The current concern with reforming and regulating managed care under the general rubric of “patients' rights” has eclipsed the more fundamental need to legislate the human rights of those without adequate access to any healthcare. To characterize the regulatory activity as a “rights” movement inflates its moral dimension. The concept of “rights” carries a serious and powerful moral force that is currently inappropriately applied to the parochial concerns of a segment of the population privileged to have health insurance coverage. By (...) contrast, the language of “rights” refers to a high level of universality for the most rudimentary of human concerns. If there was a universal right to become a patient equal to other patients, a concept of patients' rights would have legitimacy. As it is, however, the central determinant of this “right” is how much the insurance policy costs and what is covered. To so diminish the meaning of “right” within the miasma of managed care is to lose sight of the real possibilities of applying a positive “right” to healthcare and, in the long run, is to diminish the ethics of healthcare. (shrink)

The rock climber and the law share in a common etymological allusion when each reaches a steep, high, and hard place. The climber “appeals” to the mountain by inching down on a rope and the law's “rappel” is similarly a route to more comfortable footing. Each step in this common process is germane to the eventual resolution, for it is to be found in the rappel process itself and in the meaning of each appeal.

Has the private body of biethics become a microcosm of the body politic? Politics is ethics writ large. Ethics is politics writ small. However we turn it, the practice of bioethics is increasingly attuned to developments in public policy. The establishment of a “Health Policy Watch” in these pages is an invitation for research and reflection on these issues.

The challenge of determining that therapeutic intervention is futile is a recurrent ethical theme in critical care medicine. The process by which that determination is reached often involves demanding collaborative and interdisciplinary conversation and deliberation within the context of hospital policy, including ethics committee guidelines. The subsequent decision as to what happens next depends on resources, such as palliative care services, hospice, other hospital protocols, and, of course, family support.

A common tale of moral cacophony and euphemism on the city streets:Each day, an owner of a small business decides, “once and for all,” how to respond to the “homeless person” panhandling for “spare change” as she makes her way to work in the morning. Today, she looks the other way and holds more tightly to her purse. Nearby, a building contractor waits impatiently for the traffic light to change as his van is approached by a small and shabby band (...) of “street people” demanding to clean his windshield. He turns his wipers on to signal them away. Sometimes this works. At the next light, a woman carrying an infant swaddled to her torso offers a tube of three roses for a dollar. The driver smiles pleasantly, but does not stop. The businesswoman, now close to work, buys two tubes of roses and does not wait for the change from the five-dollar bill she earnestly presses into the mother's hand. (shrink)

Ongoing legislative proposals to overhaul United States immigration policy look very much like a new wave of nativism is sweeping the Congress. The movement, mounted in early 1995, is in full swing to limit immigrant populations from arriving, settling, producing, and benefiting as our parents' generations have done. Legislators and the courts are now considering the most complete antiimmigration social legislation since the decades following the First World War.

The era of managed care has arrived with portents of a new calculus to integrate cost and quality in health services. These devises such as “report cards” and “outcome measures” place performance against expectations and thus are expected to gauge the value of specific elements of healthcare delivery. From such measures and comparisons, the public will be able to better judge the appropriate, effective, and attractive place to seek their medical services. What is now widely used by utilization review, guiding (...) reimbursement decisions and allowances for the length of hospital stays, will soon have a more prosperous future as general guidelines built into the very framework of managed care agreements. (shrink)

The ideal of universal human rights is arguably the most potent moral concept marking the modern world. Its accelerated fruition in the last half of the twentieth century has created a powerful political force, laying the groundwork for future generations to extend and apply. Whereas anything resembling international legal status for human rights had to wait for the post-Nazi era, the bold proclamations of the Universal Declaration of Human Rights (UDHR, 1948) loosened a revolutionary force with endless potential for application (...) to the full range of human endeavors. The roots of this movement can be traced to each and every era in which the vulnerable and powerless sought justification to oppose arbitrary domination. Its roots are, therefore, deep and wide. (shrink)

The classic formulation of situation ethics in the 1960s was the result of the contention that the deductive application of general rules and principles in ethics was inherently flawed by the uniqueness of every situation. Quite often, ethical problems are problems precisely because existing rules do not apply four square to the singular situation at hand. There is a need, the argument ran, to assert the primacy of the special situation and to formulate a resolution of the unsettling circumstances appropriately (...) attuned to it. Situation ethics is, in a sense, a moral theory equivalent to case law in a legal system devoid of rule by law. (shrink)

Was this just another incendiary sound bite, headline news banner attacking the airwaves? Getting it wrong? Overstating some small technicality for the sake of getting attention? No, to all of the above: the most incendiary aspect of the blurb was that it was accurate. And it did get attention.

Jonathan Mann was a pioneer in establishing communication between the world of public health and that of human rights activism. At the very start, he strongly believed that although each of these two fields was in the midst of separate paradigm shifts, these shifts are essential, perhaps causal, to the combined health and human rights movement.

A 68-year-old gentleman is brought into a New York City ER at 2:30 P.M. by the squad in response to a 911 call from his neighbor, who found him unconscious in his bed. The cause of his condition is not known, but the man is unresponsive and requires immediate life support, including intubation, IV fluids, and pressors. Within minutes, his son arrives and attempts to deny permission for the LSMTx, claiming that his father is in end-stage ALS and has an (...) advance directive stipulating that he should not be invaded with LSMTx at this last moment in his life. The copy of the directive he produces is nonspecific in this context, because it qualifies refusal of LSMTx for “ … irreversible conditions …” and no one is sure if this situation is reversible. The advance directive names a daughter as proxy, and she is on her way from Maine, a 10-hour drive. (shrink)

As the concept of universal access to healthcare comes to America, an ethical paradox emerges. “Access” is the code word for being assured that sick people without financial resources get appropriate medical care. There is an ethical imperative to provide care for the sick – whether paying or not – and this value ought to give direction to any reformed system.

In this case, the patient's mother repeatedly asked about the health of any prospective child and whether she would be assured some custodial role. She also questioned the role of the prospective recipient. The committee facilitated obtaining the necessary information, sharing this information with the surrogate, and assisted the surrogate and two of her daughters to share both their feelings and additional information they possessed.