Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health (...) and healthcare with an account of fair process for setting limits or rationing care. This account is provided by three conditions that comprise "accountability for reasonableness.". (shrink)

Bryan S. Turner: Can We Live Forever? A Social and Moral Inquiry Content Type Journal Article Category Book Review Pages 301-303 DOI 10.1007/s12376-009-0024-6 Authors Thomas R. Cole, University of Texas-Houston School of Medicine McGovern Center for Health, Humanities, and the Human Spirit Houston TX 77030 USA Journal Medicine Studies Online ISSN 1876-4541 Print ISSN 1876-4533 Journal Volume Volume 1 Journal Issue Volume 1, Number 3.

The age-rationing debate of fifteen years ago will inevitably reemerge as health care costs escalate. All age-rationing proposals should be judged in light of the current system of rationing health care by price in the U.S., and the resulting pattern of excess and deprivation. Age-rationing should be rejected as public policy, but recognized as a personal virtue of stewardship among the elderly.

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)

Resistance to rationing health care to the elderly is enormous. This article lays out the need for rationing, based on projections of Medicare expenditure in the near future, and the judgment of policy experts that there will be no technological breakthrough that might lower costs. Various forms of rationing possibilities are discussed as well as cultural and political obstacles to needed reform. Some general principles for thinking about health care for the elderly are presented.

For well over 20 years I have been arguing that someday we will have to ration health care for the elderly. I got started in the mid-1980s when I served on an Office of Technology Assessment panel to assess the likely impact on elderly health care costs of emergent, increasingly expensive medical technologies. They would, the panel concluded, raise some serious problems for the future of Medicare. The panel did not take up what might be done about those costs, but (...) I decided to think about that question and wrote a book called, Setting Limits: Medical Goals in an Aging Society. (shrink)

I live on a short street in a small town, Hastings‐on‐Hudson, some fifteen miles up the Hudson River from New York City. Over the past decade a number of families have moved in, with about sixteen children among them. More than a bit housebound now because of old age and watching them romping about, I try to imagine what their world will be like when they have reached my present age, some eighty years from now. But I have a problem. (...) I just can’t imagine it. The demographic changes now appearing on the horizon will force unforeseeable changes. What would it have been like in 1930, when I was born, if someone then had to project the future of aging? They could not have guessed.Some momentous changes are now emerging, and they are bound to change the aging picture. What’s being done to respond to those growing pressures? (shrink)

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas’s theory of communicative action in order to suggest the kind of (...) pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated. (shrink)

Could age be a valid criterion for rationing? In Just health, Norman Daniels argues that under certain circumstances age rationing is prudent, and therefore a morally permissible strategy to tackle the problem of resource scarcity. Crucial to his argument is the distinction between two problem-settings of intergenerational equity: equity among age groups and equity among birth cohorts. While fairness between age groups can involve unequal benefit treatment in different life stages, fairness between birth cohorts implies enjoying approximate equality in benefit (...) ratios. Although both questions of fairness are distinct, the resolution of the one depends on resolution of the other. In this paper, I investigate whether Daniels’ account of age rationing could be defended as a fair way of setting limits to healthcare entitlements. I will focus on two main points. First, I will consider whether the age group problem could be resolved without appealing to a conception of the good. Second, I will demonstrate that the connection between the age group problem and the birth cohort problem runs deeper than Daniels initially thought—and that it ultimately suggests a method for prioritisation in problem solving strategies. (shrink)

Several authors have discussed and defended what is sometimes called the Asymmetry Thesis in social epistemology: that while reliance on testimony is essentially incontrovertible in epistemology, it is uniquely problematic for moral knowledge. This conclusion results, I argue, from considering the wrong sort of moral testimony: namely, ‘third-personal’ rather than ‘first-personal’ testimony. First-personal moral testimony is an inescapable part of the constitution of legitimate moral norms, and its role cannot be deflated as a form of mere information to be taken (...) up in private deliberation. The consequences of this argument for forms of hypothetical contractualism, in particular, are profound. (shrink)

Longevity is valuable. Most of us would agree that it’s bad to die when you could go on living, and death’s badness has to do with the value your life would have if it continued. Most of us would also agree that it’s bad if life expectancy in a country is low, it’s bad if there is high infant mortality and it’s bad if there is a wide mortality gap between different groups in a population. But how can we make (...) such judgments more precise? How should we evaluate the harm of mortality in a population? Although philosophers have written a lot about the harm of death for individuals, very little work has been done on the harm of mortality for populations. In this article, I take the first steps towards developing a theory of the harm of population mortality. Even these first steps, I argue, lead to surprising results. (shrink)

