This article responds to Tibor Machan's criticisms of government provision for needy citizens. It argues that although charity may be morally worthy, private charity is inadequate to the task of providing our fellow citizens with the security they deserve; the tremendous social good of secure access to a life of dignity can only be produced by a public social safety net. Moreover, individual rights to property do not stand in the way of providing a public social (...) safety net. Since there are social inputs in wealth creation, reasonable levels of taxation do not violate people's rights to their wealth. (shrink)

Whereas using artificial intelligence (AI) to predict natural hazards is promising, applying a predictive policing algorithm (PPA) to predict human threats to others continues to be debated. Whereas PPAs were reported to be initially successful in Germany and Japan, the killing of Black Americans by police in the US has sparked a call to dismantle AI in law enforcement. However, although PPAs may statistically associate suspects with economically disadvantaged classes and ethnic minorities, the targeted groups they aim to protect are (...) often vulnerable populations as well (e.g., victims of human trafficking, kidnapping, domestic violence, or drug abuse). Thus, determining how to enhance the benefits of PPA while reducing bias through better management is important. In this paper, we propose a policy schema to address this issue. First, after clarifying relevant concepts, we examine major criticisms of PPAs and argue that some of them should be addressed. If banning AI or making it taboo is an unrealistic solution, we must learn from our errors to improve AI. We next identify additional challenges of PPAs and offer recommendations from a policy viewpoint. We conclude that the employment of PPAs should be merged into broader governance of the social safety net and audited publicly by parliament and civic society so that the unjust social structure that breeds bias can be revised. (shrink)

This article teases out the relationship between family form and the state's social safety nets around healthcare, showing the deep unfairness of measuring social safety nets by whether a couple marries. By continuing to tie healthcare benefits to specific family structures, we perpetuate the “galloping” inequality marking America today.This article concludes that, whatever happens with the thousands of benefits given to married couples in other domains, social policy should move beyond marriage with respect to healthcare. (...) Delinking support for healthcare coverage and services from family form is just, better assists struggling families, and is in our collective self-interest. (shrink)

Approximately 20% of adult cancer patients are eligible to participate in a clinical trial, but only 2.5-9% do so. Accrual is even less for minority and medically underserved populations. As a result, critical life-saving treatments and quality of life services developed from research studies may not address their needs. This study questions the utility of the bioethical concern with therapeutic misconception (TM), a misconception that occurs when research subjects fail to distinguish between clinical research and ordinary treatment, and therefore attribute (...) therapeutic intent to research procedures in the safety net setting. This paper provides ethnographic insight into the ways in which research is discussed and related to standard treatment. (shrink)

Millions of Americans are dependent on what is often called the “safety net.” These loosely-organized networks of health and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine report, America’s Health Care Safety Net: Intact but Endangered, called attention to both the fragility and the resilience of this health care safety net. The IOM (...) report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability. Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces. (shrink)

Millions of Americans are dependent on what is often called the “safety net.” These loosely-organized networks of health and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine report, America’s Health Care Safety Net: Intact but Endangered, called attention to both the fragility and the resilience of this health care safety net. The IOM (...) report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability. Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces. (shrink)

Large-scale data systems are increasingly envisioned as tools for justice, with big data analytics offering a key opportunity to advance health equity. Health systems face growing public pressure to collect data on patient “social factors,” and advocates and public officials seek to leverage such data sources as a means of system transformation. Despite the promise of this “data-driven” strategy, there is little empirical work that examines big data in action directly within the sites of care expected to transform. In (...) this article, I present a case study on one such initiative, focusing on a large public safety-net health system’s initiation of sexual orientation and gender identity data collection within the clinical setting. Drawing from ethnographic fieldwork and in-depth interviews with providers, staff, and administrators, I highlight three main challenges that elude big data’s grasp on inequality: provider and staff’s limited understanding of the social significance of data collection; patient perception of the cultural insensitivity of data items; and clinic need to balance data requests with competing priorities within a constrained time window. These issues reflect structural challenges within safety-net care that big data alone are unable to address in advancing social justice. I discuss these findings by considering the present data-driven strategy alongside two complementary courses of action: diversifying the health professions workforce and clinical education reform. To truly advance justice, we need more than “just data”: we need to confront the fundamental conditions of social inequality. (shrink)

Working in an urban safety net facility, my colleagues and I daily face any number of challenges. In some respects, an undocumented immigration status is just another one of those challenges. However, it is a particularly interesting one given the context created by political, social, and ethical debate about immigration.

