Pay-for-performance represents an effort to improve the quality of health care by paying physicians more if they meet specified target measures. There are both empirical and theoretical reasons to be deeply suspicious of P4P schemes applied at the level of the individual physician or health provider. Most P4P programs were implemented before there were any good data to demonstrate that they achieved the desired results. Once such schemes were in use, the available data are far from reassuring. (...) Common findings are that providers may do more of the specific procedure that is being measured, but in the process may neglect to do other things that equally affect quality of care. Payers often find that the cost of implementing a P4P program far exceeds the value of the very modest resulting improvements; and payments may unfairly benefit providers who are already meeting quality targets while disadvantaging those who make the most strenuous efforts to improve. (shrink)

In recent years we have seen the emergence of “personalised medicine.” This development can be seen as the logical product of reductionism in medical science in which disease is increasingly understood in molecular terms. Personalised medicine has flourished as a consequence of the application of neoliberal principles to health care, whereby a commercial and social need for personalised medicine has been created. More specifically, personalised medicine benefits from the ongoing commercialisation of the body and of genetic knowledge, the (...) idea that health is defined by genetics, and the emphasis the state places on individual citizens as being “responsible for” their own health. In this paper I critique the emergence of personalised medicine by examining the ways in which it has already impacted upon health and health care delivery. (shrink)

In alignment with stated social, health, and environmental values, hundreds of hospitals in the United States are purchasing local, organic, and other alternative foods. Due to the logistical and economic constraints associated with feeding hundreds to thousands of people every day, new food procurement initiatives in hospitals grapple with integrating conventional supply chain norms of efficiency, standardization, and affordability while meeting the diverse values driving them such as mutual benefit between supply chain members, environmental stewardship, and social equity. This (...) paper provides empirical data and analysis on emerging values-based supply chains in hospitals that attempt to meet both the scale-based requirements and values-based goals of alternative food procurement initiatives. In particular, it examines tensions among industrial, economic, and alternative agrifood values in relation to a particular set of hospital supply chain players called Group Purchasing Organizations. Hospital membership in GPOs in the United States is ubiquitous, and 80–90 % of a hospital’s foodservice procurement comes through GPO channels in keeping with contract terms. GPO-governed supply chains are deeply rooted in industrial and commercial norms, in other words, price competition, economic efficiency, and forces of standardization through adherence to technical and quality standards. The bulk of alternative food procurement initiatives in the health care sector currently occur outside of the GPO–hospital relationship, however, over 90 % of hospital foodservice directors interviewed for this research expressed a desire to increase sustainable food procurement through their GPO. This study finds that, if alternative agrifood efforts in the health care sector are to integrate with GPO-governed supply chains without losing the robustness of the original values and goals that brought them into being, concerns related to supply chain structure, transparency and traceability of alternative food attributes, and alignment of definitions of local and sustainable food between all supply chain members will need to be addressed. This study also details points of flexibility in health care food supply chains and the potential for hospitals to create purchasing and informational alliances around common food goals in order to create new, values-based supply chain relationships both within and beyond GPO procurement channels. (shrink)

Describing the U.S. health care system meansdescribing managed care under commercial forces. Managed care creates new moral tension forpractitioners, but more importantly, in its currentform it intensifies the commercialization of healthexpectations and interactions. The largely unregulatedmarketing of health services under managed care hasbeen a major factor in the increasing number ofuninsured citizens, while claims for cost reductionthrough managed care are equivocal. Risk-ratingpractices integral to the current medical marketplacethwart concerns for justice in allocation (...) and createvulnerabilities for almost everyone. Thepolitical-moral concern of the early 1990s for a rightto health care is nowhere in sight. (shrink)

The question of corporate moral responsibility – of whether it makes sense to hold an organisation corporately morally responsible for its actions,rather than holding responsible the individuals who contributed to that action – has been debated over a number of years in the business ethics literature. However, it has had little attention in the world of health care ethics. Health care in the United Kingdom(UK) is becoming an increasingly corporate responsibility, so the issue is increasingly relevant (...) in the health care context, and it is worth considering whether the specific nature of health care raises special questions around corporate moral responsibility. For instance, corporate responsibility has usually been considered in the context of private corporations, and the organisations of health care in the UK are mainly state bodies. However, there is enough similarity in relevant respects between state organisations and private corporations, for the question of corporate responsibility to be equally applicable. Also, health care is characterised by professions with their own systems of ethical regulation. However, this feature does not seriously diminish the importance of the corporate responsibility issue, and the importance of the latter is enhanced by recent developments. But there is one major area of difference. Health care, as an activity with an intrinsically moral goal, differs importantly from commercial activities that are essentially a moral, in that it narrows the range of opportunities for corporate wrongdoing, and also makes such organisations more difficult to punish. (shrink)

