A disaster is an occurrence disrupting a community’s normal functioning and existence. The disruption may render it impossible to comply with principles and to respect, protect, and fulfill rights as it happens in ordinary times; it may induce an overwhelming shortage of resources and make tragic decisions unavoidable. From its very beginning, the COVID-19 pandemic evoked the scenario of disaster medicine, where triage is likely to imply not simply postponing a treatment but letting someone die. However, it is not only (...) the health care system that faces disruption risks. Lockdown measures and other restrictions were imposed to curb the pandemic, impinging upon individual freedom as well as economic activities. The proposal of mandatory vaccination implied a suspension of the principle of autonomy, which is a fundamental pillar of modern medicine. Out of the ordinary balancing efforts may be required, and two questions arise. Do such exceptional circumstances suggest reconsidering the criteria to apply, especially when essential, life-saving treatments are at stake? Who should decide? Science offers the premises to build on, but the last word does not belong to science. It remains the province of ethics and politics. (shrink)

Die demografische Entwicklung und der medizinische Fortschritt werden die Problematik der Ressourcenknappheit im deutschen Gesundheitswesen in Zukunft weiter verschärfen. Soll nicht nur kurzfristig akuten Sparzwängen ausgewichen werden, steht – wie in verschiedenen Ländern bereits geschehen – auch Deutschland auf Dauer eine Prioritätensetzung im Gesundheitswesen bevor. Diese sollte in möglichst transparenter Weise nach klaren Kriterien erfolgen. Eines der seit einiger Zeit häufig öffentlich zitierten Kriterien der Verteilung von Mitteln in der Gesundheitsversorgung ist die Eigenverantwortung von Patienten. Deren Berücksichtigung in der Allokation (...) von Ressourcen birgt allerdings zahlreiche Probleme. Der vorliegende Beitrag untersucht die gerechtigkeitstheoretischen Grundlagen und die praktischen Probleme bzw. die möglichen Konsequenzen von Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Auf der Grundlage eines alternativen gerechtigkeitstheoretischen Vorschlags werden drei Möglichkeiten skizziert, Eigenverantwortung von Patienten im deutschen Gesundheitswesen in gerechter Weise stärker zu betonen. (shrink)

During the last decade a “technical” approach has become increasingly influential in health care priority setting. The various country reports illustrate, however, that non-technical considerations cannot be avoided. As they often remain implicit in health care package decisions, this paper aims to make these normative judgements an explicit part of the procedure. More specifically, it aims to integrate different models of distributive justice as well as the principle of solidarity in four different phases of a decision-making procedure, and to identify (...) important moral choices which present themselves. First four important justice models are discussed, then a justification is given for their inclusion in a four-step decision making procedure. This is followed by a discussion of different justice and solidarity problems—with their inherent conceptual difficulties in each of these stages. The paper concludes with a summary of the major moral choices that are to be made in health care package decisions. (shrink)

Die demografische Entwicklung und der medizinische Fortschritt werden die Problematik der Ressourcenknappheit im deutschen Gesundheitswesen in Zukunft weiter verschärfen. Soll nicht nur kurzfristig akuten Sparzwängen ausgewichen werden, steht – wie in verschiedenen Ländern bereits geschehen – auch Deutschland auf Dauer eine Prioritätensetzung im Gesundheitswesen bevor. Diese sollte in möglichst transparenter Weise nach klaren Kriterien erfolgen. Eines der seit einiger Zeit häufig öffentlich zitierten Kriterien der Verteilung von Mitteln in der Gesundheitsversorgung ist die Eigenverantwortung von Patienten. Deren Berücksichtigung in der Allokation (...) von Ressourcen birgt allerdings zahlreiche Probleme. Der vorliegende Beitrag untersucht die gerechtigkeitstheoretischen Grundlagen und die praktischen Probleme bzw. die möglichen Konsequenzen von Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Auf der Grundlage eines alternativen gerechtigkeitstheoretischen Vorschlags werden drei Möglichkeiten skizziert, Eigenverantwortung von Patienten im deutschen Gesundheitswesen in gerechter Weise stärker zu betonen. (shrink)