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

In Setting Limits, Daniel Callahan advances the provocative thesis that age be a limiting factor in decisions to allocate certain kinds of health services to the elderly. However, when one looks at available data, one discovers that there are many more elderly women than there are elderly men, and these older women are poorer, more apt to live alone, and less likely to have informal social and personal supports than their male counterparts. Older women, therefore, will make the heaviest demand (...) on health care resources. If age were to become a limiting factor, as Dr. Callahan sug-gests it should, the limits that will be set are limits that will affect women more dras” tically than they affect men. This review essay examines the implications of Callahan's thesis for elderly women. (shrink)

In Setting Limits, Daniel Callahan advances the provocative thesis that age be a limiting factor in decisions to allocate certain kinds of health services to the elderly. However, when one looks at available data, one discovers that there are many more elderly women than there are elderly men, and these older women are poorer, more apt to live alone, and less likely to have informal social and personal supports than their male counterparts. Older women, therefore, will make the heaviest demand (...) on health care resources. If age were to become a limiting factor, as Dr. Callahan suggests it should, the limits that will be set are limits that will affect women more drastically than they affect men. This review essay examines the implications of Callahan's thesis for elderly women. (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)

Kerstein and Bognar (2010) and Persad, Wertheimer, and Emanuel (2009) defend specific principles for the allocation of health care resources, but their choice of principles is influenced by the exa...

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)

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.

The aim of this study was to describe the reasoning of people aged 60 years and over about prioritization in health care with regard to age and willingness to pay. Healthy people (n = 300) and people receiving continuous care and services (n = 146) who were between 60 and 101 years old were interviewed about their views on prioritization in health care. The transcribed interviews were analysed using manifest and latent qualitative content analysis. The participants' reasoning on prioritization embraced (...) eight categories: feeling secure and confident in the health care system; being old means low priority; prioritization causes worries; using underhand means in order to be prioritized; prioritization as a necessity; being averse to anyone having precedence over others; having doubts about the distribution of resources; and buying treatment requires wealth. (shrink)

Healthcare Providers advising patient surrogates on the appropriateness of continued care for comatose patients have often been sharply criticized for coercive behavior toward patient surrogates; with failing to provide them with adequate information; and for a general failure to adequately cinsider the cimplex needs and hopes of patients, their surrogates, and caregivers. Because decisions on the continuation or withdrawal of care often need the legal approval of surrogates the failure of both medical personnel and patient families to understand each other's (...) priorities may lead to ethical and interpersonal conflict. (shrink)

This article looks at the question of sin and disease in bioethics with a spiritual-theological analysis from the book of Job. The biblical figure Job is an innocent and just man who suffered horrendously. His dialogues with others—his wife, his friends, and God—can give many valuable insights for patients who suffer and for those who interact with them. Family, friends, physicians, nurses, chaplains, and pastoral workers can learn from Job how to communicate properly with sufferers. The main question for Job (...) was how to maintain the tension between God’s justice and God’s mercy and not yield to the temptation of cursing God but to speak well of Him in moments of difficulties. (shrink)

Health care should be preferentially allocated to younger patients. This is just and is seen as just. Age is an objective factor in rationing decisions. The arguments against 'ageism' are answered. The effects of age on current methods of rationing are illustrated, and the practical applications of an age-related criterion are discussed. Ageist policies are in current use and open discussion of them is advocated.

Bioethicists are increasingly commenting on health care resource allocation, and sometimes suggest ways to solve various rationing dilemmas ethically. I argue that both because of the assumptions bioethicists make about social reality, and because of the methods of argument they use, they cannot possibly make a useful contribution to the debate. Bioethicists who want to make a practical difference should either approach health care resource allocation as if the matter hinged upon tribal competition (which is essentially what it does), or (...) they should do political philosophy in the traditional sense, and examine the health system from the outside. (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)

Spirituality and storytelling can be resources in aging successfully and in dying well given the constraints of modern day Western culture. This paper explores the relationship of aging to time and the dynamic process of the life course and discusses issues related to confronting mortality, including suffering, finitude, spirituality, and spiritual closure in regard to death. And, finally, the role of narrative in this process is taken up.

Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal to is (...) based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah's Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care. (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)

Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as “beneficial,” “effective,” or even “futile,” the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient (...) Greek philosophical conundrum known as the “sorites paradox.” I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing). (shrink)

Resource finitude, cost containment, and a purchaser monopsony market have created public concern-about the moral and legal responsibility for quality assurance in health plans. Resource allocation and standards of care represent a clash of moral values in intensive care treatment. This essay advances a procedural model, based on legislation passed in Oregon, that could govern the incorporation of private sector health insurance plans in Oregon to assure democratic input from consumers, providers, and employers into a limited vision of individual entitlement (...) to consume futile or inappropriate care in intensive care units. The model, which I call the Oregonian ICU, presumes that rationing of care is implicit and not publicly disclosed under managed care. It focuses on maximizing the quality of limited benefits available in the basic managed care insurance tier. Limitations to futile and inappropriate care are developed on the basis of morally weighted prognostic scoring systems that inform the creation of negotiated private sector contracts. (shrink)

Resource finitude, cost containment, and a purchaser monopsony market have created public concern-about the moral and legal responsibility for quality assurance in health plans. Resource allocation and standards of care represent a clash of moral values in intensive care treatment. This essay advances a procedural model, based on legislation passed in Oregon, that could govern the incorporation of private sector health insurance plans in Oregon to assure democratic input from consumers, providers, and employers into a limited vision of individual entitlement (...) to consume futile or inappropriate care in intensive care units. The model, which I call the Oregonian ICU, presumes that rationing of care is implicit and not publicly disclosed under managed care. It focuses on maximizing the quality of limited benefits available in the basic managed care insurance tier. Limitations to futile and inappropriate care are developed on the basis of morally weighted prognostic scoring systems that inform the creation of negotiated private sector contracts. (shrink)

In matters of discontinuation of life-sustaining treatment, traditional role of the family to speak on behalf of the incompetent patient is questionable. We explore the reasons why physicians perceive patient autonomy to be transferrable to family members. Principle of patient autonomy may not suffice when futile treatment is demanded and may serve to erode the ethical integrity of medical profession. An enhanced role for bioethics committees is proposed when physicians propose to discontinue life-sustaining treatment against the wishes of the patient (...) or their families. (shrink)

The human life span has been extended considerably, and among the very old, women outnumber men by a large margin. Thus, the aging society cannot be adequately addressed without taking into account the experience of women in specific. This article focuses on women as caregivers for aging parents. It critically assesses what some women philosophers are saying about the basis and limits of these caregiving duties.

The authors describe the ethical considerations underlying the inclusion of mental health services into a prioritized health care system. The Oregon Health Plan is a process for defining and delivering basic health services to an entire state. As the plan was developed, the mental health community needed to decide whether or not to participate in the process and, if so, how. Lengthy discussions among mental health consumers, family members, and providers led to a strategy that emphasized the integration of mental (...) health and chemical dependency services into a comprehensive and universal health care program. This approach appears to have achieved relative parity for mental health. (shrink)

In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity is absolute and ongoing; and argue that (...) Kerstein and Bognar are mistaken to base their allocation principles on differences in personhood. (shrink)

Debates about the ethical and social implications of research that aims to extend human longevity by intervening in the ageing process have paid little attention to the attitudes of members of the general public. In the absence of empirical evidence, conflicting assumptions have been made about likely public attitudes towards life-extension. In light of recent calls for greater public involvement in such discussions, this target article presents findings from focus groups and individual interviews which investigated whether members of the general (...) public identify ethical issues surrounding life-extension, and if so, what these ethical issues are? In this study, while some participants were concerned primarily with the likely personal consequences of life-extension, for others the question of whether or not to pursue interventions to extend longevity, and how they should be implemented, clearly raised important ethical issues, many of which have been prominent in debates among bioethicists. (shrink)

The ethics of decision making for the critically ill elderly is an area of concern for all those involved in the decision-making process. The number of participants involved in decision making around end-of-life issues may be many: treatment and care decisions often bring together not only the patient and the physician, but the family, an extended medical care team, and impartial members of a hospital or institutional ethics committee. In addition, treatment and care decisions made at the end of life (...) occur in a variety of settings, not just the acute care hospital. Elderly patients who are critically ill, or in the final days or weeks of life, are found in intensive care or medical units of hospitals, in hospital and nursing home based hospice programs, in long-term care settings such as skilled nursing facilities, or at home, where they are tended by family caregivers. Differences in patterns of decision making regarding the care and treatment of critically ill older adults can be found across these settings, and decisions often vary according to the roles of the participants. (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)

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)