Officials must understand why and how the public lost confidence in the federal government’s ability to manage financial turmoil. Officials outsourced to private parties responsibility for monitoring and policing the safety-net exposures that were bound to be generated by weaknesses in the securitization process. When the adverse consequences of this imprudent arrangement first emerged, officials claimed for months that the difficulties that short-funded, highly leveraged firms were facing in rolling over debt reflected only a shortage of aggregate liquidity and (...) not individual-firm shortages of economic capital. Then, in September 2008, the president and other officials created an unwise sense of urgency that delays in implementation show to have been greatly exaggerated.That authorities and financiers violated common-law duties of loyalty, competence, and care they owe to taxpayers indicates a massive incentive breakdown in industry and government. Taxpayers deserve a thorough-going reorientation of: (1) how regulatory agencies report on their regulatory performance and back-room interactions with Congress and the Treasury, and (2) the contract structures and performance measures used by the financial industry and its government overseers. (shrink)

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and disabled persons and (...) indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients. (shrink)

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and disabled persons and (...) indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients. (shrink)

The overriding goal of health reform is to provide every American affordable access to adequate health care. Yet in every national effort to date, the focal means to this end has always been health insurance. Massachusetts is congratulated for having achieved nearly universal insurance coverage, and congressional Democrats are aiming for the same. But what if they don't succeed? Even in Massachusetts, 167,000 residents remain uninsured. Is it still possible to provide adequate access to medical care for those without insurance? (...) If so, shouldn't we reframe social goals to achieve universal access through any means possible, whether or not insurance is involved? (shrink)

Policy decisions during and after the New Deal tied the U.S. social contract to the employment contract, by conditioning eligibility and benefit levels for core welfare-state programs on work status and performance. The resulting system of social provision, however, embodied a set of assumptions about labor-market conditions that began to unravel with the structural economic shifts that began in the mid-1970s. Work was expected to provide open doors to employment, stable floors of security and stability over time, income (...) ladders promising adequate and rising earnings, and safety nets providing public and/or private protections against unforeseen or unavoidable hardships. Each of these assumptions was undermined by fundamental changes in the market, and this, in turn, has redefined patterns of social provision. As a result, core welfare-state programs have become less effective at meeting their own objectives of providing adequate social protections for rising numbers of working Americans. These trends preceded the recent recession and weak recovery, and cannot be reversed by the return of robust growth or pre-recession employment levels, in the absence of more fundamental change in the social contract. The roots of the current dilemma lie in the 1930s-40s, when politically mobilized employers fought alongside conservative policymakers to constrain the scope of the original system of social protections during and after the New Deal. In recent decades, they have battled to keep even this limited system from reaching those it was intended to assist, by blocking or limiting reform initiatives in areas such as employment policy, the minimum wage, health and pension insurance and modernization of the unemployment compensation system. (shrink)

In this brief paper, offered as a policy viewpoint, I introduce what I believe to be a novel concept for supporting individual citizen interaction with the U.S. Federal government, termed the individual social account. I explore whether and how the concept might be implemented so as to strengthen the U.S. social safety net and further citizen trust and responsibility in e-government interactions. I illustrate and develop the concept as a platform for reform and suggest and discuss design (...) criteria, surfacing various issues. I conclude with additional thoughts with which to stimulate further research and discussion of the concept and its practicalities. (shrink)

Feminist critiques of the social sciences are based on the assumption that because the social sciences were developed for the most part by white, middle-class, Western men, the perspectives of women were ignored. This book offers an approach for integrating gender-related content into the social work curriculum. The distinguished contributors discuss the shortcoming of dominant knowledge, address the pressing need for a gender-integrated curriculum, consider the pedagogies consistent with the implementation of an integrate curriculum, address specific areas (...) in social work education, assessing content, and assumptions, and discuss strategic issues for the implementation of curricular knowledge. (shrink)

