The importance of preserving trust in physicians and in medical institutions has received widespread attention in recent years. Primarily, this is due to the threats to trust posed by managed care, but there is a general and growing recognition that trust deserves more attention than it traditionally has received in all aspects of medical ethics, law, and public policy. Trust has both intrinsic and instrumental value. Trust is intrinsically important because it is a core characteristic that affects the emotional and (...) interpersonal aspects of the physician/patient relationship. As an instrumental value, trust is widely believed to be essential for effective therapeutic encounters. It has been hypothesized or shown to affect a host of important behaviors and attitudes relating to care, including seeking care, disclosing private information, complying with treatment, and being satisfied with care. Moreover, trust may be a mediator of measurable clinical outcomes and a key factor in the mind–body interactions that underlie placebo/nocebo effects and the effectiveness of alternative medicine. It is no surprise, then, that preserving, justifying, and enhancing trust is the fundamental goal of much of medical ethics, and is a prominent objective in healthcare law and public policy. Discussions of trust and related concepts were commonplace in professionally based medical ethics prior to the 1970s. a 1 2. (shrink)

This book explores the making of health care rationing decisions through the analysis of three alternative decision makers: patients paying out of pocket; officials setting limits on treatments and coverage; and physicians at the bedside. Hall develops this analysis along three dimensions: political economics, ethics, and law. The economic dimension addresses the practical feasibility of each method. The ethical dimension discusses the moral aspects of these methods, while the legal dimension traces the most recent developments in jurisprudence and health (...) law. (shrink)

On September 8, 2015, the Department of Health and Human Services issued a Notice of Proposed Rule Making to revise the Federal Policy for the Protection of Human Subjects, widely known as the “Common Rule.” The NPRM proposes several changes to the current system, including a dramatic shift in the approach to secondary research using biospecimens and data. Under the current rules, it is relatively easy to use biospecimens and data for secondary research. This approach systematically facilitates secondary research with (...) biospecimens and data, maximizing the capacity for substantial public benefit. However, it has been criticized as insufficiently protective of the privacy and autonomy interests of biospecimen and data sources. Thus, the NPRM proposes a more restrictive regime, although more so for biospecimens than data. Both the status quo and the NPRM's proposal are critically flawed. (shrink)

“Unconscionable.” “Outrageous.” “Indefensible.” These are just some of the tamer descriptions for the billing practices of most hospitals, and also many physicians, that have recently come to the public's attention. Earlier this year, Time magazine published an extraordinary 24,000‐word exposé—the longest article it has ever published—detailing how even charitable hospitals routinely price‐gouge their patients.1 With characteristic flare for telling details, journalist Steven Brill documented ten‐fold markups of charges over costs at some prominent hospitals for common services like X rays and (...) lab tests, and one‐hundred‐fold mark‐ups on mundane supplies such as gauze pads and generic aspirin. Just as the buzz from Brill's article was abating, the Centers for Medicare & Medicaid Services released a comprehensive data set in May that galvanized local and national media across the country. This news tsunami caught hospital managers flat‐footed and tongue‐tied. Typical responses conceded that hospitals’ pricing practices are based neither on actual cost structures nor rational marketplace dynamics. Instead, hospitals attempted to deflect blame by noting that hardly anyone actually pays list prices, and they characterized their indefensible pricing as a symptom of a broken system that is beyond them to fix. There are two glaring faults in these standard defenses. (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)

Health insurance mandates have been a component of many recent health care reform proposals. Because a federal requirement that individuals transfer money to a private party is unprecedented, a number of legal issues must be examined. This paper analyzes whether Congress can legislate a health insurance mandate and the potential legal challenges that might arise, given such a mandate. The analysis of legal challenges to health insurance mandates applies to federal individual mandates, but can also apply to a federal mandate (...) requiring employers to purchase health insurance for their employees. There are no constitutional barriers for Congress to legislate a health insurance mandate as long as the mandate is properly designed and executed, as discussed below. This paper also considers the likelihood of any change in the current judicial approach to these legal questions. (shrink)

