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PubMed1986

DRGs and the ethical reallocation of resources.

To allocate resources ethically under DRGs, we need an expanded medical ethics. Appealing to traditional patient-centered principles such as individual beneficence and autonomy will not be sufficient. We also need to take into account the social principles of full beneficence and justice. If marginal benefits must be eliminated, clinicians should not participate in deciding who should get less care but should remain committed to their patients' interests.

Beneficence↗
PubMed1986

Should undocumented aliens be entitled to health care?

Congress recently decided that undocumented aliens are ineligible for medical benefits under the 1966 Medicaid Act, overruling a judicial decision that would have required the federal government to reimburse states partially for the costs of providing free care. Is providing such care simply a matter of prudence and charity? Or do illegal aliens have strong moral claims to medical care that generate duties for hospitals and government agencies?

Delivery of Health Care↗
PubMed2004

A neuroanatomical model of passivity phenomena.

Any attempt to elucidate the nature and mechanism of passivity phenomena, i.e., experiences that one's conscious actions or thoughts have not been 'willed' by oneself, requires an integrative philosophical-neurobiological approach. The model proposed here adopts some fundamental positions that have long been advocated by philosophers and theoretical psychologists and have now found support from functional neuroanatomy. First, we experience our actions not from the standpoint of the executive but through the perception of its effects. Second, the 'self' is not an agent of behaviour. Third, behaviour is energized and integrated by basic drives (instincts). Fourth, the view that the experience of an acting self is related to drive reduction associated with voluntary actions is perhaps less well developed. The model thus proposes that passivity phenomena are actions that are induced by the perception of salient events but that are not integrated with or conducive to the overall motivational state of the organism. It has been suggested that, following the perception of salient events, competition arises between automatic response tendencies seeking expression. The prefrontal cortex appears to play an important role not only in determining which events are to be perceived but also which of the corresponding response dispositions is to be selected and actualized in overt behaviour. Thus, action selection is the outcome of competition between response tendencies in the context of prefrontal biasing signals that represent drives and strivings for goals. Action selection may be uncoupled from drives and strivings as a result of a lowering of the threshold for action selection--as is suggested to be the case in schizophrenic passivity phenomena--or due to disconnection from prefrontal regions--as may be the case in the alien limb syndrome.

Association↗
PubMed1981

Change and permanence: reflections on the ethical-social contract of science in the public interest.

Modern science, dedicated since its 17th century origins to the mastery and possession of nature for the relief of man's estate, is a source of great social change, affecting our opinions, practices, and ways of life. It thus exists necessarily in tension with law and morality, our institutions of stability and order. This tension between change and permanence, between science and law or morals, was institutionalized by the American Founders who sought to encourage, under law, the progress in science and the useful arts, by means of the copyright and patent laws. American science and technology have flourished under the patent law, an ingenious ethical and social contract between scientists and the polity, through which private right and interest and public good generally coincide. Nevertheless, this contract has its limitations. Some of these limitations are vividly seen through the recent Supreme Court decision (in the Chakrabarty case) to permit the patenting of living microorganisms. Analysis of this case shows why the contract between science and the polity embodied in the Patent Laws may not always serve the public good and may also be harmful to science itself. Also, permitting ownership of living species shows how close we have come in our thinking to overstepping the sensible limits of the project for the mastery and possession of nature.

Contracts↗
PubMed1990

An unintentional irony: the autopsy in modern medicine and society.

Autopsy rates continue to decline despite abundant evidence of the autopsy's value. Such an extraordinary contradiction requires that we look beyond issues of education to consider our basic moral and political commitments; to consider, in other words, the kind of society in which we live, and the kind of people we are. In a heterogeneous culture, we should not be surprised to find that even our most basic obligations may be in conflict. This essay draws on social and ethical perspectives to examine a peculiar phenomenon: the reluctance of physicians to have autopsies performed on themselves or their family members. Such behavior reflects an unintentional irony, a conflict between our societal commitments to treat dead persons properly and our professional commitments to remain self-critical. The resources needed to resolve medicine's unintentional irony are to be found in our traditional language of medicine as a moral praxis, an uncertain but honorable craft devoted to the care of those who suffer. Autopsies remain the best way to learn whether or not clinical judgments are made correctly. Therefore, the autopsy is not an option; it is a professional obligation. We simply cannot hope to maintain our professional integrity as long as we proclaim the value of autopsies for our patients, but deny for ourselves and our families the same privilege.

Autopsy↗