The United States health care industry is the second largest in the world, expending an estimated 479 million metric tons (MMT) of carbon dioxide per year, nearly 8 percent of the country's total emissions. The importance of carbon reduction in health care is slowly being accepted. However, efforts to “green” health care are incomplete since they generally focus on buildings and structures. Yet hospital care and clinical service sectors contribute the most carbon dioxide (...) within the U.S. health care industry, with structures/equipment and pharmaceuticals ranking as the third and fourth highest emitters in the industry. Given the magnitude of health care carbon emissions—and the paucity of attention to the carbon of hospital care and clinical services—this essay identifies overuse of health care as a health threat with serious ethical implications, offers a data‐driven action plan for carbon reduction in health care, and provides practical suggestions for more sustainable health care delivery in the United States. (shrink)

The American Society for Bioethics and the Humanities (ASBH) issued its Core Competencies for Health Care Ethics Consultation just as it is becoming ever clearer that secular ethics is intractably plural and without foundations in any reality that is not a social–historical construction (ASBH Core Competencies for Health Care Ethics Consultation , 2nd edn. American Society for Bioethics and Humanities, Glenview, IL, 2011 ). Core Competencies fails to recognize that the ethics of health care (...) ethics consultants is not ethics in the usual sense of a morally canonical ethics. Its ethics is the ethics established at law and in enforceable health care public policy in a particular jurisdiction. Its normativity is a legal normativity, so that the wrongness of violating this ethics is simply the legal penalties involved and the likelihood of their being imposed. That the ethics of ethics consultation is that ethics legally established accounts for the circumstance that the major role of hospital ethics consultants is as quasi-lawyers giving legal advice, aiding in risk management, and engaging in mediation. It also indicates why this collage of roles has succeeded so well. This article shows how moral philosophy as it was reborn in the 13th century West led to the ethics of modernity and then finally to the ethics of hospital ethics consultation. It provides a brief history of the emergence of an ethics that is after morality. Against this background, the significance of Core Competencies must be critically reconsidered. (shrink)

In this article, we develop a non-rights-based argument based on beneficence (i.e., the welfare of individuals and communities) and justice as the disposition to act justly to promote equity in health care resource allocation. To this end, we structured our analysis according to the following main sections. The first section examines the work of Amartya Sen and his equality of capabilities approach and outlines a framework of health care as a fundamental human need. In the subsequent (...) section, we provide a definition of health equity based on the moral imperative to guarantee that every individual ought to have the freedom to pursue health goals and well-being. In the later part of the article, we outline a non-right approach to health care based on three pillars: (1) human flourishing, (2) justice as a disposition not a process, and (3) solidarity. (shrink)

This paper compares and contrasts three different substantive principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing principle. (...) In conclusion, it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions. (shrink)

Autonomous robots are increasingly interacting with users who have limited knowledge of robotics and are likely to have an erroneous mental model of the robot’s workings, capabilities, and internal structure. The robot’s real capabilities may diverge from this mental model to the extent that one might accuse the robot’s manufacturer of deceiving the user, especially in cases where the user naturally tends to ascribe exaggerated capabilities to the machine (e.g. conversational systems in elder-care contexts, or toy robots in child (...) care). This poses the question, whether misleading or even actively deceiving the user of an autonomous artifact about the capabilities of the machine is morally bad and why. By analyzing trust, autonomy, and the erosion of trust in communicative acts as consequences of deceptive robot behavior, we formulate four criteria that must be fulfilled in order for robot deception to be morally permissible, and in some cases even morally indicated. (shrink)

This article argues that because racial inequalities are embedded in American society, as well as in medicine, more evidence-based investigation of the effects and implications of affirmative action is needed. Residency training programs should also seek ways to recruit medical students from underrepresented groups and to create effective mentorship programs.

Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community care versus hospital care ; a life with care versus a life without care ; stimulation of the client toward greater responsibility versus protection against such responsibility (...) ; budgetary control versus financial incentives , and respect for the client versus particular private needs . These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values—namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity. (shrink)

Background In Scandinavia 13–28% of gynecology patients have experienced abuse in health care in their life time, which contradicts the ethical obligations not to harm the patient and to protect the patient's dignity. Concerning learning to act ethically, scholars have emphasized the importance of combining theoretical and practical dimensions. This article explores Forum Play as a way of learning to act ethically in abusive situations in health care. Method Ten health-care workers participating in a (...) Forum Play course took part in this study. To explore participants' experiences of Forum Play, semi-structured interviews were conducted and processed by using the grounded theory analysis techniques of coding and constant comparison. Results The analysis resulted in the core category “developing response–ability.” It encompasses the processes bringing about the ability to respond adequately to situations where abuse occurs and the conditions for these processes, as well as the participants' achieved understanding of the third person's potential to act in a situation with a power imbalance. Forum Play allows participants to reflect on both verbal and body language, and gives them time to enact and think through issues of moral agency. Conclusion The simulated reality of Forum Play offers a platform where learning to act ethically in abusive situations in health care is facilitated by providing a safe space, suspending constricting structural conditions such as hierarchies and lack of time, fostering moral imagination, allowing creativity in developing and trying out a variety of acting alternatives, and reflecting upon the observed and experienced situation. (shrink)

Health care reform that includes universal coverage could lower a major barrier to care for people of color and ethnic minorities—the inability to pay for care. But universal coverage alone, even with comparable fee-for-service payment or appropriately risk-adjusted capitated reimbursement, will not eradicate the racial and ethnic inequities in health care delivery. Restrictive admissions practices, geographic inaccessibility, culture, racial stereotypes, and the failure to employ minority health care professionals will still create barriers (...) to minority health care. In addition to universal financing, health care reform should include new civil rights legislation to address and reduce these noneconomic barriers to minority health care. (shrink)

This article addresses some ambiguities and normative problems with the concept of mature care in professional relationships and in health care priorities. Mature care has recently been introduced in the literature on care ethics as an alternative to prevailing altruistic conceptions of care. The essence of mature care is an emphasis on reciprocity, where the mature agent has the ability to balance the concerns of self with those of others and act from a (...) principle of not causing harm. Our basic claim is that the prevailing concept of mature care does not capture the real nature of professional relationships and role obligations in health care. As the focus of attention in professional care is and must be the patient’s particular medical and care needs, such care must principally be altruistic. Furthermore, we argue that mature care cannot adequately address moral conflict in health care without accepting some more principle-based approaches and a richer notion of partiality. (shrink)

Clinical ethics is a relatively new discipline within medicine, generated not so much by the Can we . . . ? questions of fact and prognosis that physicians ...

Are values and social priorities universal, or do they vary across geography, culture, and time? This question is very relevant to Asia’s emerging economies that are increasingly looking at Western models for answers to their own outmoded health care systems that are in dire need of reform. But is it safe for them to do so without sufficient regard to their own social, political, and philosophical moorings? This article argues that historical and cultural legacies influence prevailing social values (...) with regard to health care financing and resource allocation, and that the Confucian dimension provides a helpful entry point for a deeper understanding of ongoing health care reforms in East Asia – as exemplified by the unique case of Singapore. (shrink)

Medicine increasingly envisions health promotion in terms of reducing risk as determined by quantitative risk factors, such as blood pressure, blood lipids, or genetic variants. This essay argues that this vision of health care as risk reduction is dangerous for Christian bioethics, since risk can be infinitely reduced leading to a self-defeating spiral of iatrogenic effects. Moreover, it endangers character because this vision of health is connected to a reductionist vision of the body and an understanding (...) of individual risk that undermines the more communal virtue of solidarity. The essay concludes by discussing how recent Thomistic analyses in favor of physical enhancements illustrate some of the problems that envisioning health care in terms of risk reduction holds for Christian bioethics. (shrink)

Objective: To explore the ways in which health care practitioners working within the morally contested area of prenatal screening balance their professional and private moral values.Design: Qualitative study incorporating semistructured interviews with health practitioners followed by multidisciplinary discussion groups led by a health care ethicist.Setting: Inner city teaching hospital and district general hospital situated in South East England.Participants: Seventy practitioners whose work relates directly or indirectly to perinatal care.Results: Practitioners managed the interface between their (...) professional and private moral values in a variety of ways. Two key categories emerged: “tolerators”, and “facilitators”. The majority of practitioners fell into the “facilitator” category. Many “facilitators” felt comfortable with the prevailing ethos within their unit, and appeared unlikely to feel challenged unless the ethos was radically challenged. For others, the separation of personal and professional moral values was a daily struggle. In the “tolerator” group, some practitioners sought to influence the service offered directly, whereas others placed limits on how they themselves would contribute to practices they considered immoral.Conclusions: The “official” commitment to non-directiveness does not encourage open debate between professionals working in morally contested fields. It is important that practical means can be found to support practitioners and encourage debate. Otherwise, it is argued, these fields may come to be staffed by people with homogeneous moral views. This lack of diversity could lead to a lack of critical analysis and debate among staff about the ethos and standards of care within their unit. (shrink)