Both the USA and Europe limit access to care by undocumented immigrants. In the debate over what level of access to confer to IMs, there are various public policy rationales operating either explicitly, or below the surface, ranging from minimalist humanitarianism to full cosmopolitan equality, with several intermediate positions between these two poles. This article informs the international debate by providing a conceptual mapping of these underlying policy rationales. Each position is based on different lines of reasoning or bodies of (...) evidence, and each leads to somewhat different conclusions about the extent to which IMs should have access to different types of health care. It is unlikely that broad consensus will be achieved in this ongoing debate. However, by articulating the ethical, legal, pragmatic and conceptual reasons to support or oppose various positions, we hope to help determine where in the landscape of reasoned argument various positions lie, and how each position might be best supported or refuted. In particular, we see in this debate an illustration of Michael Walzer’s classic analysis of competing spheres of justice. Various positions depend to a considerable extent on whether their advocates approach this issue from the health policy sphere rather than the sphere of immigration policy, or whether they attempt to blend the two spheres. (shrink)

Centralized, democratic rules are often asserted as a superior basis for rationing than individualized physician discretion. This article counters this prevailing wisdom by exploring the deficiencies of rule-based rationing. Rules are too imprecise to accurately reflect all the nuances of physical and mental impairment and the complexity of medical science, particularly considering the widely varying personal values that different patients attach to medical risk and benefit. Rule-based rationing also suffers from the biasing effects of interest group pressure on political processes (...) and the tendency to absolve physicians from any moral responsibility for the rationing decisions they implement. Internalizing cost constraints is a more socially and professionally acceptable means of rationing and, in any event, it is inevitable since even a preponderance of rule-based rationing will leave considerable areas of discretion for physician judgment in the implementation and interpretation of the rules. As a consequence, despite the flaws of bedside rationing, it is foolhardy to dispense with it entirely in favor of an exclusively rule-based system. Keywords: Bedside rationing, cost-constraints, rule-based rationing CiteULike Connotea Del.icio.us What's this? (shrink)

Not since the civil rights era has enacted national legislation been fought so fiercely as the Patient Protection and Affordable Care Act. Political, ideological, and social forces have mobilized to undermine the ACA at numerous fronts, including the Supreme Court, Congress, state governments, and the court of public opinion. The ACA has survived a constitutional challenge, a presidential re‐election, numerous repeal votes in the House, and avowedly obstreperous state regulators. But it has not yet run the full gauntlet of lethal (...) strategies. The latest line of attack is a collection of orchestrated lawsuits seeking to keep the federal exchange from paying any premium tax subsidies.What if the challengers eventually prevail? What would happen then? (shrink)

Opponents of the Affordable Care Act have attempted to topple it in court by challenging the legality of two of its three legs. Three years ago, in NFIB v. Sibelius, Chief Justice Roberts narrowly upheld the constitutionality of the individual mandate, in a 5-to-4 decision that characterized the mandate as an optional tax rather than as a regulatory command. This year, on June 25, the health policy community exhaled a giant sigh of relief when the Supreme Court upheld the subsidy (...) leg of the ACA structure. In King v. Burwell, Justice Roberts again wrote the majority opinion, ruling as a matter of statutory interpretation that subsidies for insurance premiums are available not just through state-based exchanges but also through the federal exchange. (shrink)

It was a happy surprise when, overcoming partisan divisions and interest‐group lobbying, Congress enacted the No Surprises Act, which bans unfair out‐of‐network “balance billing.” Although this is only a modest legislative victory, key efforts by the health policy community made a real difference in a time of legislative gridlock.