In our society, some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries, and kidneys. Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests cannot supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood, health care is too precious, intimate, and corruptible to entrust to the market.The hospice movement in the United States is approximately 40 years old. During (...) these past four decades, the concept of holistic, multidisciplinary care for patients who are suffering from a terminal illness has evolved from a modest, grassroots constellation of primarily volunteer-run and community-governed endeavors to a multimillion dollar industry where the surviving nonprofits compete with for-profit providers, often publicly traded, managed by M.B.A.-trained executives, and governed by corporate boards. The relatively recent emergence of for-profit hospice reflects an increasing commercialization of health care in the United States, the potentially adverse impact of which has been well documented. (shrink)

Surrogacy tourism in Asian countries has surged in recent decades due to affordable prices and favourable regulations. Although it has recently been banned in many countries, it is still carried out illegally across borders. With demand for surrogacy in developed countries increasing and economically vulnerable Asian women lured by lucrative compensation, there are efforts by guest countries to ease the strict surrogacy regulations in host countries. Despite a shift toward “altruistic surrogacy”, commercial surrogacy persists. Recent research carried out by international (...) organizations that seek to establish a legal relationship between the commissioning parents and children in cross-border surrogacy arrangements, under the guise of the “best interests of the child,” appears to promote a resurgence of overseas commercial surrogacy rather than restrict it. Further commercialization of surrogacy should be prevented by carefully investigating the reality of the surrogacy process. (shrink)

One of the commonest complaints in Britain against the current National Health Service is that business and commercial values are being allowed, and even encouraged, to dominate the more humane values involved in caring for people in their weakness. What is the situation and where are the problems, and what can Britain learn from Germany and Holland? We are grateful to the distinguished author on business ethics and member of our Editorial Board, Professor Tom Sorell, for undertaking the production (...) of this FOCUS section of the October Review on such a sensitive and topical issue. (shrink)

The Patient Protection and Affordable Care Act represents the most significant reform of the United States health care system in decades. ACA also substantially amplifies the federal role in health care regulation. Among other provisions, ACA expands government health care programs, imposes detailed federal standards for commercial health insurance policies, creates national requirements on employers and individuals, and enlists state administrative capacity to implement various federal reforms. In response, a persistent voice in (...) the protracted, contentious debate surrounding ACA was, and continues to be, resistance from states. The rhetoric of federalism — states’ rights, reserved powers, state sovereignty, limited government, and local diversity — resonates deeply even around provisions of ACA that do not specifically implicate state interests. For example, the loudest and most persistent state objections target the new mandate that individuals maintain health insurance, a requirement imposed by ACA and enforced through federal tax penalties. (shrink)

For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody’s and Edmund Pellegrino’s writings. Based on their (...) writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine’s position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody’s response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine’s ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine’s position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine’s professionalism crisis depends on medicine’s positioning and defining itself in terms of the professionalism for each of the other professions within the health care network. (shrink)

Financial incentives and disincentives are fundamental to a category of proposals, usually characterised as forms of managed care, whereby the pecuniary interests of health care providers are directly affected by their clinical decision-making. Presently, Australian health care administrators and private insurers are adopting financial incentives as a means of ensuring provider compliance with ‘health outcome ’ and cost-constraint objectives. To the extent that this has occurred, health-care relationships are transformed to emulate, more (...) closely, a commercial transaction.This paper questions the ideological assumptions which inform the use of financial incentives in the health care domain and raises concerns with regard to the potential for financial incentives to undermine the moral integrity of clinical decision-making. It also challenges the legitimacy of rationing health care resources through the use of this measure, particularly when adopted by private insurers of health care. (shrink)