Chronic deficiencies of the Greek welfare state and the introduction of austerity measures as part of the international financial bailout agreements have created an explosive cocktail of poverty and social exclusion that severely tested the resilience of the frail social safety net and the demands of equity. The score on the indicators of social quality has worsened considerably as the Greek welfare system was overhauled. This article examines the four conditional factors of social quality from (...) the viewpoint of socio-economic policies and everyday experiences in Greece during the crisis. (shrink)

The election of Donald Trump has exposed American society’s profound crisis of hope. By 2016 a generation of shrinking employment, rising inequality, the attack on public education, and the shredding of the social safety net, had set the stage for stunning insurgencies at opposite ends of the political spectrum. Against this dire background, Ronald Aronson offers an answer. He argues for a unique conception of social hope, one with the power for understanding and acting upon the present (...) situation. Hope, he argues, is far more than a mood or feeling—it is the very basis of social will and political action. It is this kind of hope that Aronson sees brewing in the supporters of Bernie Sanders, who advocated the tough-minded and inspired disposition to act collectively to make the world more equal, more democratic, more peaceful, and more just. And it was directly contrasted by Trump’s supporters who showed a cynical and nostalgic faith in an authoritarian strongman replete with bigotry and misogyny. Beneath today’s crisis Aronson examines our heartbreaking story: a century of catastrophic violence and the bewildering ambiguity of progress—all of which have contributed to the evaporation of social hope. As he shows, we are now in a time when hope is increasingly privatized, when—despite all the ways we are connected to each other—we are desperately alone, struggling to weather the maelstrom around us, demoralized by the cynicism that permeates our culture and politics, and burdened with finding personal solutions to social problems. Yet, Aronson argues, even at a time when false hopes are rife, social hope still persists. Carefully exploring what we mean when we say we “hope” and teasing hope apart from its dangerously misconstrued sibling, “progress,” he locates seeds of real change. He argues that always underlying our experience—even if we completely ignore it—is the fact of our social belonging, and that this can be reactivated into a powerful collective force, an active we. He looks to various political movements, from the massive collective force of environmentalists to the movements around Sanders and Jeremy Corbyn, as powerful examples of socially energized, politically determined, and actionably engaged forms of hope. Even in this age of Donald Trump, the result is an illuminating and inspiring call that anyone can clearly hear: we can still create a better future for everyone, but only if we resist false hopes and act together. (shrink)

This paper examines racial discrimination and algorithmic bias in predictive policing algorithms (PPAs), an emerging technology designed to predict threats and suggest solutions in law enforcement. We first describe what discrimination is in a case study of Chicago’s PPA. We then explain their causes with Broadbent’s contrastive model of causation and causal diagrams. Based on the cognitive science literature, we also explain why fairness is not an objective truth discoverable in laboratories but has context-sensitive social meanings that need to (...) be negotiated through democratic processes. With the above analysis, we next predict why some recommendations given in the bias reduction literature are not as effective as expected. Unlike the cliché highlighting equal participation for all stakeholders in predictive policing, we emphasize power structures to avoid hermeneutical lacunae. Finally, we aim to control PPA discrimination by proposing a governance solution—a framework of a social safety net. (shrink)

This paper examines the conservative point of view about distributive justice. The first section explains the methodology used to develop this point of view. The second section describes one conservative point of view and briefly provides empirical evidence that it reflects the viewpoint of many ordinary conservatives. The third section explains how this conservative view can ground objections to social safety net programs, using as examples the recent health reform legislation and more extensive proposals for a true national (...) health system. The fourth section sketches ways that non-conservative philosophers might try to refute those objections. Examining a conservative point of view leads to several important conclusions. One is that the conservative point of view is not properly represented in contemporary philosophical discussions. Another is that the conservative point of view cannot be refuted by appealing to existing egalitarian writings. A third is that if progressive philosophers such as myself want to address the conservative point of view, we must expand the range of issues that we discuss in contemporary political philosophy. Doing so is a vital task, because otherwise we ignore the political views held by as much as half the American population. (shrink)

