? What else do you have planned? JS: I'll go and get seafood as soon as I'm done with this interview. It's pretty good here in Guadalajara. That's my top priority at this very moment. About my solo project at SAPS, it's due to open in late July. I'm quite looking forward to it. I'm still closely working with the curator on the general feel for the show but I can say that it'll be more of a revision of past works that have not been shown in Mexico City except for a couple pieces. It definitely won't be a showcase for new projects, although we may include one or two previously unseen works. What you can expect is a rereading of what I've been working on during the past few years. In a way, that's exciting to me because for some reason I don't really care about, I'm not that active in Mexico City even though that's where I lived and work for years. I've hardly shown there after my solo project at Yautepec in February of 2010. It'll be nice to see how it all comes together and I'm more thrilled about it because I totally love the space and I think they're doing an excellent job with their programming and its direction. And in a certain way it feels like going back home. About everything else, I need a period to reflect and fully understand what I've been thinking and working on. I've got a few group shows here and there: New York, San Francisco, and Melbourne are the ones happening soon. I will present my censored project Untitled ( Gringo Loco ) as part of the programming of the Museo de Arte de Zapopan in Guadalajara, two years after being escorted at gunpoint from the installation site by police sent by the extreme right-wing mayor of the city, which I found pretty amusing for an otherwise typical Saturday afternoon. I'm also involved in a couple "curatorial" projects. In my case, "curatorial" means that I help put together stuff I like and I'm interested in. One of them will open in late September of 2011 at Arena Mexico Arte Contemporaneo, and I will work with three of whom I consider to be some of the best artists in a lively and active scene such as the one here in Guadalajara. But most importantly, I've been doing heavy research so there are also a number of projects that I've yet to finalize. That'll be my main focus during the rest of the year, even though I really enjoy procrastination. There'll be time for that later. Or maybe not. We'll see. About Joaquin Segura The action, installation, intervention and photographic work of Joaquin Segura (b. Mexico City, 1980) has been shown in solo and group exhibitions in Mexico, the United States, Europe, and Asia. Some spaces that have featured his work include La Panaderia, Museo de Arte Carrillo Gil, Centro de la Imagen and Ex-Teresa Arte Actual in Mexico City; El Museo del Barrio and apexart, New York, NY; Museo Nacional Centro de Arte Reina Sofia in Madrid, Spain; National Center for Contemporary Art, Moscow, Russia; and Palace Adria in Prague, Czech Republic. In 2008 and 2009, Segura was an artist-in-residence at the International Studio and Curatorial Program, New York, NY and at the 18th Street Arts Center, Santa Monica, CA. He is represented YAUTEPEC in Mexico City and by Arena Mexico Arte Contemporáneo in Guadalajara. Further Reading Joaquin Segura’s website YAUTEPEC artist page for Joaquin Segura Capps, Kriston. “ID-ENTITY: Washington, DC.” ART PAPERS . 2009. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Problem with BreathÉglantine Colon (bio)On day 1, when my comrades and I talked about it, we couldn't quite figure out how it happened. It just seemed as though we had suddenly been incited not to communicate or enact our love for each other. This time, no policy had been formulated, no law had been issued. It was harder than usual to locate where, to which parts of (...) the apparatus, we should direct our attention.On day 2, we were at a loss. We had gotten so good at reading the apparatus. We had developed wonderfully efficient techniques of resistance. Each and every one of us had become most brilliant at crafting discrete gestures of love. On day 3 onwards, we were misfiring on a regular basis, falling in and out of love with the same wrong comrades, over and over again, and always out of sync. The loving gestures we composed were barely legible and when we would intuitively find a genre in which to communicate our love, something would inevitably break down. Voices, generally. Sometimes the entire figurative system. Bodies, always. We would lose sleep and appetite over love and get useless for weeks.And then, the problem with love became a problem with breath. On day 6, the air got hot and busy with ashes and all sunsets turned red. At every breath, for all we knew, we could be inhaling particles of carbonized pine sap, debris of melted trailer parts, or burnt baby birds in bits. I quit smoking. I bought boxes of white masks at the construction store. The dominant smell during these days was a cagey mix of ghost paint, polymer fibers, and dry chemistry.On day 17, the air got cold and saturated with drops of viral poison. The city shut down. An incredibly sad number of lungs, too. The perspective to live in pods and die alone, disconnected from each other's breath, hyper-connected to life-support machines, plunged many of us, myself included, into brand new strands of historical despair. For those of us whose lungs had been weakened by bad inner-city fumes, evil chemicals, or entire centuries of racialized exposure to horrendous air quality, the problem with breath became plain lethal.Our neighborhoods were saturated with wildfire smoke and unnecessary death. Elsewhere, the streets were not empty. And when I say not empty, I mean they were just not. Or not yet. Usual metallic densities on the bridge. Geometrical glows of digital light in the underground. [End Page 237]Abnormally, no bodies of any ancestries were being captured, or hanged, or tortured, or kneeled upon. Nothing tangible, nothing blatantly repressive this time. No gas, no gag, no name, no whip, no rope. No strangulating remnant of sovereignty within no softness of biopower. A racist and classist brand of distributive pneumocracy is what it was, or at least this is how it initially appeared.On day 25, "Critical Pandemic Studies" became a thing, and "Pod Theory" a subgenre in post-social anthropology. Denounced as a "white fantasy of networked individualism," (in one of its purest forms) as "domestic fascism dressed as elective affinity," the pod appeared to us, from the get-go, as a thoroughly ratchet social formation. On day 29, the "podtag" emerged as a timely intervention in existing forms of street art. Equational in its form, efficient in its power of evocation, and satirical in its poetic economy, the podtag proliferated on the privatized walls of neighborhoods where the biggest challenges presented to breathing were unreasonably difficult Pilates classes on Zoom. Click for larger view View full resolutionOn day 35, the air got complex and full of knots, so striated that we could no longer count on our capacity to share the same air. A meal was being cooked, an instrument was being played, a child was given birth to, and suddenly the rhythm of all breaths would break. Sometimes a pair of lungs would refuse, stubbornly, to take in any oxygen until someone else's pair of lungs had released its own dose of carbon dioxide. At other times, the quantity of air available to each one of us would decrease with... (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of (...) the empirical literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (shrink)