In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficence and solidarity as mutual advantage. I argue that only the latter is capable of providing a complete foundation for national universal health care programs. On the mutual advantage account, the rationale for universal insurance is parallel to the rationale for a labor union’s “closed shop” policy. In both cases, mandatory participation is necessary in order to stop individuals free-riding on an ongoing system of (...) mutually advantageous cooperation. (shrink)

Imagine you are the CEO of a hospital [. . .]. Decisions are constantly being made in your organization about how to spend the organization's money. The amount of money available to spend is never adequate to pay for everything you wish you could spend it on, therefore you must set spending priorities. There are two questions you need to be able to answer . . . How should we set priorities in this organization? How do we know when we (...) are doing it well? When people seek to achieve good public policy, the result will tend to be good public policy. In a collective choice process, public‐spirited individual participants produce good public policy by deliberating—talking with each other, listening to each other's arguments, and being willing to learn and change their minds based on such dialogue. –Steven Kelman (1992: 181) Public policy scholars agree that those persons (or agencies) vested with the authority to establish health care priorities should elicit public input before making rationing decisions. The two most common approaches are (i) consultation and (ii) deliberation. Though deliberation has obvious advantages over consultation, it falters in the face of the objection that ordinary citizens lack the cognitive resources for the extended, rigorous inquiry required of them in undertaking the priority‐setting task. To overcome this objection, I propose that deliberative forums for health care rationing should be designed so that they imitate the natural pattern of human experience. The experience of deliberation should encompass both prolonged periods of less‐demanding cognitive activity, in which citizens passively receive information, and briefer periods of more‐demanding cognitive activity, in which they engage in active problem‐solving. In arguing for this thesis, I rely on two theoretical sources and one practical case study, in the following order: (i) John Dewey's metaphysics of experience, (ii) cognitive science research on schemas and frames, and (iii) the Health Care Council in São Paulo, Brazil. (shrink)

Extracts from the New Zealand Minister of Health's Speech to the New Zealand Medical Association Conference. 19 April 1994.

Book reviewed in this article: Practical Medical Ethics. By Alastair Campbell, Grant Gillett, and Gareth Jones. If I Were a Rich Man Could I Buy a Pancreas? and Other Essays on the Ethics of Health Care. By Arthur L. Caplan. Bloomington Ethics on Call: A Medical Ethicist Shows How to Take Charge of Life and Death Choices in Today's Health Care System. By Nancy Dubler and David Nimmons.

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

With widespread advances in the diffusion and application of medical technologies, the phenomena of misuse and overuse have become pervasive. These phenomena not only increase the cost of health care systems and deplete the accessibility and availability of health care services, they also jeopardize patient autonomy. From a literature review on this aspect of medical technology, an impact on patient autonomy is found in almost all cases, with the exception of philosophical or ethical writings, in which (...) there is not much practical application for health policy and law. In this article, the major finding is that in the area of patient autonomy, it does not matter much whether the “physician decides” or the “patient decides” in the current “disease care” health system, where most of the doctors focus only on disease treatment using aggressive medical technologies. It is also our “disease care” system that ensures that the patients, the health care professionals, or the health care management cannot safeguard their autonomy. Only when the genuine health care system is restored will patient autonomy be protected. (shrink)

The family, like so many other modern institutions, often looks more like an arena of competing wills than an ordered life in common. If we hope, therefore, to protect the special role that parents should have in relation to their children, and that the family in general should have in relation to its members, we will need a much more developed account of the goods that are at stake and why we think they are important enough to require authority, even (...) when members of the family oppose the decisions of that authority. This essay develops an older account of authority, one rooted in the thought of Aristotle and St. Thomas Aquinas, and applies this account to our present difficulties concerning the authority of the family over its members in health care decision making. (shrink)

This authoritative Handbook brings together experts with backgrounds in philosophy, sociology, law, public policy and the health professions and reflects the increasing impact of globalization and the dynamic advances in the fields of ...