Health care reform is being assaulted from all sides. In January, the House of Representatives voted to repeal The Patient Protection and Affordable Care Act (the "Affordable Care Act"). For now, that effort will not succeed, owing to Democratic control of the Senate and the presidential veto. But conservative lawmakers in the House threaten to withhold key funding for implementation, and we can expect ongoing efforts to enact various partial amendments.Meanwhile, a core component of the reform law is running the (...) gauntlet of constitutional challenges in dozens of courts.1 So far, two federal district judges—in Richmond, Virginia, and Pensacola, Florida—have declared the individual mandate unconstitutional, as .. (shrink)

This article reviews the primary avenues of judicial challenge to the ACA, focusing on those that have reached, or have the potential to reach, the Supreme Court. The review demonstrates how deep-seated public policy opposition can be expressed through litigation.

The new millennium is still very young, so it is too early to declare National Federation of Independent Business v. Sebelius1 the health law “case of the century,” but that title would not be hyperbolic. Never before have we seen a case of such monumental importance for how health care is financed and delivered in the United States. At the Supreme Court, no decision has been more closely watched and more anxiously awaited since Bush v. Gore in 2000. In the (...) balance was the fate of President Obama's signature piece of domestic legislation, one that affects nearly every aspect of the largest segment of our economy, and so is perhaps the most important piece of social legislation since the New Deal. To no one's surprise, the decision was announced at the very end of the Court's term and was split five to four.What was very surprising, however, was the Court's embrace of the tax power defense of the individual mandate. And what was outright shocking was a seven‐to‐two majority in favor of finding the Medicaid expansion unconstitutional unless states are allowed to opt out of the expansion.The case holds great significance not only for the fate of the Patient Protection and Affordable Care Act—and, thus, for the nation's health care public policy—but also for constitutional doctrine that applies much more broadly than in the health care arena. (shrink)

As politicians revisit the merits of health insurance reform and courts deliberate its constitutionality, government regulators are busily working on the wonky details of implementation. The Affordable Care Act leaves vast swaths of regulation for various agencies to prescribe, most notably the Department of Health and Human Services. Infamously (or perhaps apocryphally, since I'm certainly not going to bother counting), the statute contains more than a thousand commands to the effect of, "the Secretary shall decide." This massive delegation of authority (...) is unavoidable in any attempt to comprehensively reform, yet preserve, our Byzantine health insurance system.Throughout this regulatory nativity, the government .. (shrink)

Since 1991, over half the states have enacted laws that restrict or prohibit insurers’ use of genetic information in pricing, issuing, or structuring health insurance. Wisconsin was the first state to do so, in 1991, followed by Ohio in 1993, California and Colorado in 1994, and then several more states a year in each of the next five years. Similar legislation has been pending in Congress for several years. Also, a 1996 federal law known as the Health Insurance Portability and (...) Accountability Act prohibits group health insurers from applying “preexisting condition” exclusions to genetic conditions that are indicated solely by genetic tests and not by any actual symptoms. (shrink)

From the early days of European settlement in North America, Christianity has had a profound impact on American law and culture. This volume profiles nineteen of America's most influential Christian jurists from the early colonial era to the present day. Anyone interested in American legal history and jurisprudence, the role Christianity has played throughout the nation's history, and the relationship between faith and law will enjoy this worthy and unique study. The jurists covered in this collection were pious men and (...) women, but that does not mean they agreed on how faith should inform law. From Roger Williams and John Cotton to Antonin Scalia and Mary Ann Glendon, America's great Christian jurists have brought their faith to bear on the practice of law in different ways and to different effects. (shrink)

Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions—an “aspirational ethic” that exhorts physicians to treat all patients the same regardless of their ability to pay, and an “agency ethic” that calls on physicians to (...) be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay. (shrink)

Investigator and institutional financial conflicts of interest have raised concerns about both the integrity of clinical research and protecting the rights and welfare of research participants. In response, professional groups and governmental bodies have issued guidance for managing conflicts of interest to minimize their potential untoward effects. Although a variety of approaches have been offered, a common protection is to disclose financial interests in research to potential research participants as part of the recruitment and informed consent process. This approach reinforces (...) a basic norm of candor, ideally allowing potential research participants to evaluate whether financial interests should affect their decision to participate in research. Disclosure to potential research participants is viewed as an alternative to having regulators or research institutions limit or prohibit all financial interests in research, assuming that not all such interests are unacceptable. (shrink)

This article introduces the Special Issue on ‘Interpretivism and the English School of International Relations’. It distinguishes between what we term the interpretivist and structuralist wings of...

