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PubMed1986

'Medical ethics'--an alternative approach.

Contemporary medical ethics is generally concerned with the application of ethical theory to medico-moral dilemmas and with the critical analysis of the concepts of medicine. This paper presents an alternative programme: the development of a medical philosophy which, by taking as its starting point the two questions: what is man? and, what constitutes goodness in life? offers an account of health as one of the primary concepts of value. This view of the subject resembles that implied by ancient theories of goodness, and in later sections of the paper it is shown how Aristotle points us towards a coherent theory of human nature as psycho-physical, which overcomes the inadequacies of dualism and physicalist reductionism. What is on offer therefore, is the prospect of an integrated account of human nature and of what constitutes its flourishing: to be healthy is to be an active unity-of-parts in equilibrium.

Ethical Theory↗
PubMed1986

Priorities in the allocation of scarce resources.

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

Decision Making↗
PubMed1987

The ethics of human cadaver organ transplantation: a biologist's viewpoint.

The rights of the various individuals involved in decision-making in cadaver organ donation are considered, and there is discussion of the relation of human cadavers to the planetary biomass. I conclude that the rights of the potential recipient should outweigh those of the other parties concerned and that education and legislation should recognise and promote this.

Biology↗
PubMed1989

Autonomy, welfare and the treatment of AIDS.

Many AIDS-related issues are polarised. At the social level, civil rights or liberties are seen as being in conflict with general utility, and an analogous distinction is often assumed to exist at the one-to-one, individual level at which doctors work. In this paper the latter form of the distinction is argued to be false. By seeing autonomy as part of welfare, doctors can think more directly about such issues as paternalism, confidentiality, and consent. A number of these issues are discussed in the light of the revised conception of welfare, in the form of simplified case studies.

Acquired Immunodeficiency Syndrome↗
PubMed1990

The global distribution of health care resources.

The international disparities in health and health-care provision comprise the gravest problem of medical ethics. The implications are explored of three theories of justice: an expanded version of Rawlsian contractarianism, Nozick's historical account, and a consequentialism which prioritizes the satisfaction of basic needs. The second too little satisfies medical needs to be cogent. The third is found to incorporate the strengths of the others, and to uphold fair rules and practices. Like the first, it also involves obligations transcending those to an agent's relations and fellow-citizens. These conclusions are applied to international health-care provision, which they would transform.

Cost Allocation↗
PubMed1992

Who should get the kidney machine?

This paper considers the problem that arises when the number of patients who need a resource exceeds the supply. An initial decision-making model is proposed that uses two essential criteria, medical prognosis and the priority of life-threatening situations. The model is then subjected to the criticism that it is grotesque to ignore questions relating to the value of, for example, a productive mother over against an aged recluse, and to treat them as having equal rights to access. It is argued that this criticism need not be an expression of prejudice but may reflect a defendable view in which utilitarian considerations enter into the selection process provided that certain fundamental, or 'deontological' rights are observed for all. In the light of the discussion the model is modified in order to contain both a non-utilitarian feature that stresses the intrinsic importance of all persons, and a utilitarian feature that can allow one, in certain circumstances, to take consequences into account, especially those that follow from the 'irreplaceability' of some people.

Algorithms↗
PubMed2004

Prescribing cannabis: freedom, autonomy, and values.

In many Western jurisdictions cannabis, unlike most other psychoactive drugs, cannot be prescribed to patients even in cases where medical professionals believe that it would ease the patient's pain or anxiety. The reasons for this prohibition are mostly ideological, although medical and moral arguments have been formulated to support it. In this paper, it is argued that freedom, properly understood, provides a sound ethical reason to allow the use of cannabis in medicine. Scientific facts, appeals to harm and autonomy, and considerations of symbolic value cannot consistently justify prohibitions.

Cannabis↗
PubMed2005

Medical learning curves and the Kantian ideal.

A hitherto unexamined problem for the "Kantian ideal" that one should always treat patients as ends in themselves, and never only as a means to other ends, is explored in this paper. The problem consists of a prima facie conflict between this Kantian ideal and the reality of medical practice. This conflict arises because, at least presently, medical practitioners can only acquire certain skills and abilities by practising on live, human patients, and given the inevitability and ubiquity of learning curves, this learning requires some patients to be treated only as a means to this end. A number of ways of attempting to establish the compatibility of the Kantian Ideal with the reality of medical practice are considered. Each attempt is found to be unsuccessful. Accordingly, until a way is found to reconcile them, we conclude that the Kantian ideal is inconsistent with the reality of medical practice.