This paper stems from the current global worsening of the scarcity of resources for healthcare, which will deepen even more in future public emergencies. This justifies strengthening the reflection on the allocation of resources which, in addition to considering technical issues, should also involve ethical concerns. The two plans in which the allocation of resources develops—macro and micro—are then systematized, both requiring the identification of ethical criteria for the respective complex decision-making. Then, we describe how the complexity at the macro (...) level focuses on the joint consideration of the rectitude of the principles, the goodness of the ends, and the integrity—respectively the deontological, teleological, and procedural perspectives; and at the micro level, it focuses in prioritizing people, which can result in the exclusion of some, as happened with the elderly during peaks of COVID-19. The main objective of this article is to show that, in public health emergency situations, in which the daily criteria for prioritizing access to health care are not efficient, it is possible not only to ration the available means but also to rationalize them. We argue that rationing and rationalization are different concepts, entail different consequences, have different ethical foundations, and draw different guidelines for patient care. We apply them to the distribution of intensive care and vaccines to the elderly thus demonstrating the ethically legitimate domain of implementation of each of these two prioritization criteria. We conclude that rationalization respects more strictly the core ethical principles of our common morality. (shrink)

Mr. M. was a 77-year-old decisionally incapacitated long-term nursing home resident with chronic schizophrenia who was admitted to the hospital with a bacterial pneumonia. His past medical history was notable for deteriorating functional status over the past 2-3 years, urinary retention requiring chronic indwelling bladder catheterization, and two recent hospitalizations for urinary tract infections leading to sepsis. He developed respiratory failure soon after admission and was intubated and placed on mechanical ventilation. Follow-up studies suggested worsening pneumonia and acute respiratory distress (...) syndrome, as well as worsening kidney function. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

Critically examining what most people take for granted is central to philosophical inquiry. Philosophers who accept positions on policy making commissions, tasks forces, or committees cannot, however, play the same uncompromisingly critical role in this capacity as they do in the classroom or in their personal research or writing. Still, philosophers have much to contribute to such bodies, and they can do so without compromising their integrity or betraying themselves as philosophers. Keywords: compromise, critical reflection, embryo research, integrity, organ transplantation, (...) policy development, Warnock Committee CiteULike Connotea Del.icio.us What's this? (shrink)

In this commentary on Eva Feder Kittay's Love's Labor: Essays on Women, Equality, and Dependency, I focus on Kittay's dependency theory. I apply this theory to an analysis of women's inadequate access to high-quality, cost-effective healthcare. I conclude that while quandaries remain unresolved, including getting men to do their share of dependency work, Kittay's book is an important and original contribution to feminist healthcare ethics and the development of a normative feminist ethic of care.

Public intellectuals have long played a role in American culture, filling the gap between the academic elite and the educated public. According to some commentators, the role of the public intellectual has undergone a steady decline for the past several decades, being replaced by the academic expert. The most notable cause of this decline has been both the growth of the academy in the twentieth century,which has served to concentrate intellectual activity within its confines, and the changing nature of the (...) media, which has framed the way in which information is conveyed to the public. We argue that although bioethics has developed primarily within the academic tradition and utilized the role of expert when dealing with the public, bioethicists are well suited to don the mantle of the public intellectual. Indeed, because they address issues in medicine and science of great relevance for the general public, bioethicists have a duty to revitalize the tradition of public intellectuals as a necessary complement to the important, but narrower role of expert. (shrink)

In contemporary bioethics, two vocabularies can be distinguished:person-speak andnature-speak. The first is built around the claim that a person's moral decisions are to be respected, while the other stands on the claim that moral decisions should comply with standards for human behaviour conveyed by nature. While most bioethicists have obtained a thorough mastery ofperson-speak, they are considerably less well-versed innature-speak. Apparently, the latter has lost much of its former ability to capture important aspects of moral existence. In this paper I (...) attempt to rehabilitatenature-speak from a hermeneutical perspective. I believe that the task of ethics is to enlarge our range of moral description and to rediscover neglected ways of speaking about human experience. The ethicist should enable individuals in health care settings to become more articulate about their moral experience. He should not content himself with applying those moral vocabularies which happen to be readily available, but should rather proceed by recovering forgotten vocabularies from within the philosophical tradition. Finally, one particular effort at restoringnature-speak is critically reviewed. (shrink)