Governments in New Zealand have legislated a large number of settlements extinguishing many hundreds of claims taken by Māori against the Crown for breaches of the country’s founding document, Te Tiriti o Waitangi. They portray settlements as a great success for Māori and the Crown. Māori disagree. Settlements are government-determined and imposed on Māori using a smoke and mirrors approach that masks successive governments’ true intentions: to claw back Māori legal rights; to extinguish all claims; and to maintain White control (...) over Māori. In short, to uphold the Doctrine of Discovery in further breach of Te Tiriti o Waitangi. Māori claimants and negotiators report being enticed into the process by false promises only to become traumatised and disenchanted. Yet many take a pragmatic stance and sign settlements, making the best they can out of a bad deal that goes nowhere near compensating for their actual loss. They know that despite what legislation may say, the settlements are not full, not fair and not final and that, like all previous settlements, they will be revisited. They also know that unless fundamental changes are made to the constitutional makeup of the country, there is no prospect of justice and reconciliation for Māori. (shrink)

The Indonesian Ulema Council (MUI) has issued an illegitimate fatwa against smoking in mosques because it endangers the health of worshippers and interferes with the comfort of worshippers. This study aims to investigate smoking behaviour in mosques and violations of fatwas from ulama and governor regulations. This study follows a cross-sectional design conducted by interviewing 531 Muslims who have prayed in the mosque for the last 14 days and observed the compliance of the mosque in implementing a smoke-free (...) policy in 315 mosques. Frequency distribution and cross-tabulation were carried out using JASP 16 software using cross-tabulation. The results of this study indicate that the implementation of the smoke-free policy for mosques in Medan has been violated many times (57.8%), especially the violation regarding smoking in mosques (32.1%); cigarette butts were still found in the yard of the mosque (44.1%). Violations of the policy of fatwa smoke-free areas occurred in public mosques (61%) and muhammadiyah mosques (46.5%). Smoking behaviour in mosques was seen in the last 2 weeks, namely smoking behaviour carried out by worshippers (57.6%), smoking behaviour carried out by mosque administrators (39.2%), smoking behaviour carried out by community leaders in mosques (19.4%) and smoking behaviour that ulemas carried out in mosques (14.3%). Worshippers must comply with the rules against smoking in mosques because it can endanger the health of other worshippers. Cigarette smoke in the mosque will make other worshippers uncomfortable to worship so that it can damage the solemnity of the congregation to worship in the mosque. Contribution: This study is expected to explain smoking behaviour in mosques, violations of smoking behaviour in mosques that violate the ulama’s fatwa regarding smoking behaviour in mosques and the governor’s regulation on smoking behaviour in mosques. (shrink)