This article develops contractarian business ethics by applying social contract arguments to a specific question: What are the pre-legal (or moral) rights and responsibilities of corporations? The argument uses a hypothetical social contract to show the existence of for-profit corporations in democratic capitalist societies is consistent with Rawls’s fundamental principles of justice. Corporations ought to have recognised their rights to be autonomous, to pursue private purposes, and to engage in economic activities. Corporations have a responsibility to respect the (...) freedom and human rights of all people, and not to interfere with government programs that ensure people have the education and training they need to find and keep corporate employment and that provide a safety-net that prevents destitution. If corporations have any other rights and responsibilities, those rights and responsibilities need to be established by actual social contracts, probably in the form of legitimate democratic processes. (shrink)

Inequality is the defining feature of our times. Many argue that it calls for a policy response, yet the most obvious policy responses require legislative action. And if inequality is the defining feature of our times, partisan acrimony and gridlock are the defining features of the legislature. That being so, it is worth considering what role administrative agencies, and administrative law, might play in ameliorating or exacerbating economic inequality. Here, I focus on American safety net programs, many of which (...) are joint operations between federal administrative agencies and state governments. In this context, a central mode of bureaucratic policy innovation comes in the form of administrative waivers, whereby a federal administrative agency waives some statutory requirement that is otherwise binding on state administrators. For example, the Centers for Medicare and Medicaid Services recently granted waivers to allow several states to impose various “personal responsibility” requirements on Medicaid beneficiaries. Faced with a choice between legislative inactivity and policy innovation through waivers, many scholars and policymakers of both parties have tended to favor waivers. The appeal of waivers as a path around legislative gridlock is compelling. However, I argue that this view has neglected the federal structure of American safety net programs, and does not account for the state politics of implementation. Moreover, scholars have not focused on the severe information problems that federal agencies face when issuing waivers; a permissive waiver regime exacerbates these problems. Focusing on Medicaid implementation, I highlight the risks of waivers for American safety net programs. Before concluding, I discuss possible reforms to administrative procedures, and offer a case study of litigation surrounding one recent waiver application. The case study illustrates many of the theoretical arguments, and further demonstrates the failure of judicial review; it indicates how review might be adjusted to promote more effective use of waivers and diminish their perils. (shrink)

The traditional mission of safety net hospitals has been charity, providing the best healthcare for all individuals no matter their ability to pay. The focus has been on vulnerable populations that are low-income, uninsured, and other upstream circumstances that manifest downstream as poor health, poor health outcomes, and repeated high-cost interventions that fail to break cycles of perpetual health instability. Safety net hospitals are committed to serving their populations, even if only temporarily, through provision of subsidies and filling (...) gaps that exist in patients’ lives. These interventions do not lead to the elimination of gaps, hence cyclical health instability persists. It is a new day in healthcare and what it means for people to be well. The focus is on improving health outcomes by addressing root causes of health instability such as unstable housing, income, education, and access to affordable healthy foods. This gives us pause to reflect on the traditional mission of safety net hospitals and the impact of charity in isolation. Are safety net hospitals missing an opportunity to mitigate and eliminate perpetual health instability? Can they shift the paradigm of healthcare for vulnerable populations to alter their quality-of-life course? To move forward, safety net hospitals have to change their mind set and existing narratives about what is possible for vulnerable populations to achieve. These historic giants in healthcare have an opportunity to use their assets and employ a methodology of disruption and innovation to shift the mission of safety net healthcare from charity to equity. (shrink)

More and more development projects are using group or community approaches to disseminate technology and resources. It is believed that using such an approach will provide a safety net as well as social control to ensure the sustainability of the technology and resource. However, little is known of the exact process and social networks that are mobilized and used in using such an approach. Particular attention is devoted in the paper to gender differences and the concept of (...) social capital for analyzing social networks. Cases and the analysis were drawn from Heifer Project International's efforts to disseminate improved goat breeds through a village group process in Tanzania. An examination of these case studies shows that internal processes are crucial in understanding technology transfer. In all groups, a person's social capital did determine whether a member got a goat, and a person's ability to access and manage information also played an important role. Of all the groups, the most successful and sustainable had a history of interaction and were involved within several projects in which the members met each other in different arenas. (shrink)

