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PubMed1983

Rawlsian justice and a human right to health care.

This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the provision of health care. Ronald Green argues that contractors in the original position would establish a basic right to health care. Green's proposal, however, requires considerable relaxation of the constraints Rawls places on the original position and thus jeopardizes Rawls' arguments for the two principles of justice. Norman Daniels claims that health care is best understood as a means for helping to achieve Rawls' goal of equality of fair opportunity. Daniels acknowledges, however, that his interpretation cannot justify a basic right to health care; rather, it would at best require that certain kinds of care be made available to certain kinds of individuals. Finally, in place of the notion of health care as a human right, it is suggested that the provision of health care is a social ideal which may inspire the creation of specific legal rights. On this view, social provision of health care may properly vary significantly from culture to culture. Despite this variability, social systems may still be criticized on moral grounds.

Ethical Analysis↗
PubMed1983

Opportunity and health care: criticisms and suggestions.

orman Daniels' proposal to distribute health care on the basis of fair equality of opportunity, is, in this writer's opinion, unworkable. His concepts of species-typical activity and normal opportunity range are unclear; so is the relationship between them. His view that justice accords disease a better claim on the health dollar than other causes of death, pain, and disability, commits him unknowingly to indefensible positions on particular sorts of health care, such as the care of the aging and of pregnant women. Daniels' concept of opportunity is so inclusive, his notion of balancing opportunities so vague, that his theory loses systematic power. I offer a different account from Daniels' concerning why health care needs are objective and of special importance. I also argue for a voucher system which levels out class inequalities and which finances current medical practices more or less uncritically, but allows for change through a diversity of insurance plans available to consumers. This system is just, and more practical than rating health care needs by impact on opportunity.

Aging↗
PubMed1983

Justice, beneficence, or common sense?: The President's Commission's Report on access to health care.

The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published in March of 1983 its Report, Securing Access to Health Care: The Ethical Implications of Differences in the Availability of Health Services. Concluding that there are "ethical obligations" on behalf of society which are balanced by individual obligations, the Report provides an ethical framework for ensuring "ultimate responsibility" of the Federal government to arrange for equitable access to health and to a fair share of cost. In doing so the Report neither makes justice nor beneficence the prime moral principle in public health care, it rather calls for a common sense approach in "approximating adequacy". But how to define equality without creating uniformity in a society rich in its diversity, including attitudes towards health?

Advisory Committees↗
PubMed1998

Consequentialism, reasons, value and justice.

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources.

Age Factors↗
PubMed2000

The ethics of elective (non-therapeutic) ventilation.

Elective ventilation (EV) is ventilation applied, not in the interest of patients, but in order to secure transplantable organs. It carries with it a small risk that patients who would otherwise have died will survive in a persistent vegetative state. Is EV ever justifiable? We argue: (1) The only thing which can justify exposing patients to risk not taken for their benefit is their consent, and we cannot rely on implied consent or third party consent in the case of EV. Thus absent explicit consent of patients, EV is not justifiable. (2) It is not clear that explicit consent should be sought, or where it is offered honoured, given the potential EV has for deterring organ donors and causing stress to staff and families.

Brain Death↗
PubMed1998

Class, health and justice.

Class inequalities in health are intuitively unjust. Although the link between social class and health status has been fully documented, the precise nature of the injustice has not been made clear. Four alternative views are presented, corresponding to four goals: (1) maximizing the sum total of health; (2) equalizing the health status of higher and lower social classes; (3) maximizing the health status of the lowest social class; and (4) maximizing the health status of the sickest individuals in society. The nature of the injustice is further obscured by several theoretical and empirical questions, like the degree and significance of personal responsibility for illness and the relation of the degree of economic inequality to sum total of health.

Health Care Rationing↗
PubMed1999

The misuse of Kant in the debate about a market for human body parts.

Passages from the writings of Immanuel Kant concerning how a person should treat her body are often cited in the present-day debate about a market for human body parts. In this paper, I demonstrate that this has been a misuse of Kant because unlike those who cite him, Kant was not primarily concerned with prohibiting the sale of body parts. In the first section, I argue that once these particular passages are understood against the background of Kant's moral philosophy, they indicate he had much broader concerns relating to the correct moral relationship a rational person should have with her body. In the second section, I examine Stephen Munzer's unusually detailed analysis of these passages, but conclude that like those who have provided less detailed analyses, he also fails fully to understand the rationale for Kant's various prescriptions and prohibitions concerning the treatment of human body parts, and in doing so misrepresents Kant's position.