Background Immense volumes of personal health information are required to realize the anticipated benefits of artificial intelligence in clinical medicine. To maintain public trust in medical research, consent policies must evolve to reflect contemporary patient preferences. Methods Patients were invited to complete a 27-item survey focusing on: broad versus specific consent; opt-in versus opt-out approaches; comfort level sharing with different recipients; attitudes towards commercialization; and options to track PHI use and study results. Results 222 participants were included in (...) the analysis; 83% were comfortable sharing PHI with researchers at their own hospital, although younger patients were more uncomfortable than older patients. While 56% of patients preferred broad consent, 38% preferred specific consent; 6% preferred not sharing at all. The majority of patients preferred to be asked for permission before entry into a contact pool. Again, this trend was more pronounced for younger patients. Approximately half of patients were uncomfortable sharing PHI with commercial enterprises. Most patients preferred to track PHI usage, with the highest proportion once again reported by the youngest patients. A majority of patients also wished to be notified regarding study results. Conclusions While most patients were willing to share their PHI with researchers within their own institution, many preferred a transparent and reciprocal consent process. These data also suggest a generational shift, wherein younger patients preferred more specific consent options. Modernizing consent policies to reflect increased autonomy is crucial in fostering sustained public engagement with medical research. (shrink)

The rapidly changing field of genetics affects society through advances in health-care and through implications of genetic research. This study addresses the impacts of new genetic discoveries and technologies on different segments of today's society. The book begins with a chapter on genetic complexity, and subsequent chapters discuss moral and ethical questions arising from today's genetics from the perspectives of health care professionals, the media, the general public, special interest groups and commercial interests.

The first stage of the human embryonic stem(ES) cell research debate revolved aroundfundamental questions, such as whether theresearch should be done at all, what types ofresearch may be done, who should do theresearch, and how the research should befunded. Now that some of these questions arebeing answered, we are beginning to see thenext stage of the debate: the battle forproperty rights relating to human ES cells. The reason why property rights will be a keyissue in this debate is simple and (...) easy tounderstand: it costs a great deal of money todo this research, to develop new products, andto implement therapies; and private companies,researchers, and health professionals requirereturns on investments and reimbursements forgoods and services. This paper considersarguments for and against property rightsrelating to ES cells defends the followingpoints: (1) It should be legal to buy and sellES cells and products. (2) It should be legalto patent ES cells, products, and relatedtechnologies. (3) It should not be legal tobuy, sell, or patent human embryos. (4) Patentson ES cells, products, and related technologiesshould not be excessively broad. (5) Patents onES cells, products, and related technologiesshould be granted only when applicants statedefinite, plausible uses for their inventions. (6) There should be a research exemption in EScell patenting to allow academic scientists toconduct research in regenerative medicine. (7)It may be appropriate to take steps to preventcompanies from using patents in ES cells,products, and related technologies only toblock competitors. (8) As the field ofregenerative medicine continues to develop,societies should revisit issues relating toproperty rights on a continuing basis in orderto develop policies and develop regulations tomaximize the social, medical, economic, andscientific benefits of ES cell research andproduct development. (shrink)

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses (...) not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim. (shrink)

This essay has two aims: The first is to demonstrate that the basic conceptual framework of principal/agent theory can be fruitfully applied to decisionmaking in health care and in such a way as to facilitate the more efficient pursuit of the moral values of individual well-being and autonomy which health care is supposed to promote. The second is to show that this application results in an enrichment of principal/agent theory itself, by removing some of the limitations (...) on the theory that are valid only for the more exclusively self-interested, commercial contexts to which the theory is usually applied. (shrink)

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can (...) access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services. (shrink)

As a problem for science studies, the commercialization of scientific knowledge is characterized as whether scientific knowledge is a public good, like health care and education, or a positional good, a good whose value allows for exclusion to clients, the opposite of a public good (Callon 1994; Mirowski and Sent 2007). Mirowski and Sent (2007) have highlighted the problem of the commercialization and privatization of scientific knowledge. Furthermore, Mirowski (2009) avers that the commercialization of scientific (...) knowledge is the apotheosis of a neoliberal program to promote and to construct free markets as the central condition of success of the neoliberal agenda. Mirowski argues that the problem of commercialization of scientific knowledge is that scientific knowledge is being transformed from a public good to a positional good. A further argument from Mirowski (2009b) is that science has been harmed by its commercialization. (shrink)