The American food system has produced both abundance and food insecurity, with production and consumption dealt with as separate issues. The new approach of community food security (CFS) seeks to re-link production and consumption, with the goal of ensuring both an adequate and accessible food supply in the present and the future. In its focus on consumption, CFS has prioritized the needs of low-income people; in its focus on production, it emphasizes local and regional food systems. These objectives are not (...) necessarily compatible and may even be contradictory. This article describes the approach of community food security and raises some questions about how the movement can meet its goals of simultaneously meeting the food needs of low-income people and developing local food systems. It explores the conceptual and political promise and pitfalls of local, community-based approaches to food security and examines alternative economic strategies such as urban agriculture and community-supported agriculture. It concludes that community food security efforts are important additions to, but not subsitutes for, a nonretractable governmental safety net that protects against food insecurity. (shrink)

Corporate change and employee dislocation are inevitable in a free market. However, the current employment relationship in the U.S. that affords a perceived employment safety net is contrary to the natural canon of honesty. Employees cannot be guaranteed employment when a company fails or a product is no longer viable. Attempts to provide costly employment safety nets cause a firm to allocate resources to nonproductive programs that may ultimately cause a loss of competitiveness. These strategies to provide alternate (...) employment may provide only short-term solutions. But even short-term safety nets against unemployment may be sending employees unrealistic messages ... a permanent safety net against unemployment. As a result, employees may lose incentive to be innovative in creating their own personal safety nets. The resolution is candor about the risk of employment. A false employment safety net is not what employees want or need and in the long run it may be detrimental to American competitiveness. (shrink)

Distance Learning (DL) courses have become ubiquitous, especially since the pandemic. Having had some experience with DL in high school, first-year students might be inclined to enroll in DL courses. Other students take DL because of completing demands on their time, such as work, family, or athletics participation, and some students just like the flexibility afforded by DL courses. However, many college students are unprepared for the self-regulative practices, including time management and assistance-seeking behaviors, required for success in a DL (...) course. (shrink)

The world is at an inflection point. Advancing technologies are creating new opportunities and challenges. Great demographic changes are occurring rapidly, with significant consequences. Governance everywhere is in disarray. A new world is emerging. These are some of the key insights to emerge from a series of interdisciplinary roundtables and global expert contributions hosted by the Hoover Institution. In these pages, George P. Shultz and James Timbie examine a range of issues shaping our present and future, region by region. Concrete (...) proposals address migration, reversing the decline of K-12 education, updating the social safety net, maintaining economic productivity, protecting our democratic processes, improving national security, and more. Meeting these transformational challenges will require international cooperation, constructive engagement, and strong governance. The United States is well positioned to ride this wave of change--and lead other nations in doing the same. (shrink)