This article analyses the evolution of the English school’s approach to international relations from the work of the early British Committee in the late 1950s and early 1960s to its revival in the...

We are currently seeing a revival of interest in Aquinas's moral thought among Christian ethicists, both Protestant and Catholic. Although recent studies of his moral thought have touched on a number of topics, the majority of these have focused on his account of the virtues and their place in the Christian life. Probing the questions of the relation of virtue and law, the role of reason and will, and the place of the passions in Aquinas's moral theology, I will examine (...) recent studies by Diana Cates, Pamela Hall, Simon Harak, James Keenan, Daniel Nelson, Daniel Westberg, and Paul Waddell. In different ways these studies return us repeatedly to the vexed and unresolved question of the scope of human freedom. (shrink)

This article responds to Charlotta Friedner Parrat’s critique of our argument that the English School of international relations should embrace a more thoroughgoing interpretivism. We address four of Friedner Parrat’s objections to our argument: that our distinction between structuralism and interpretivism is too stark; that our understanding of the relationship between agency and structure is problematic; that our approach would confine the English School to the study of intellectual history; and that the English School should eschew explanation. We argue that (...) if the School is to use structuralism, it must be clearer about how it understands structures and their relationships to agents. We argue too that interpretivism not only offers a better account of situated agency, but also that it provides the English School with one way to move beyond the description and classification of institutions in international society towards better explanations of international relations. (shrink)

Interest in NFIB v. Sebelius has been extraordinarily high, from as soon as the legislation was passed, through lower court rulings, the Supreme Court’s grant of certiorari, and the decision itself, both for its substantive holdings and the purported behind-the-scene dynamics. Legal blogs exploded with analysis, bioethicists opined on our collective responsibilities, and philosophers tackled concepts like ‘coercion’ and the activity/inactivity distinction. This volume aims to bring together scholars from disparate fields to analyze various features of the decision. It comprises (...) over twenty essays from a range of academic disciplines, namely law, philosophy, and political science. Essays are divided into five units: context and history, analyzing the opinions, individual liberty, Medicaid, and future implications. (shrink)

Conspiracy theories (CTs) are widespread ways by which people make sense of unsettling or disturbing cultural events. Belief in CTs is often connected to problematic consequences, such as decreased engagement with conventional political action or even political extremism, so understanding the psychological and social qualities of CTs belief is important. CTs have often been understood to be “monological”, displaying the tendency for belief in one conspiracy theory to be correlated with belief in (many) others. Explanations of monologicality invoke a nomothetical (...) or “closed” mindset whereby mutually supporting beliefs based on mistrust of official explanations are used to interpret public events as conspiracies, independent of the facts about those events (which they may ignore or deny). But research on monologicality offers little discussion of the content of monological beliefs and reasoning from the standpoint of the CT believers. This is due in part to the “access problem” (Wood & Douglas, 2015): CT believers are averse to being researched because they often distrust researchers and what they appear to represent. We used several strategies to address the access problem, and investigated the symbolic resources underlying CTs by reconstructing a conspiracy worldview - a set of beliefs held by CT believers about important dimensions of ontology, epistemology, and human agency. To do this, we analysed media documents, conducted field observation, and engaged in semi-structured interviews,. We describe six main dimensions of a conspiracy worldview: Views of the nature of reality, the self, the outgroup, the ingroup, action, and the future. We also describe a typology of five types of CT believers, which vary according to their positions on each of these dimensions. Our findings converge with prior explorations of CT beliefs but also revealed novel aspects: A sense of community among CT believers, a highly differentiated representation of the outgroup, a personal journey of conversion, variegated kinds of political action, and optimistic belief in future change. These findings are at odds with the typical image of monological CT believers as paranoid, cynical, anomic and irrational. For many, the CT worldview may rather constitute the ideological underpinning of a nascent pre-figurative social movement. (shrink)

