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PubMed1985

Unsolicited medical opinion.

By virtue of their professional ethics as healers and because of their specialized technical knowledge and clinical experience in assessing and reacting to real and potential emergencies, physicians have an obligation to offer an unsolicited medical opinion when the following conditions are met: (1) physicians assess a high probability of potentially serious disease in a stranger because of information presented to them, either in the form of a communication or physical signs; (2) physicians judge this information to be latent (not readily interpretable as potentially dangerous by the stranger) and likely to remain latent prior to the onset of symptoms; (3) the physicians possess the medical knowledge appropriate to the professional interpretation of this information. Although not a morally risk-free endeavor (invasion of privacy and the potential creation of a 'sick role' whether or not the diagnosis is correct), offering an unsolicited medical opinion under the above conditions can prevent suffering and save lives in unsuspecting strangers.

Acromegaly↗
PubMed1987

Justice and competitive markets.

This essay challenges the view that the provision of health care must take place within a competitive-free system. The author argues that, presuming that there is a requirement to meet the demands of those who cannot pay for health care, a competitive market provides a good way to deal with injustices within the health care system. The author concludes that the demands for justice are best met when indigent individuals use some portion of the funds they receive from the government to purchase one of the many competing forms of health care. This scheme requires a competitive market in the delivery of health care.

Economic Competition↗
PubMed1987

The doctor, the rich, and the indigent.

This essay explores the major conflict between doing the best for indigents requiring health care and not unfairly imposing burdens on those who pay for that care through cost-shifting. The author argues that there is in fact no dilemma or conflict of duties presented here, but only because the doctor's concern with justice in bearing the burden of health care requires a system within which different levels of health care are available and in which indigent care is provided in a manner that minimizes the cost of providing that care.

Cost Allocation↗
PubMed1987

Economic competition in health care: a moral assessment.

Economic competition threatens equity in the delivery of health care. This essay examines four of the various ways in which it does that: the reduction of charity care, increased patient cost-sharing, "cream-skimming" of healthy subscribers, and lack of information to patients about rationed care that is not prescribed. In all four cases, society must guard against distinct inequities and injustices, but also in all four, either the particular problem is not inherent in competition or, though inherent, it is not irremediable. Competition therefore cannot be finally morally accepted or rejected as an economic structure for delivering health care without knowing what among a wide range of supplementary things our society is actually going to do with it.

Cost Allocation↗
PubMed1987

Competition and the patient-centered ethic.

This essay critically evaluates the claim that competition in medicine destroys the moral integrity of the traditional patient-physician relationship. The author argues that the traditional patient-centered ethic is indefensible on moral grounds, and that it should be jettisoned in favor of a fiduciary ethic. A fiduciary ethic is found to provide the best defensible account of the patient-physician relationship because it takes seriously the roles economic efficiency, competition, and respect for individual self-determination play in fashioning moral health care delivery.

American Medical Association↗
PubMed1987

Prospective payment and medical ethics.

This article considers the ethical implications of prospective payment from the perspective of physicians and other health care practitioners. It focuses on the argument that prospective payment creates ethical conflict by giving physicians an economic incentive to do less for their patients. This argument is criticized in two respects. First, available evidence is reviewed which suggests that the incentives actually created by different prospective payment schemes and their effect on "optimal" patterns of practice is uncertain. Further, it is pointed out that ethical conflict originates in the dual role of physicians as agents and suppliers of service. Recognizing that such conflict exists under any payment mechanism, a better focus for the ethical evaluation of prospective payment is suggested that considers whether the incentive to do less is likely to have adverse effects on physician decisions, relative to decisions made under other payment mechanisms.

Cost Control↗
PubMed1987

Incentives and obligations under prospective payment.

In this paper I analyze the alleged conflict between economic incentives to efficiently utilize health care resources and the obligation to provide patients with the best possible medical care. My analysis is developed in four stages. First, I discuss briefly the nature of prospective payment systems and economic incentives as well as the issue of professional autonomy. Second, I disscuss the notion of an incentive for action both as an economic incentive and as a concept of moral psychology. Third, I analyze several definitions of the physician's professional obligation and discuss four conditions that morally qualify the obligation. And fourth, I explore why the views of economists and physicians differ so strikingly on the question of economic incentives. In the process of this analysis, I argue that criticisms of prospective payment systems which are premised primarily on the conflict between economic incentives to contain cost and the professional obligation of beneficence are probably as much a matter of rhetoric as serious argumentation.

Beneficence↗
PubMed1987

DRGs and the idea of a just price.

Ostensibly, the DRG prospective payment system represents a modern effort to legislate an enforceable system of just prices. As a practical matter, however, justice is conflated with mere familiarity, and the real goal of DRGs has always been cost containment. Abstract and concrete discussions of the computation of DRG payment schedules illustrate their actual operation.

Cost Control↗
PubMed1987

DRGs: justice and the invisible rationing of health care resources.