Large organisations are especially advised to consider the possibility of an Ethics Helpdesk in which all employees and managers can report with all suspected cases of unethical conduct, critical comments, dilemmas and advice for which there is insufficient room within the organisational hierarchy. A helpdesk is a central contact point where it is decided who the most appropriate person is to dealing with a given case. The helpdesk model is characterised by low barriers in its easy accessibility, positive approach and (...) the simple procedures employees need to follow. It offers employees consistent support while relying on the responsibilities of the individual employee as much as possible and it facilitates adequate monitoring and reporting. A helpdesk increases the chances of detecting unethical conduct which enables management to take adequate and timely measures against improper conduct. This article formulates principles, discusses critical factors and considers three models for adopting a sound and integrated ethics safety net. It also presents a case study and shows why organisational openness needs to be institutionalised. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Operating in a Contemporary Safety NetJason D. KeuneIt is summer, and I have just started my fourth year of general surgery residency, having just returned from two years in the lab. My “lab years” were spent as a Scholar–in–Residence of the American College of Surgeons. The scholarship that I engaged in included obtaining an MBA and a Graduate Certificate in Professional Ethics. The ethics component was self–designed with (...) help from an advisor, and was made up of graduate courses in political theory, healthcare financing law and bioethics. To say that I was reflective as I returned to the clinical rotations of the fourth year of residency would be understated.During this two–year period, I did not operate. I did do some clinical work during this time, but there wasn’t anyone in town willing to hire a partially–trained surgeon to do anything operative. I ended my third year of residency very happy with my technical skills, and was not sure just how these skills would survive a two–year hiatus. The challenge, as I thought of it then, would be to return to clinical rotations with this insecurity in mind and try to gain insight into just how rusty my skills were in a short period of time, and rectify them. I was in for a surprise.I felt a chill of trepidation when I discovered that the rotation that had been selected for me to return to was one in which I would be assigned to operate on and care for a low–income population of uninsured or underinsured patients with surgical problems—with minimal attending supervision. The patients were referred from the Federally Qualified Health Centers in town. The rotation had arisen from altruistic roots. The surgical service, provided at a large, academic urban hospital, was established when the city’s last remaining public hospital closed its doors for surgical patients. The service was an upright attempt to provide surgical continuity for this population. As I started the rotation and performed my first surgeries in two years with very minimal supervision, I realized that I would be participatory in what sums to a thoroughly unjust healthcare system. I would be caught in a swirl of humanitarian justice celebrated and a focus on a justice that seemed to fall short of a mark.The indigent hospital itself managed the clinic with a full complement of staff befitting a contemporary surgical clinic, albeit with a rather rudimentary computer system. The recordkeeping mechanism in our surgical office, however, was done without administrative assistance. We occupied a small room amongst the academic surgical offices at our home institution. The chief resident sat at a large [End Page 12] desk, the intern at a smaller desk, and the medical student had a chair and a laptop. The recordkeeping mechanism tracking who needed surgery, who had had surgery, and who needed follow–up on pathology was maintained by all members of the team. It involved one labyrinthine Excel spreadsheet, with multiple tabs, and a complex color–coordinated scheme of organization. The team would scan the entire thing on a daily basis to make sure nothing would be missed.When it came time to schedule a patient for the operating room, it was my responsibility as a chief resident to get an attending to “cover the case”, which amounted to finding an attending who agreed, at the bare minimum, to be present for the “critical portion” of the case. If the case was complex or very difficult, an attending surgeon would have to be sought who would scrub in and help perform the procedure. Not every attending would cover a charity case—the reasons why were not forthcoming. One surgeon would scrub every case he was asked to cover, stating that he felt every patient should have the same chance at the best treatment. Another would come to the room, but sit along the wall and review manuscripts as we operated, there to grant reassurance, and answer questions, but not, presumably, to direct the overall decision–making. All patients with breast cancer were seen, and operated on by one very dedicated breast surgeon with a humanitarian bent.I... (shrink)

A question arising from the COVID-19 crisis is whether the merits of cases for climate policies have been affected. This article focuses on carbon pricing, in the form of either carbon taxes or emissions trading. It discusses the extent to which relative costs and benefits of introducing carbon pricing may have changed in the context of COVID-19, during both the crisis and the recovery period to follow. In several ways, the case for introducing a carbon price is stronger during the (...) COVID-19 crisis than under normal conditions. Oil costs are lower than normal, so we would expect less harm to consumers compared to normal conditions. Governments have immediate need for diversified new revenue streams in light of both decreased tax receipts and greater use of social safety nets. Finally, supply and demand shocks have led to already destabilized supply-side activities, and carbon pricing would allow this destabilization to equilibrate around greener production for the long-term. The strengthening of the case for introducing carbon pricing now is highly relevant to discussions about recovery measures, especially in the context of policy announcements from the European Union and United States House of Representatives. Key Policy Insights: • Persistently low oil prices mean that consumers will face lower pain from carbon pricing than under normal conditions. • Many consumers are more price-sensitive during the COVID-19 context, which suggests that a greater relative burden from carbon prices would fall upon producers as opposed to consumers than under normal conditions. • Carbon prices in the COVID-19 context can introduce new revenue streams, assisting with fiscal holes or with other green priorities. • Carbon pricing would contribute to a more sustainable COVID-19 recovery period, since many of the costs of revamping supply chains are already being felt while idled labor capacity can be incorporated into firms with lower carbon-intensity. (shrink)

Two major safety net providers – community health centers and public hospitals – continue to play a key role in the health care system even in the wake of coverage reform. This article examines the gains and threats they face under the Affordable Care Act.