As health care systems have been recast as innovation assets, commercial aims are increasingly prominent within states’ health and medical research policies. Despite this, the reformulation of notions of social and of scientific value and of long-standing relations between science and the state that is occurring in research policies remains comparatively unexamined. Addressing this lacuna, this article investigates the articulation of ‘actually existing neoliberalism' in research policy by examining a major Australian research policy and funding instrument, the (...) Medical Research Future Fund. We identify the MRFF and allied initiatives as a site of state activism: reallocating resources from primary and preventive health care to commercially-oriented biomedical research; privileging commercial objectives in research and casting health as a “flow on effect”; reorganising the publicly funded production of health and medical knowledge; and arrogating for political actors a newly prominent role in research grant assessment and funding allocation. We conclude that rather than the state’s assumption of a more activist role in medical research and innovation straightforwardly serving a ‘public good’, it is a driver of neoliberalisation that erodes commitments to redistributive justice in health care and significantly reconfigures science-state relations in research policy. (shrink)

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that (...) have, to date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term ‘medical tourism’ and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces. (shrink)

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. (...) The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)

The increased attention of the Orthodox Church to issues of medical education in our country was the result of the fact that in the 1990s it once again became one of the most active forces in our society. The connection between the church and the medical community, which goes back to a time when the doctoring of the mind and bodily health was in fact the work of the same people, cannot leave the church indifferent to the professional formation (...) of healthcare workers. The Soviet era saw the forced de-Christianization of the medical profession and measures taken to abolish medical ethics rooted in the Hippocratic Oath and the Gospel commandments. The restoration of dialogue between church and medicine began after the collapse of the Soviet state, but it is still insufficiently regular. Currently, factors complicating this dialogue are liberal medical legislation and capitalist economies in health care. The former, by legalizing abortion, artificial insemination, and sterilization, absolves the doctor of moral responsibility in matters concerning the management of human life; the latter encourages him to view his profession not as a service, but as a means of making money from other people’s suffering. If the dialogue between church and medicine were to be carried on permanently within the walls of medical schools, it would strengthen the spiritual and moral foundations of the medical profession, upon which it has always existed. One of the most significant forms of this dialogue should undoubtedly be the teaching of biomedical ethics, which should be grounded in modern theology and the values of traditional spiritual cultures of Russia. (shrink)

Distribution of sufficient health care resources to the maximum number of people in LIC is the central theme of the book. Bangladesh is taken as a representative of low income countries (LIe. In LIC, there is scarcity of health care resources like other resources but the deserving persons are numerous. Therefore, it requires an efficient distribution of resources. Considering 'Inequality to get access to health care' as the basic problem in LIC, John Rawls' principle (...) of fair equality of opportunity is proposed to apply to give people access to health care resources. In this book it is critically analyzed how the principle fails to return a good result in LIC. Instead the principle of maximizing utility is proposed for the purpose. It is argued that maximum number of people can be provided sufficient health care by applying the principle. The principle has also been justified theoretically in concerned low income country and a fruitful result has been achieved from the test. It is claimed that applying principle of utility to provide sufficient health care to the maximum number of people is the most efficient way of health care resources distribution in LIC. (shrink)

This book is a collection of articles about communication and ethics in the field of medicine and health care. Common to all the articles is that they are not directly based on empirical investigations. The discussions refer to research, but this is research that has already been carried out and documented in existing literature. In this sense the articles belong to what is often called applied philosophy. All the articles address communicative and ethical challenges in patient interaction on (...) the basis of assumptions in modern moral philosophy and philosophy of language. There is a great need for literature that deals more comprehensively with the themes in this book than many introductory books do. It is particularly difficult to find suitable reading material that can be used in teaching at graduate and master levels. This book is designed to meet this need. It is suitable for use in all higher-level courses where the aim is to give students a theoretical understanding of ethical dilemmas and communicative challenges in health care. (shrink)

The purpose of this paper is to review the rising influence of commercialism in American medicine and to examine some of the consequences of this trend. Increased competition subverts physician collegiality, draws hospitals into for-profit ownership and behavior, and leads clinical investigators into secrecy and possibly into bias and abuse. Medicine faces a deprofessionalization evidenced in loss of control over the clinical setting and over self-regulation. Health care becomes a commodity relying on cultivation of desires instead of satisfaction (...) of needs, even as many basic needs go unmet. Patients become consumers empowered with lawsuits and the connection of medicine to the relief of suffering is attenuated. Medical encounters are increasingly impersonal, dominated by specialization, technology, and bureaucracy. Patients are losing their physician-advocates to new conflicts of interests, physicians are losing their impulse to charity, and trust in the doctor-patient relationship and in medicine generally is eroding. (shrink)