Are DRGs just? This is the primary question which this essay will answer. But there is a prior methodological question that also needs to be addressed: How do we go about rationally (non-arbitrarily) assessing whether DRGs are just or not? I would suggest that grand, ideal theories of justice (Rawls, Nozick) have only very limited utility for answering this question. What we really need is a theory of "interstitial justice," that is, an approach to making justice judgments that is suitable to assessing the social practices and institutions that comprise the interstices of our social life as opposed to its basic structure. Rawls's appeal to "our considered moral judgments" provides us with a useful starting point for this task, which we shall discuss in the first part of this essay. In the second part, we shall actually assess DRGs from the perspective of interstitial justice. What we shall show is that DRGs violate a large number of our considered judgments regarding a just approach to financing health care for the elderly in a cost-effective manner. This is true to such an extent that efforts to reform DRGs and make them fairer, such as the recent effort by Robert Veatch, should be abandoned. In the concluding section of the essay we discuss one especially pernicious feature of DRGs, namely, that they represent an invisible approach to rationing access to health care. In the minds of many this is one of the virtues of DRGs. That claim needs critical examination.

Aged↗
PubMed1988

Age and the allocation of medical resources.

How are we to decide where our scarce medical resources are most effectively spent? The notion of a quality-adjusted-life-year has been proposed as a way of doing this. Some economists appear to think that this can be done without making ethical assumptions. We examine the application of this notion to the treatment of premature newborns, and especially to comparisons between the value of medical care for newborns, and the value of medical care for older people. We find that some highly questionable ethical assumptions are involved in such comparisons.

Aged↗
PubMed1988

Generational equity and social insurance.

In recent years, critics have argued that, when inter-generational transfer programs such as Medicare are judged by the standard of "generational equity", these programs are seen to be unfair. It is argued that, under a pay-as-you-go system, future generations are committed to burdens without their consent; that claims are not contractually guaranteed; that early entrants reap windfalls gains; that successive cohorts are tempted to provide insupportably high benefit levels; and, finally, that fluctuations leave future generations at unacceptable risk. Attempts have been made to defend social insurance programs by means of a "lifespan prudential model" of age-group resource allocation, but this defense does not adequately take account of uncertainties and inequities faced by historical birth cohorts. A deeper defense must acknowledge an element of risk-sharing and solidarity while trying to limit inequities within reasonable bounds.

Aged↗
PubMed1988

Justice and the severely demented elderly.

In this paper I address the relation between just claims to health care and severe cognitive impairment from dementia. Two general approaches to justice in allocation of health care are distinguished--prudential allocation and interpersonal distribution. First, I analyze why a patient who has died has no further claims to health care. Second, I show why prudential allocators would not provide for health care treatment should they be in a persistent vegetative state. Third, I argue that the destruction of personal identity from severe dementia implies that only claims to palliative, but not life-sustaining, health care remain. Finally, I argue that the prudential allocator approach is indeterminate regarding life-sustaining care for the moderately demented and that social policy should not deny that care to patients.

Aged↗
PubMed1989

Concepts of health and disease.

The paper differentiates between three levels of the notion of health - biological health, medical health, and social health - and underlines the cultural concept of health and disease, its dependence on religion, ideology, and the general view of life.

Cultural Diversity↗
PubMed1989

Towards a theory of age-group justice.

Norman Daniels' and Daniel Callahan's recent work attempts to develop and deepen theories of justice in order to accommodate intergenerational moral issues. Elsewhere, I have argued that Callahan's arguments furnish inadequate support for the age rationing policy he accepts. This essay therefore examines Daniels' account of age rationing, together with the complex theory of age-group justice that buttresses it. Sections one and two trace the main features of Daniels' prudential lifespan approach. Section three calls into question the theory's conformity to liberal tenets. The next section attempts to show that the outcome of the prudential approach fails to match our considered judgements. The brief final section offers a broader perspective on the task of articulating a liberal theory of age-group justice.

Age Factors↗
PubMed1990

Justice in health care: the contribution of Edmund Pellegrino.

Edmund Pellegrino has pioneered work in medical ethics calling for a reconstruction of Hippocratic ethics. In particular, he has spoken of incorporating principles that concern justice and the common good. This article traces his commitment to the common good, concern for the poor, opposition to libertarianism, acknowledgement of the necessity of rationing, and reluctance to give clinicians social allocational tasks. It asks how Pellegrino relates distributive justice to the common good. Drawing on his theory relating autonomy to patient-centered beneficence (in which autonomy is one element of the good rather than a side constraint on the good), the author argues that Pellegrino appears to make justice one element of the common good rather than a distributional moral constraint on promoting the good. He suggests that Pellegrino stands in three consequentialist or teleological moral traditions: professional physician ethics, Aristotelianism, and Catholic moral theology, but that there are the makings of a more independent, more egalitarian theory of justice in his writings.

Beneficence↗
PubMed1996

Darren's case: narrative ethics in Perri Klass's Other Women's Children.

During the past fifteen years, the relationship between literature and medical ethics has evolved from the occasional use of stories as a substitute for the traditional case study in medical ethics to the emergence of a narrative approach to ethical analysis and decision making. Thus far, literary theory has been more important to narrative medical ethics than have works of literature themselves. Perri Klass's novel Other Women's Children deserves special scrutiny, however, because an analysis of it demonstrates ways that a narrative approach could enhance traditional philosophical and legal approaches to resolving ethical dilemmas in medicine.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Health as a normative concept: towards a new conceptual framework.

One of the main concerns in defining health is determining its status in relation to value. The main proposals in this direction generally assume a strict dichotomy between descriptive and evaluative dimensions. This essay argues that such a dichotomy leads to a theoretical inconsistency, which becomes evident once a definition of health is practically operative. A new conceptual framework uniting these two moments is proposed as an alternative, capable of preserving the fundamental insights of both descriptive and evaluative accounts of health, and of avoiding the theoretical inconsistencies on the level of practical application.

Health↗