The expansion of the corpus of international human rights to include the right to water and sanitation has implications both for the process of recognizing human rights and for future developments in the relationships between technology, engineering and human rights. Concerns with threats to human rights resulting from developments in science and technology were expressed in the early days of the United Nations (UN), along with the recognition of the ambitious human right of everyone “to enjoy the benefits of scientific (...) progress and its applications.” This comment explores the hypothesis that the emerging concepts most likely to follow recognition of the human right to water primarily involve issues of science and technology, such as access to medicines or clean and healthy environment. Many threats to human rights from advances in science, which were identified in the past as potential, have become real today, such as invasion of privacy from electronic recording, deprivation of health and livelihood as a result of climate change, or control over individual autonomy through advances in genetics and neuroscience. This comment concludes by urging greater engagement of scientists and engineers, in partnership with human rights specialists, in translating normative pronouncements into defining policy and planning interventions. (shrink)

Lack of guidance and regulation for authorizing medical cannabis for conditions involving the health and neurodevelopment of children is ethically problematic as it promulgates access inequities, risk-benefit inconsistencies, and inadequate consent mechanisms. In two virtual sessions using participatory action research and consensus-building methods, we obtained perspectives of stakeholders on ethics and medical cannabis for children and youth. The sessions focused on the scientific and regulatory landscape of medical cannabis, surrogate decision-making and assent, and the social and political culture of medical (...) cannabis. We found that evidence-gathering and data dissemination, pressures on clinical relationships, and the lack of integration of culturally diverse perspectives and Indigenous knowledges were key areas of concern. Participants emphasized the importance of utilizing adaptive study designs, highlighted the importance of trust-building between clinicians, patients and caregivers, and discussed barriers including historical and ongoing stigmatization of medical cannabis. We conclude that continued public consultation and strength-based research that integrate diverse perspectives are critical steps forward. (shrink)

Arguably, Hume's greatest single contribution to contemporary philosophy of science has been the problem of induction (1739). Before attempting its statement, we need to spend a few words identifying the subject matter of this corner of epistemology. At a first pass, induction concerns ampliative inferences drawn on the basis of evidence (presumably, evidence acquired more or less directly from experience)—that is, inferences whose conclusions are not (validly) entailed by the premises. Philosophers have historically drawn further distinctions, often appropriating the term (...) “induction” to mark them; since we will not be concerned with the philosophical issues for which these distinctions are relevant, we will use the word “inductive” in a catch-all sense synonymous with “ampliative”. But we will follow the usual practice of choosing, as our paradigm example of inductive inferences, inferences about the future based on evidence drawn from the past and present. A further refinement is more important. Opinion typically comes in degrees, and this fact makes a great deal of difference to how we understand inductive inferences. For while it is often harmless to talk about the conclusions that can be rationally believed on the basis of some.. (shrink)

IN a review of Excavations at Phylakopí, Class. Rev. 1905, p. 80, I find I have misquoted Dr. Arthur Evans. In Ms article on the ‘Pottery-marks’ Dr. Evans writes that ‘the method of writing from right to left, instead of from left to right, is not found in the Cnossian linear inscriptions.’ By a slip which I much regret I wrote ‘Cretan’ for ‘Cnossian’ in quoting this sentence. I of course understood Dr. Evans to be referring to the Cnossian inscriptions (...) only, not to the whole ‘Minoan’ system of picture-writing generally. He shews that right-to-left writing could be used in the Minoan system by the Melian example, which reads in the reverse direction to that of an otherwise identical Cnosaian sign-group. This being so, I still doubt whether all the Cnossian inscriptions will eventually prove to read from left to right. (shrink)