Despite its effectiveness, limited research has examined the provision of telemental health and how practices may vary according to treatment paradigm. We surveyed 276 community mental health providers registered with a commercial telemedicine platform. Most providers reported primarily offering TMH services to adults with anxiety, depression, and trauma-and stressor-related disorders in individual therapy formats. Approximately 82% of TMH providers reported endorsing the use of Cognitive Behavioral Therapy in their remote practice. The most commonly used in-session and between-session exercises (...) included coping and emotion regulation, problem solving, mindfulness, interpersonal skills, relaxation, and modifying and addressing core beliefs. CBT TMH providers had a higher odds of using in-session and homework exercises and assigning them through postal mail, email or fax methods, as compared to non-CBT TMH providers. TMH providers, regardless of treatment paradigm, felt that assigning homework was neither easy nor difficult and they believed their patients were somewhat-to-moderately compliant to their assigned exercises. CBT TMH providers also collected clinical information from their patients more often than non-CBT TMH providers. They reported being less satisfied with their method, which was identified most often as paper-based surveys and forms. Overall, TMH providers employ evidence-based treatments to their patients remotely, with CBT TMH providers most likely to do so. Findings highlight the need for innovative solutions to improve how TMH providers that endorse following the CBT treatment paradigm remotely assign homework and collect clinical data to increase their satisfaction via telemedicine. (shrink)

ABSTRACT:Much has been written about the deplorable state of American health care, but rarely with the wealth of historical and political information packed into Peter Swenson’s Disorder: A History of Reform, Reaction, and Money in American Medicine (2021). In this meticulously researched and comprehensive study of the role of organized medicine, particularly the American Medical Association (AMA) and affiliated state and county medical societies, Swenson provides detailed insight into the AMA’s political evolution from a force advocating progressive reforms (...) to a protective guild backed by powerful economic and ideological interests. Swenson addresses the conflicts leading to and arising from these movements, always with an eye on the profession’s failure over the last century to fulfill its implicit social contract. Swenson describes the American medical disorder without fear or favor, including a public health system in disarray, defective government regulation of drugs, unchecked and concealed commercial influence on medical research, publications, and clinical guidelines. Swenson’s hope is clear: that a progressively reformed AMA—combined with a broad coalition of concerned citizens and legislators—will lead the medical profession back to its rightful mission. (shrink)

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition_is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics. With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state of the art (...) introductions to the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation. This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field. Developments from the First Edition include:_ The focus on ‘Four Principles Method’ is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section. (shrink)

Continued scientific and medical progress in Central and Eastern Europe depends on the development of an atmosphere that is conducive to implementing the changes that are necessary to bring better health and longer lives for everyone. Privatization and commercialization are threatening the objectivity of clinical research and the availability of health care because uncontrolled market mechanisms focused on profit are nurturing conflict of interest that generate bias and unreliability into research and medicine. Changes are needed that (...) address the following: – The amount of public support for basic and clinical research and health care, – standards for the conduct of clinical trials and delivery of health care, – administrative procedures for responding to the conflict of interest problem. (shrink)

This book brings together ten influential essays on justice and healthcare, written by a major figure in bioethics and political philosophy. What emerges is a systematic and unified approach to the issues that challenges widely-held dogmas and unsettles the framing assumptions of a number of prominent debates. Unlike most work in bioethics, this book takes the problem of implementing justice seriously, exploring the relationship between institutions, incentives, and moral commitments.

Ordeals are burdens placed on individuals that yield no benefits to others; hence they represent a dead-weight loss. Ordeals – the most common is waiting time – play a prominent role in rationing health care. The recipients most willing to bear them are those receiving the greatest benefit from scarce health-care resources. Health care is heavily subsidized; hence, moral hazard leads to excess use. Ordeals are intended to discourage expenditures yielding little benefit while simultaneously (...) avoiding the undesired consequences of rationing methods such as quotas or pricing. This analysis diagnoses the economic underpinnings of ordeals. Subsidies for nursing-home care versus home care illustrate. (shrink)

I Conceptual Foundations Ethical problems emerging from modern medical technology have been evaluated on an issue-by-issue basis. ...