According to John Tomasi's Free Market Fairness, there are serious constraints on what a liberal state may do to promote economic justice. Tomasi defends this claim by arguing that important economic liberties ought to be regarded as “basic” and given special priority over other liberal concerns, including those of economic justice. I argue that Tomasi's defense of this claim is unsuccessful. One problem takes the form of a dilemma: depending on how the claim is formulated more precisely, Tomasi's argument seems (...) either to be compatible with standard (e.g., Rawlsian) liberalism or to tell against even the minimal taxation that would be necessary to support the social safety net he supports. Second, granting “basic” status to economic liberties would in many cases defeat the goal, self-authorship, that Tomasi sees himself as sharing with other liberals. Third, contrary to Tomasi's suggestions, no inconsistency arises when liberals (such as Rawls) refuse to recognize the economic liberties as basic. Fourth and finally, the special significance that Tomasi attaches to agency does not provide any additional reason for accepting Tomasi's conclusions. (shrink)

As a population, people who self‐identify as lesbian, gay, bisexual, or transgender face significant risks to health and difficulty in obtaining medical and behavioral health care, relative to the general public. These issues are especially challenging in safety‐net health care institutions, which serve a range of vulnerable populations with limited access, limited options, and significant health disparities. Safety‐net hospitals, particularly public hospitals with fewer resources than academic medical centers and other nonprofit hospitals that also serve as safety (...) nets, are under immense financial pressures. However, with the introduction in 2011 of standards for LGBT inclusion by The Joint Commission, showing progress on LGBT health care has become a compliance issue for hospitals. And because the health care community itself has contributed to LGBT health disparities through prejudice, disrespect, or inadequate knowledge that have made it difficult for LGB and especially T people to seek care or to obtain the care they need, there is a moral case for allocating scarce resources to this population: we owe them some investment in righting wrongs that the health care system itself has produced.So, where to begin in the typical safety‐net hospital or clinic? Beyond staff training, which is essential and for which good models now exist, what does justice demand from a service‐utilization perspective? Given the range of health care services that an LGBT person in the safety net may need or want, how should we set priorities? And what can't we promise to do for this member of our community? (shrink)

Should you be targeted by police for a crime that AI predicts you will commit? In this paper, we analyse when, and to what extent, the person-based predictive policing (PP) — using AI technology to identify and handle individuals who are likely to breach the law — could be justifiably employed. We first examine PP’s epistemological limits, and then argue that these defects by no means refrain from its usage; they are worse in humans. Next, based on major AI ethics (...) guidelines (IEEE, EU, and RIKEN, etc.), we refine three basic moral principles specific to person-based PP. We also derive further requirements from case studies, including debates in Chicago, New Orleans, San Francisco, Tokyo, and cities in China. Instead of rejecting PP programs, we analyse what necessary conditions should be met for using the tool to achieve social good. While acknowledging its risks, we conclude that the person-based PP could be beneficial in community policing, especially when merging into a larger governance framework of the social safety net. (shrink)

Simon A Longstaff; Democratic Education and the Curriculum Safety-net: a tantalising illusion?, Journal of Philosophy of Education, Volume 23, Issue 1, 30 May 2.

Healthcare systems in Singapore, Hong Kong, and mainland China are strikingly distinct from those in the West. Economically speaking, each of the aforementioned Eastern systems relies in great measure on private expenditures supplemented by savings accounts. Western nations, on the other hand, typically exhibit government funding and wariness about healthcare savings accounts. This essay argues that these and other differences between Pacific Rim healthcare systems and Western systems should be assessed in light of background Confucian commitments operating in the former. (...) In the Confucian context, bioethics and healthcare policy have a unique content, texture, and set of implications that often affront Western assumptions about the appropriate individual autonomy of patients and the appropriate character of social safety nets for healthcare. (shrink)

Clinical ethics mediation is invaluable for resolving intractable disputes in the hospital. But it is also a critical day-to-day skill for clinicians, especially those who serve a disproportionate number of vulnerable patients. While mediation is typically reserved for intractable cases, there are two important opportunities to expand its use. First is preventative mediation, in which clinicians incorporate clinical ethics mediation into their daily routine in order to address value-laden conflicts before they reach the point at which outside consultation becomes necessary. (...) Second is guided mediation, in which clinical teams resolve conflicts with patients or surrogates with guidance from an ethics consultant, who operates at some distance from the conflict and, rather than recommending a single action, counsels clinicians on the process they can use to resolve the conflict on their own. These approaches build the capacity of all clinicians to use clinical ethics mediation to improve the care of vulnerable patients. (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)