Commerce↗
PubMed1999

Smokers' rights to health care: why the 'restoration argument' is a moralising wolf in a liberal sheep's clothing.

Do people who cause themselves to be ill (e.g. by smoking) forfeit some of their rights to healthcare? This paper examines one argument for the view that they do, the restoration argument. It goes as follows. Smokers need more health-resources than non-smokers. Given limited budgets, we must choose between treating everyone equally (according to need) or reducing smokers' entitlements. This paper criticises the restoration argument on the following grounds. In order to avoid generating unpalatable conclusions elsewhere, it must be combined with a principle according to which activities which are sufficiently 'socially valuable' (e.g. parenting) are immune from restoration claims. This however means that what was supposed to be one of the argument's most attractive features, its compatibility with 'liberal neutrality' with respect to the values of different lifestyles, doesn't really exist. Hence, the restoration argument is nowhere near as attractive as it first appears to be.

Delivery of Health Care↗
PubMed2000

A Kantian argument for a duty to donate one's own organs. A reply to Nicole Gerrand.

Nicole Gerrand is right to criticize Munzer for not connecting a person's dignity to the "capacity to exhibit humanity by acting rationally." However, connecting these does not mean that they are one and the same concept. Gerrand fails to make two distinctions that are decisive in the context of Kant's ethics. First, she does not distinguish between vital organs, integral organs and mere "accumulations", each of which requires a specific moral argument. Second, she does not distinguish between human rational nature in itself, or the capacity to have free will, and the possibility of action rationally, or freedom of choice. Having drawn these distinctions, I argue that Kant's own principles fully allow certain kinds of organ transplants such as blood, skin and marrow transplants from living bodies as well as the transplantation of both vital organs and essential organs from fresh corpses. In fact, Kant's own moral principles should make of these an enforceable duty of right. Unlike Gerrand, then, I think that the question of whether or not donors should be paid--and the patient should pay--is a key issue even in a Kantian context.

Cadaver↗
PubMed2001

Health equity and social justice.

There is consistent and strong empirical evidence for social inequalities in health, as a vast and growing literature shows. In recent years, these findings have helped to move health equity high on international research and policy agendas. This paper examines how the empirical identification of social inequalities in health relates to a normative judgment about health inequities and puts forward an approach which embeds the pursuit of health equity within the general pursuit of social justice. It defends an indirect approach to health equity, which views social inequalities in health as unjust in so far as they are the result of an unjust basic structure of society in Rawls' sense.

Health↗
PubMed2002

Autonomy, constraining options, and organ sales.

Although there continues to be a chronic shortage of transplant organs the suggestion that we should try to alleviate it through allowing a current market in them continues to be morally condemned, usually on the grounds that such a market would undermine the autonomy of those who would participate in it as vendors. Against this objection Gerald Dworkin has argued that such markets would enhance the autonomy of the vendors through providing them with more options, thus enabling them to exercise a greater degree of control over their bodies. Paul Hughes and T.L. Zutlevics have recently criticized Dworkin's argument, arguing that the option to sell an organ is unusual in that it is an autonomy-undermining "constraining option" whose presence in a person's choice set is likely to undermine her autonomy rather than enhance it. I argue that although Hughes' and Zutlevics' arguments are both innovative and persuasive they are seriously flawed--and that allowing a market in human organs is more likely to enhance vendor autonomy than diminish it. Thus, given that autonomy is the preeminent value in contemporary medical ethics this provides a strong prima facie case for recognizing the moral legitimacy of such markets.

Commerce↗
PubMed1990

Moral education for nursing decisions.

This paper attacks the Kantian conception of mortality that predominates in our society and the rationalist educational strategies that flow from it. In its place it offers an Aristotelian conception of ethics in which sensitivity and feeling are important components of practical reason. It argues that a nurse's ethical concerns extend further than the several moral dilemmas discussed in the daily press and that those concerns should be responded to in moral education by a process called 'empowerment'. Empowerment seeks to develop confidence and sensitivity in the making of difficult decisions and does so by training habits, developing attitudes, and encouraging reflection on actions performed.

Attitude↗