In her final fragmentary novel Sanditon, Jane Austen develops a theme that pervades her work from her juvenilia onward: illness, and in particular, illness imagined, invented, or self-inflicted. While the “invention of odd complaints” is characteristically a token of folly or weakness throughout her writing, in this last work imagined illness is also both a symbol and a cause of how selves and societies degenerate. In the shifting world of Sanditon, hypochondria is the lubricant for a society bent on turning (...) health into a commodity. As a result, people’s rationality and their moral character come under attack. Catherine Belling’s recent subtle study, A Condition of Doubt: The Meanings of Hypochondria, unveils hypochondria’s discursive and cultural character. Running sharply against the tenor of Austen’s treatment, however, she argues in defense of the rationality of hypochondriacs; the notion that the condition may involve morally significant defects is not entertained; any connection to the commercialization of health care is muted. Here, I contrast Austen’s morally and epistemically negative rendering of her hypochondriacal characters in Sanditon with Belling’s efforts to create a sympathetic understanding of people with hypochondria. I will argue that, despite time gaps and genre differences, joint consideration of these texts can help bioethicists better appreciate how medicine can intensify, pathologize, and exploit anxieties about illness and death, thus adding to the challenges of living well in the face of mortality and morbidity. (shrink)

Ongoing research in the fields of genetics and biotechnology hold the promise of improved diagnosis and treatment of genetic diseases, and potentially the development of individually tailored pharmaceuticals and gene therapies. Difficulty, however, arises in determining how these services are to be evaluated and integrated equitably into public health care systems such as Canada's. The current context is one of increasing fiscal restraint on the part of governments, limited financial resources being dedicated to health care, and (...) rising costs for new health care services and technologies. This has led to increasing public debate in the last few years about how to reform public health care, and whether we should prohibit, permit or perhaps even encourage private purchase of health care services. ;In Canada, some of these concerns have crystallized around the issue of gene patents and commercial genetic testing, in particular as illustrated by the case of Myriad Genetics' patented BRACAnalysis test for hereditary breast and ovarian cancer. While most Canadians who currently access genetic services do so through the public health care system, for those with the means, private purchase is becoming an option. This situation raises serious concerns---about justice in access to health care; about continued access to safe and reliable genetic testing supported by unbiased patient information; and about the broader effects of commercialization for ongoing research and the Canadian public health care system. Commercial genetic testing presents a challenge to health care professionals, policy analysts, and academics concerned with the social, ethical and policy implications of new genetic technologies. Using the Myriad case as an exemplar, tools from moral philosophy, the social sciences, and health policy and law will be brought to bear on the larger issues of how as a society we should regulate commercial research and product development, and more coherently decide which services to cover under public health insurance and which to leave to private purchase. Generally, the thesis is concerned with the question of "how best to bring capital, morality, and knowledge into a productive and ethical relationship". (shrink)

Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immunooncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance (...) of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications — including high prices and often limited evidence of efficacy at approval — compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates. (shrink)

The growing prevalence of health care ethics consultation (HCEC) services in the U.S. has been accompanied by an increase in calls for accountability and quality assurance, and for the debates surrounding why and how HCEC is evaluated. The objective of this study was to evaluate the effectiveness of HCEC as indicated by several novel outcome measurements in East Asian medical encounters.

Health care is not merely a matter of individual encounters between patients and physicians or other health care personnel. For patients and those who provide health care come to these encounters already possessed of learned habits of perception and judgment, valuation and action, which define their roles in relation to one another and affect every aspect of their encounter. So the presuppositions of these encounters must be examined if our understanding of patients' autonomy is (...) to be complete. In this paper I sketch three models of what is presupposed in the relationship between the health care professional and the lay patient; and I discuss the ways in which patients' autonomy is preserved and/or compromised under each of the three models. The models discussed are the Guild Model, the Commercial Model, and the Interactive Model. (shrink)

_The medical profession is set for a change. It is being redesigned as a corporate enterprise. The health-care industry has proved to be lucrative and therefore has seen the entry of newer players from the corporate field into the market. The "Medical-Industrial complex" has led to the commercialization of health care well beyond what traditional practitioners would consider ideal. Medicine is being treated as a business, with cost curtailment measures and profit margins often dictating physicians' (...) choices. A number of factors decide working environment in a corporate setup, all of which may affect the sacrosanct physician-doctor relationship and "physician" ethics. On the other side, the ability of the corporate sector to bring about a welcome change in the health-care sector in terms of availability of newer modalities of management, implementation of preventive and personalized health-care programme and, at the same time, adding to the comfort of the treating physician cannot be ignored._. (shrink)