Recent developments in biogerontology—the study of the biology of ageing—suggest that it may eventually be possible to intervene in the human ageing process. This, in turn, offers the prospect of significantly postponing the onset of age-related diseases. The biogerontological project, however, has met with strong resistance, especially by deontologists. They consider the act of intervening in the ageing process impermissible on the grounds that it would (most probably) bring about an extended maximum lifespan—a state of affairs that they deem intrinsically (...) bad. In a bid to convince their deontological opponents of the permissibility of this act, proponents of biogerontology invoke an argument which is grounded in the doctrine of double effect. Surprisingly, their argument, which we refer to as the ‘double effect argument’, has gone unnoticed. This article exposes and critically evaluates this ‘double effect argument’. To this end, we first review a series of excerpts from the ethical debate on biogerontology in order to substantiate the presence of double effect reasoning. Next, we attempt to determine the role that the ‘double effect argument’ is meant to fulfil within this debate. Finally, we assess whether the act of intervening in ageing actually can be justified using double effect reasoning. (shrink)

North Atlantic culture lacks a commonly shared view on dying well that helps the dying, their social environment and caregivers to determine their place and role, interpret death and deal with the process of ethical deliberation. What is lacking nowadays, however, has been part of Western culture in medieval times and was known as the ars moriendi (art of dying well) tradition. In this paper an updated version of this tradition is presented that meets the demands of present day secularized (...) and multiform society. Five themes are central to the new art of dying: autonomy and the self, pain control and medical intervention, attachment and relations, life balance and guilt, death and afterlife. The importance of retrieving the ancient ars moriendi outreaches the boundaries of palliative medicine, since it deals with issues that play a central role in every context of medical intervention and treatment. (shrink)

This article is a critical discussion of the book Setting Health-Care Priorities by Torbjörn Tännsjö. This critique targets mainly Tännsjö’s method, but also several unjustified conclusions and some implicit assumptions.

A response to a critique by Roger W. Hunt of my views on the eventual likely need to use age as a standard for the allocation of expensive, high-technology, life-extending medical care for the elderly. The response encompasses three elements: 1. that while the elderly have a substantial claim to publicly-provided health care, it cannot be an unlimited claim; 2. that a health care system which provided a decent, coherent set of medical and social services for the elderly would be (...) sufficient, even if some limits had to be set; and 3. allocation and rationing decisions should not be made by individual doctors at the bedside but by regional or national policy. (shrink)

Populations around the world are aging at a very fast rate, so much so that care for the elderly will soon rupture even the most carefully planned, enlightened care provisions societies can offer. The demographics in advanced countries demonstrate this dilemma, even without projections based on antiaging medications that may be possible in the near future, and a healthier lifestyle that has preoccupied the yuppies for about 10 years.

The varieties of meaning in which we use the terms illness and health requires that we develope a conceptualization allowing us to maintain a unity between the differences. In fact, the experiences of health and illness are complex ones and they need to be understood in their different levels so that the need for help of patients and their desire for health is adequately faced. At its roots, the experience of illness is that of a threat posed to the unreflective (...) credit given to life in good health. This threat has not only a biopsychosocial dimension, but a moral and sybolic one as well, and it is mainly at this level that illness represents a moral challenge. Contemporary culture seems to be at pains in suggesting a shared set of meanings enabling the patient to give an intersubjectively valid sense of illness, since the only kind of answer offered is a technical one. The symbolic dimension of the notions of health and illness call for a deeper cultural enterprise of looking for a credible sense of illness for our times. (shrink)

In the article the concept of natural death as used in end-of-life decision contexts is explored. Reviewing some recent empirical studies on end-of-life decision-making, it is argued that the concept of natural death should not be used as an action-guiding concept in end-of-life decisions both for being too imprecise and descriptively open in its current use but mainly since it appears to be superfluous to the kind of considerations that are really at stake in these situations. Considerations in terms of (...) the quality of life cost of the intervention in relation to the quality and length of life benefits of the same intervention. In referring to the concept of natural death we risk to blur these considerations and end up in difficult distinctions between what is a natural and non- or un-natural death, a distinction which it is argued is of no real moral interest. (shrink)

A society is said to age when its number of older members increases in relation to its number of younger members. The societies in most of the world’s industrialized nations have been aging since at least 1800. In 1800 the demographic makeup of developed countries was similar to that of many Third World countries in the early 1990s with roughly half the population under the age of 16 and very few people living beyond age of 60. Since that time, increases (...) in life expectancy, combined with declines in fertility rates, have dramatically increased the proportion of older persons in developed nations. The rapid increase in the number of older persons relative to younger ones carries important societal implications. In the domain of healthcare, societal aging will increase costs and exert greater pressure to ration services. It will, thus, bring to the fore questions, regarding a just distribution of healthcare between young and old age groups. This paper considers some of the most influential arguments to date for age-based rationing of health care. I show that these arguments fall short, and that the theoretical assumptions underlying them do not withstand careful scrutiny. (shrink)

Authors in this special Hypatia issue seem called to heal ethics, medicine, and the new field - medical ethics. After explaining why feminists should feel this calling, I group authors' contributions as responses to questions: 1. Why hasn't medical ethics already healed medicine? 2. What role should 'caring' play? 3. Must we first heal science? 4. Are we calling health a virtue? 5. Why haven't the many medical ethics books helped? 6. How do our sisters in sociology support us?