I wish to consider the possibility that a good part of the opposition to the main lines of American foreign policy is based on deep-seated objections to the political and economic systems of the United States. This is not to say that existing policy is necessarily wise or that there may not be good and sufficient reasons for wishing to change it. Indeed, at any time and place, the United States might well be overestimating the threat from the (...) Soviet Union or using too much force. What I wish to suggest is that across-the-board criticism of American policy as inherently aggressive and repressive, regardless of circumstance – a litany of criticism so constant that it does not alert us to the need for explanation – has a structural basis in the rise of a political culture that is opposed to existing authority. To the extent that this criticism is structural, that is, inherent in domestic politics, the problem of fashioning foreign policies that can obtain widespread support is much more difficult than it is commonly perceived to be. For if the objection is to American ways of life and, therefore, “to the government for which it stands,” only a transformation of power relationships at home, together with a vast redistribution of economic resources, would satisfy these critics. If the objection is not only to what we do but, more fundamentally, to who we are, looking to changes in foreign policy to shore up domestic support is radically to confuse the causal connections and, therefore, the order of priorities. (shrink)

Cigarette smoke is the most dangerous of the toxic elements in our environment. Smoking is responsible for almost 500 000 deaths each year in the United States — more than any other environmental toxin. The medical evidence is clear, mainstream and sidestream smoke kills people, and anyone who participates in the spreading of this smoke is acting unethically. Yet, when there are no governmental laws that ban smoking in public, most business-people allow smoking in their places of (...) business. These businesspeople are acting in an unethical manner, a manner which endangers customers and employees. This paper examines the impact on the environment of smoking in public and concludes that businesses must move quickly to ban smoking, or we will need nationwide, uniform legal restrictions to force ethical action in this critical area. (shrink)

The urgent importance of dealing with the climate crisis has led some influential theorists to argue that at least some demands for justice must give way to pragmatic and strategic considerations. These theorists (Cass Sunstein, Eric Posner, and David Weisbach, all academic lawyers, and John Broome, an academic philosopher) contend that the failures of international negotiations and other efforts to change economic policies and practices have shown that moral exhortations are worse than ineffective. Although Broome's position is similar in these (...) respects to that of Sunstein, Posner and Weisbach, it differs in other important respects, including his understanding of the idea of justice, his disagreement with the policy approach (which he calls "efficiency with sacrifice") favored by the economists Nicholas Stern and William Nordhaus, and his proposal for establishing a new international financial institution, a World Climate Bank, in addition to putting a price on carbon. Elsewhere I offer a critical analysis of the position taken by Posner and Weisbach in their book, Climate Change Justice. Their arguments against allowing principles of distributive justice (narrowly understood) to constrain treaty negotiations fail to rule out the principles of John Rawls' Law of Peoples (which is a conception of the moral basis of a just international order, including states' obligations to secure basic human rights for all). Therefore their arguments against shaping climate treaties to reflect any principles of justice do not succeed in supporting their position. Here I offer a critical analysis of Broome's position. I raise and discuss objections to Broome's proposal for a WCB, and I argue that the continued relevance of these objections is contingent on how the proposal for a WCB may get developed. (shrink)

Experimental vaccines are being developed for the treatment of ‘unhealthy lifestyles’ and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of ‘lifestyle vaccines’ for public health. Based on findings from a qualitative (...) study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The ‘vaccinization’ of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future. (shrink)

I wish to consider the possibility that a good part of the opposition to the main lines of American foreign policy is based on deep-seated objections to the political and economic systems of the United States. This is not to say that existing policy is necessarily wise or that there may not be good and sufficient reasons for wishing to change it. Indeed, at any time and place, the United States might well be overestimating the threat from the (...) Soviet Union or using too much force. What I wish to suggest is that across-the-board criticism of American policy as inherently aggressive and repressive, regardless of circumstance – a litany of criticism so constant that it does not alert us to the need for explanation – has a structural basis in the rise of a political culture that is opposed to existing authority. To the extent that this criticism is structural, that is, inherent in domestic politics, the problem of fashioning foreign policies that can obtain widespread support is much more difficult than it is commonly perceived to be. For if the objection is to American ways of life and, therefore, “to the government for which it stands,” only a transformation of power relationships at home, together with a vast redistribution of economic resources, would satisfy these critics. If the objection is not only to what we do but, more fundamentally, to who we are, looking to changes in foreign policy to shore up domestic support is radically to confuse the causal connections and, therefore, the order of priorities. (shrink)

This case study takes place in the context of a large corporate technology services firm. It explores the question of what constitutes sexual harassment as well as how best to draft a no-tolerance policy. The scenario examines behaviors that may or may not be considered illegal, the responsibility of all employees to foster a harassment-free environment, and what an effective no-tolerance policy might look like that minimizes possible conflicts of interest. Students are given an opportunity to reflect on (...) several issues, including how the agents should act situationally, and how the policy might best be (re)designed and implemented going forward. (shrink)