The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the (...) authors refer to as `dimensions of ethical practice'. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional—patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study's participants would help to improve quality of care. (shrink)

At the 2022 Central American Philosophical Association meeting, there was an Author-Meets-Critics session on Carolyn McLeod’s book, Conscience in Reproductive Health Care: Prioritizing Patient Interests. The event was organized and chaired by Heather Stewart and sponsored by the APA Committee on the Status of Women and Kate Norlock, chair of that committee. There were four speakers, including McLeod and three “critics”: Javiera Perez Gomez, Alison Reinheld, and Jennifer Parks, who were all generous enough to provide McLeod with their (...) comments beforehand. The sessions occurred over Zoom even though some speakers were present in person at the conference. McLeod kicked things off by providing a summary of her book, which was then followed by critical comments by the critics in the order in which they’re named above. McLeod responded to their remarks and then Stewart led a Q&A session with our small but lively and intelligent audience. The content of what was said has been reproduced here. (shrink)

In this essay, I explore John Stuart Mill’s theory of government and its application to the issue of health care reform. In particular, I ask whether Mill’s theory of government would justify or condemn the creation of a public health-insurance option. Although Mill’s deep distrust of governmental authority would seem to align him with Republicans, Tea Partiers, libertarians, and others, who cast the public option as a “government takeover” of “our” health care system, I argue (...) that Mill offers good reasons for seriously considering some form of government-operated health insurance. For Mill theorizes government as having a positive as well as a negative role to play in people’s lives, and he explicitly endorses “public options” in different areas of life. According to his theory of government, a public health-insurance option would be just as long as it would meet the following two conditions: (1) it would not invade the “reserved territory” of individual liberty; and (2) “the case of expediency is strong.” I argue that a public option would in fact meet both of these conditions, and that Mill would have likely endorsed it as an effective solution to the current health care crisis in the United States. (shrink)

The book provides an argument against a right to conscientious objection by healthcare professionals. In increasingly multicultural societies inspired by pluralism, and given the range of controversial medical procedures that are or will be legal in many countries, claims about healthcare professionals' right to abide by their own moral or religious views in the exercise of their profession become more frequent. This book explains why arguments for pluralism, tolerance, and diversity that support a right to freedom of conscience in society (...) at large do not support the same right within the healthcare profession, or indeed any profession governed by internal norms of professionalism that someone freely decides to enter. (shrink)

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

Perhaps some simple change will do the trick, like relying less on insurance and employers as middlemen. But if we are willing to consider radical change, let me offer a different suggestion. We are buying the wrong thing. What we want is health, i.e., a long healthy life, but when we sit down and draw up a contract, what we buy is health care, i.e., a certain degree of attention from health care specialists.

When the President’s Commission of 1983 concluded that there is an “ethical obligation” to secure universal access to a decent minimum of health care, some hoped that this standard would be achieved in the United States within a few years. Nearly 30 years later, when we began work on this issue of the Journal of Medicine and Philosophy (JMP), that standard had yet to be achieved, although the bills that would later become the Affordable Care Act (ACA) (...) were then working their way through Congress. Now, the ACA has been passed and signed into law. The provisions of that bill aim at achieving universal access to an “essential health benefits (EHBs) package". (shrink)

This paper discusses two interrelated concepts: (1) the ethics of planned social change and (2) primary health care. It takes the World Health Organization’s definition of primary health care as a point of departure to examine four identified potential areas where ethical dilemmas may occur. In addition, questions are raised about nursing education, as well as about the class and status differences between nurses and patients and communities. It takes the position that our first task (...) is to encourage more discussion and examination of ethical issues in the planned social change of primary health care. (shrink)

Eric Nord's book is required reading for all those interested in resource allocation. It is largely a book on health economics, but the importance of the issues discussed and the clarity of this book mean that it is relevant to all those involved in resource allocation. One of the more common objections to QALYs (Quality Adjusted Life Years) is that they focus on maximising the benefit produced by health care without paying attention to other factors relevant to (...) allocation. One of the basic theses of Nord's book is that there is something right about this line of criticism and he sets out to correct cost-effectiveness studies by building into them societal concerns for the way in which health care resources are distributed. In chapter four he argues that the standard approach to QALYs is inconsistent with two major societal concerns about fairness. First it violates the strength with which people wish to give priority to the severely ill over the less severely ill at the expense of the total amount of health produced. Second, …. (shrink)