"A very good book indeed: there is scarcely an issue anyone has thought to raise about the topic which Childress fails to treat with sensitivity and good judgement....Future discussions of paternalism in health care will have to come to terms with the contentions of this book, which must be reckoned the best existing treatment of its subject."--Ethics. "A clear, scholarly and balanced analysis....This is a book I can recommend to physicians, ethicists, students of both fields, and to those (...) most affected--the patients themselves."--Edmund D. Pellegrino, John Carroll Professor of Medicine and Medical Humanities, Georgetown University Medical Center. (shrink)

University of Utrecht, Department of Philosophy, Heidelberglaan 6, 3584 CS Utrecht, The Netherlands. Tel.: +31 30 253 28 74, Email: Thomas.Nys{at}phil.uu.nl ' + u + '@' + d + ' '//-->Measures in public health care seem vulnerable to charges of paternalism: their aim is to protect, restore, or promote people's health, but the public character of these measures seems to leave insufficient room for respect for individual autonomy. This paper wants to explore three challenges to these charges: (...) Measures in PHC are aimed to protect, restore or promote ‘deep autonomy’, Measures in PHC are directed at the public and, as such, they do show respect for autonomy, and Some measures in PHC can be justified on grounds of justice and need not be defended as cases of ‘justified paternalism’. Although charges of unjustified paternalism in PHC might still be relevant, we should at least face these different challenges. CiteULike Connotea Del.icio.us What's this? (shrink)

It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) (...) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine. (shrink)

Immigrants lacking health insurance access the health care system through the emergency departments of non-profit hospitals. Because these persons lack health insurance, continued care can pose challenges to those institutions. I analyze the values of our health care institutions, utilizing a Walzerian approach that describes its appropriate sphere of justice. This particular sphere is dominated by a caring response to need. I suggest that the logic of this sphere would be best preserved by (...) providing increased access to health insurance to this population. This access would marry the rights of these members of our community to access care to our responsibility to contribute to financing of the system. I close with some considerations on what it means to be a member of the community. (shrink)

The factions debating health care reform in the United States have gravitated toward one of two positions: that just health care is an individual responsibility or that it must be regarded as a national concern. Both arguments overlook a third possibility: that justice in health care is multilayered and requires the participation of multiple and diverse communities. _Communities of Health Care Justice_ makes a powerful ethical argument for treating communities as critical moral (...) actors that play key roles in defining and upholding just health policy. Drawing together the key community dimensions of health care, and demonstrating their neglect in most prominent theories of health care justice, Charlene Galarneau postulates the ethical norms of community justice. In the process, she proposes that while the subnational communities of health care justice are defined by shared place, including those bound by culture, religion, gender, and race that together they define justice. As she constructs her innovative theorization of health care justice, Galarneau also reveals its firm grounding in the work of real-world health policy and community advocates. _Communities of Health Care Justice_ not only strives to imagine a new framework of just health care, but also to show how elements of this framework exist in current health policy, and to outline the systemic, conceptual, and structural changes required to put these justice norms into fuller practice. (shrink)

The ethical foundation of the medical profession, which values service above reward and holds the doctor-patient relationship as inviolable, continues to be challenged by the commercialization of health care. This article contends that a realigned leadership framework - one that distinguishes being a leader as the ontological basis for what leaders know, have, and do - is central to safeguarding medicine's ethical foundation. Four ontological pillars of leadership - awareness, commitment, integrity, and authenticity - are proposed as (...) fundamental elements that anchor this foundation and the basic tenets of professionalism. Ontological leadership is shaped by and accessible through language; what health care leaders create in language "uses" them by providing a point of view (a context) within and from which they orient their conversations, decisions, and conduct such that they are ethically aligned and grounded. This contextual leadership framework exposes for us the limitations imposed by our mental maps, creating new opportunity sets for being and action (previously unavailable) that embody medicine's charter on professionalism. While this leadership methodology contrasts with the conventional results-oriented model where leading is generally equated with a successful clinical practice, a distinguished research program, or a promotion, it is not a replacement for it; indeed, results are essential for performance. Rather, being and action are interrelated and their correlated nature equips leaders with a framework for tackling health care's most complex problems in a manner that preserves medicine's venerable ethical heritage. (shrink)