Anyone who thinks contemporary American society is hopelessly contentious and lacking in shared values has probably not been paying attention to the way the popular media portray the hospice movement. Over and over, we are told such things as that “Humane care costs less than high-tech care and is what patients want and need,” that hospices are “the most effective and least expensive route to a dignified death,” that hospice personnel are “heroic,” that their “compassion and dedication seem inexhaustible,” and (...) that “few could argue with the powerful message that it is better [for dying patients] to leave wrapped in the love of family and care givers than locked in the cold, metallic embrace of a machine.“. (shrink)

Sometimes one’s greatest academic disappointments can have unexpected outcomes. This is especially true when one is trying to change career trajectories or do something that others did not take seriously. My path into neuroethics was an unexpected journey catalyzed in part by constructive disappointment and the disbelief of colleagues who thought that the work I was pursuing nearly two decades prior was a fool’s errand. After all, could anyone—in his or her right mind—ever conceive of waking up a person unconscious (...) from brain injury and getting him to speak?1. (shrink)

This collection features comprehensive overviews of the various ethical challenges in organ transplantation. International readings well-grounded in the latest developments in the life sciences are organized into systematic sections and engage with one another, offering complementary views. All core issues in the global ethical debate are covered: donating and procuring organs, allocating and receiving organs, as well as considering alternatives. Due to its systematic structure, the volume provides an excellent orientation for researchers, students, and practitioners alike to enable a deeper (...) understanding of some of the most controversial issues in modern medicine. (shrink)

Health and beauty are the most important physical ideals. This paper seeks to compare and contrast these ideals, based on a value theory of human abilities. Health is comprehended as a potential ability to act grounded in bodily functions. Beauty is explained as a symbolising reference to happiness, physical beauty as a combination of organic orientation to purpose and virtuous orientation to action. Physical beauty is the implicit symbolic expression of mental and physical health. This teleological theory is tested and (...) exemplified using current stereotypes such as youthfulness, slimness and shapeliness. (shrink)

This article examines two questions pertaining to the extension of infertility treatment to postmenopausal women. First, what concepts and principles of infertility practice apply to assisted reproduction for the postmenopausal patient? Second, what role should these concepts play in the development of an ethical justification for extending women's reproductive lives past the menopausal boundary? The argument offered here supports their claim to infertility services on the basis of the formal principle of justice, which requires that similar cases be treated similarly. (...) The cases of many postmenopausal patients are argued to be relevantly similar to classes of patients who already receive assistance in reproduction. (shrink)

De moderne filosofie lijdt aan muziekvergetelheid. Opvallend is echter dat filosofen, wanneer ze toch aandacht schenken aan muziek, hun aandacht bij voorkeur op één bepaald genre richten, namelijk de opera. Filosofen zoals Søren Kierkegaard en Friedrich Nietzsche lieten hun gedachten over Don Giovanni, Parsifal en Carmen gaan, terwijl omgekeerd de filosofie van Arthur Schopenhauer de opera heeft beïnvloed via Wagner. Diens werk lijkt zich op het snijpunt van het grensverkeer tussen moderne filosofie en moderne muziek te bevinden. Het was zijn (...) ambitie de menselijke existentie en de menselijke geschiedenis in één panoramisch oeuvre te vatten, vanaf het primordiale begin tot en met de dramatische finale die ophanden leek: een catastrofale apotheose die een geheel nieuwe toekomst mogelijk zou maken. Dat is althans de verhaallijn van zijn meesterwerk Der Ring des Nibelungen. Aan het slot van Götterdämmerung lijkt zich een algehele verwoesting te hebben voltrokken: ‘Everything is destroyed and there is an enigmatic kind of hovering over the scene of destruction’ (Badiou 2010, p. 106), een ambivalente stemming van hoop en destructie zette Wagner op muziek. Voor Wagner is dan ook een hoofdrol in deze studie weggelegd: voor zijn muziektheoretische geschriften (waarin hij over een ‘muziek van de toekomst’ filosofeerde), maar meer nog voor de muzikale totaalkunstwerken die hij daadwerkelijk componeerde. (shrink)