Consider the difference between reaching over to the desk to grab your copy of Kant’s first Critique and reaching over to grab some book or other. This is the difference between an action directed on a specific thing and an action directed on something, but no one thing in particular. In the first case, you will be successful only if you grab your copy of Kant—only one book will do; in the second, you will be successful if you grab a (...) book, and here any book will do. This is a difference that is frequently displayed: many intentional actions are directed on things, and of these, a good many are directed on specific things. In speech, we mark this difference by saying that you have a particular thing in mind in the first case but not in the second. This establishes that we can get at the notion of having a particular thing in mind (IM) with the help of intentional action, but a full-blown analysis of IM should be grounded in an assessment of its role in all contexts where it applies. That there should be additional contexts beyond intentional action seems apparent from the language we use in applying IM and the range of cases in which we apply it. Attention to language reveals that we often talk about having things “in mind” without mentioning actions, such as when we say that we had a friend in mind just last week; we might even say that we had something in mind while denying that we acted, such as when we say that we had the friend’s birthday in mind but didn’t buy a card. Turning to the range of cases, note that we are willing to describe people as having some particular thing in mind when they are not acting, such as when we say that a student had a party in mind when they should have been concentrating on a lecture. These examples suggest that IM is applicable beyond the context of intentional action. In this essay, I supply an account of what it is to have a particular thing in mind. I begin by arguing that, despite appearances, IM applies only within the context of intentional action. Any evidence that suggests otherwise depends on an incomplete appreciation of the role played by intentional action in examples such as those considered above.. (shrink)

A comprehensive introduction to contemporary political ethics What is the relationship between politics and morality? May politicians bend moral constraints in the name of political necessity? Is it always wrong for leaders to lie? How much political compromise is too much? In Political Ethics, some of the world’s leading thinkers in politics, philosophy, and related fields offer a comprehensive and accessible introduction to key issues in this rapidly growing area of political theory. In a series of original essays, the contributors (...) examine a range of urgent political problems: lies and deception, compromise and refusal to compromise, the meaning and limits of political integrity, representation and failures of representation, good and bad democratic leadership, the virtues and excesses of partisanship, administrative ethics, political corruption, whistleblowing, legitimate and illegitimate claims of political emergency, and lobbying. What emerges are realistic but demanding ethical standards—and a clear-eyed understanding of the ethical challenges of political life in the twenty-first century. With contributions by Richard Bellamy, Alin Fumurescu, Edward Hall, Suzanne Dovi and Jesse McCain, Eric Beerbohm, Russell Muirhead and Nancy Rosenblum, Joseph Heath, Elizabeth David-Barrett and Mark Philp, Michele Bocchiola and Emanuela Ceva, Nomi Lazar, Phil Parvin, and Andrew Sabl. (shrink)

Christian Wolff's 1721 Discourse on the Practical Philosophy of the Chinese is generally read as championing the autonomy of ethics from religion. This is too simple: Wolff's ethics was an antivoluntarist religious ethics. The example of the Chinese confirmed for Wolff that revelation is not necessary for knowledge or practice of genuine virtue, though he held that the Chinese achieve only the first of three “degrees of virtue.” (Most Christians, including the Pietists who drove Wolff from Halle shortly after he (...) delivered the Discourse, did not, in his judgment, achieve even that.) China's being perceived as outside of Western (and sacred) history made it a congenial example for the ethics and moral anthropology that, in Wolff's time, were struggling against the voluntarism of a Christian ethics premised on original sin. (shrink)

In a monograph published last year, literary theorist Mark Noble notes that, in the way Deleuze understands the relationship between materialism and subjectivity, Deleuze “also sounds curiously like Santayana.” For example, the work of both philosophers “locates human value in a source at once immanent and alien.” Noble also wonders “whether the lesson of Santayana’s own negotiation with his tendency to humanize the non-human ground of experience also anticipates the thrill Deleuze chases when positing the univocity of being.” In (...) the present article, I will attempt to elaborate on this “anticipation,” the implications of which include a greater appreciation of Santayana on the part of Deleuze enthusiasts, an understanding of both philosophers as U.S.-influenced, European quasi-pragmatists, and a decision in favor of Michael Brodrick’s recent interpretation of Santayana as a “total natural event” philosopher of mind. (shrink)