Education, Medical↗
PubMed2005

Epistemic paternalism in public health.

Receiving information about threats to one's health can contribute to anxiety and depression. In contemporary medical ethics there is considerable consensus that patient autonomy, or the patient's right to know, in most cases outweighs these negative effects of information. Worry about the detrimental effects of information has, however, been voiced in relation to public health more generally. In particular, information about uncertain threats to public health, from-for example, chemicals-are said to entail social costs that have not been given due consideration. This criticism implies a consequentialist argument for withholding such information from the public in their own best interest. In evaluating the argument for this kind of epistemic paternalism, the consequences of making information available must be compared to the consequences of withholding it. Consequences that should be considered include epistemic effects, psychological effects, effects on private decisions, and effects on political decisions. After giving due consideration to the possible uses of uncertain information and rebutting the claims that uncertainties imply small risks and that they are especially prone to entail misunderstandings and anxiety, it is concluded that there is a strong case against withholding of information about uncertain threats to public health.

Decision Making↗
PubMed1995

Double jeopardy and the use of QALYs in health care allocation.

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it.

Attitude to Health↗
PubMed1995

Double jeopardy and the veil of ignorance--a reply.

This paper discusses the attempt in this issue of the journal by Peter Singer, John McKie, Helga Kuhse and Jeff Richardson, to defend QALYs against the argument from double jeopardy which I first outlined in 1987. In showing how the QALY and other similar measures which combine life expectancy and quality of life and use these to justify particular allocations of health care resource, remain vulnerable to the charge of double jeopardy I am able to clarify some of the central issues concerning the value of life. In particular, the idea that the value of a life varies with its life expectancy and with its quality, understood in terms of its richness, variety, success etc, is subjected to special examination. It is shown how defenders of QALYs are committed to the view that so far from all lives being of equal value, all lives are necessarily of subtly different value. The paper then analyses the use to which the notorious 'veil of ignorance' has been put both by Singer et al and by others and shows how this device of John Rawls's cannot do the work so often assigned to it. The paper then considers the issue of hypothetical consent and the role that it can play in justifying disposing of the lives of people who have not in fact consented to their lives being disposed of in particular ways. Finally, the paper makes some points about the comprehensive nature of the data collection and storage which would be required by QALY advocates and points out the independent problems attaching to licensing such comprehensive collection and use of personal data.

Confidentiality↗
PubMed1996

Another peep behind the veil.

Harris argues that if QALYs are used only 50% of the population will be eligible for survival, whereas if random methods of allocation are used 100% will be eligible. We argue that this involves an equivocation in the use of "eligible", and provides no support for the random method. There is no advantage in having a 100% chance of being "eligible" for survival behind a veil of ignorance if you still only have a 50% chance of survival once the veil is lifted. A 100% chance of a 50% chance is still only a 50% chance. We also argue that Harris provides no plausible way of dealing with the criticism that his random method of allocation may result in the squandering of resources.

Australia↗
PubMed1998

The brain-mind quiddity: ethical issues in the use of human brain tissue for therapeutic and scientific purposes.

The use of human brain tissue in neuroscience research is increasing. Recent developments include transplanting neural tissue, growing or maintaining neural tissue in laboratories and using surgically removed tissue for experimentation. Also, it is likely that in the future there will be attempts at partial or complete brain transplants. A discussion of the ethical issues of using human brain tissue for research and brain transplantation has been organized around nine broadly defined topic areas. Criteria for human brain tissue transplantation and laboratory use of brain tissue are proposed.

Animal Experimentation↗
PubMed1999

Does justice require genetic enhancements?

It is argued that justice in some cases provides a pro tanto reason genetically to enhance victims of the genetic lottery. Various arguments--both to the effect that justice provides no such reason and to the effect that while there may be such reasons, they are overridden by certain moral constraints--are considered and rejected. Finally, it is argued that justice provides stronger reasons to perform more traditional medical tasks (treatments), and that therefore genetic enhancements should not play an important role in a public health care system.

Adolescent↗
PubMed2006

The moral basis of animal-assisted therapy.

Is nonhuman animal-assisted therapy (AAT) a form of exploitation? After exploring possible moral vindications of AAT and after establishing a distinction between "use" and "exploitation," the essay distinguishes between forms of animal-assisted therapy that are morally unobjectionable and those modes of it that ought to be abolished.

Animal Welfare↗
PubMed1986

Pricing human life.

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Cost-Benefit Analysis↗