Tussen zijn veertigste en zijn zestigste levensjaar was Jan Hendrik van den Berg (1914) een uitermate succesvol en populair auteur. Boeken van zijn hand, zoals Metabletica (1956) en Medische macht en medische ethiek (1969), waren ongekende bestsellers. Hij was de Nederlandse vertegenwoordiger van een belangrijke Europese stroming in de filosofie: de historische fenomenologie. In de jaren zeventig raakte hij echter in conflict met zijn tijd. Terwijl de Nederlandse publieke opinie een wending naar links doormaakte, bond Van den Berg de strijd (...) aan tegen verloedering, hooliganisme en anarchisme. Dit ging ten koste van zijn populariteit, maar niet van zijn productiviteit, noch van zijn innovativiteit. Tot op de dag van vandaag werkt hij aan een indrukwekkend , panoramisch oeuvre. Hij is de belangrijkste Nederlandse filosoof sinds Bolland. -/- Deze studie wil het werk van Van den Berg reconstrueren, situeren en beoordelen. Reconstrueren door de methodische en thematische coherentie ervan zichtbaar te maken. Situeren door het te confronteren met dat van andere, verwante auteurs zoals Husserl, Freud, Bachelard en Foucault. Beoordelen door na te gaan in hoeverre Van den Berg de inzet van zijn project, zowel inhoudelijk als methodologisch, waarmaakte. -/- Het werk van Van den Berg is geen curiosum, maar opvallend actueel. Hij onderzoekt het begin, de aanvang van wetenschappelijke en maatschappelijke ontwikkelingen waarvan het belang in de huidige situatie met nadruk zichtbaar wordt. Zijn beeldende stijl wekt de geschiedenis van de wetenschap tot leven, maar werd vaak als ‘anekdotisch’ afgedaan; zijn talent voor polemiek lokte soms felle reacties uit en zijn methodologische flexibiliteit maakte hem een gemakkelijk doelwit van academische kritiek. Aan de positieve kant van de balans staan echter zijn intellectuele enthousiasme en zijn internationale faam. Zijn werk verdient een rehabilitatie. (shrink)

In the discussion on rationing health care in The Netherlands, a fundamental tension emerges between two ethical perspectives: liberalism and communitarianism. A Dutch government committee recently issued a report opting for a community-oriented approach. This approach proves less communitarian as compared to the views on rationing elaborated by Callahan. Moreover, the community-oriented approach is conceptualised in such a way that it seems compatible with some basic aspects of the liberal account of a just society.

This article accounts for the failure of the Dutch Government Committee on Choices in Health Care to develop useful criteria of necessary care by which to set health care priorities and ration resources. The Government Committee has been inspired by philosophers who think that allocation problems cannot be solved without placing broad moral questions about the good life, and about the place of health and illness in our lives on the public agenda. The fruitless attempts of the Committee to formulate (...) an effective notion of essential care, based upon a community-oriented perspective of health, shows why the communitarian approach is bound to fail. Questions about essential health care cannot be answered on a macro-level. The only way to get some reasonable control over day-to-day health care allocation decisions in hospitals and institutions is by trying to understand the history, laws, habits and contingencies of what is going on between doctors and patients. Such an understanding can be gained by developing a relational and biographical view on the doctor-patient relationship. (shrink)

Die wachsende Nachfrage nach Anti-Aging-Medizin wirft die Frage auf, welche medizinischen Leistungen ein solidarisches Gesundheitssystem tragen sollte. Die deutsche Entscheidungspraxis beruft sich auf den Begriff der Krankheit. Im Blick auf Anti-Aging wäre demnach 1) zu klären, was der Krankheitsbegriff bedeutet, 2) zu prüfen, ob das Altern sich unter diesen Begriff subsumieren lässt, um 3) abzuleiten, inwieweit Anti-Aging-Maßnahmen zur Verfügung zu stellen sind. Dieses Prozedere führt jedoch zu keinem brauchbaren Ergebnis. Unter Berufung auf den Krankheitsbegriff allein ist der Umfang solidarischer Gesundheitsversorgung (...) nicht zu bestimmen. Allerdings lässt sich durch Reflexion auftretender Probleme ein gangbarer Entscheidungsweg aufzeigen. Er sieht eine faire Verständigung über die Frage vor, wie wir alt werden wollen. (shrink)