Bioethicists have typically disdained where they did not simply ignore the Hippocratic tradition in medicine. Its exclusivity—an oath of and for physicians—seemed contrary to the perspective that bioethicists have attempted to invoke. Robert M. Veatch recently articulated this rejection of the Hippocratic tradition, and of a professional ethic of medicine in general, in a volume based on his Gifford lectures. Here that argument is critiqued. The strengths of the Hippocratic tradition as a flexible and ethical social doctrine are offered in (...) its stead. (shrink)

There are in two assumptions inherent in this issue's theme, both inimical to the traditional goals of medicine and to the standards of care it proposed. First, the idea that treatment must be limited for some (but not others) on the basis of cost was born in the early literature of bioethics. Second, that there is a quantifiable and diagnostically predictable period at the “end-of-life” where treatment is “futile,” and therefore not worth supporting in a context of scarcity grew out (...) of bioethics's construction of allocative protocols in the 1990s. This paper traces the history of these ideas as constructs grounded in neither natural scarcity nor in firm diagnostic categories. Their relation to issues of care is therefore suspect. (shrink)

Early announcements of this special journal issue solicited authors interested in contributing articles on the subject of “costs at the end of life.” Those who replied were then informed the title was being changed, on the basis of early subscriber interest, in “rational end-of-life treatment.” Because that seemed a still inadequate reflection of the authorial concerns of responding potential contributors, the editors again changed the title, two months later, to “Making Treatments More Rational and Compassionate for the Chronically Critically Ill.” (...) At that point the editors gave up and decided this issue’s final title would be determined only after the papers were submitted and reviewed. (shrink)

For all its apparent debate bioethical discourse is in fact very narrow. The discussion that occurs is typically within limited parameters, rarely fundamental. Nor does it accommodate divergent perspectives with ease. The reason lies in its ideology and the political and economic perspectives that ideology promotes. Here the ideology of bioethics' fundamental axioms is critiqued as arbitrary and exclusive rather than necessary and inclusive. The result unpacks the ideological and political underpinnings of bioethical thinking and suggests new avenues for a (...) broader debate over fundamentals, and a different approach to bioethical debate. (shrink)

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond (...) to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health. (shrink)

Discussions about the role of practice guidelines and the strength of the evidence on which they are based should begin with a set of more basic questions: What is the function of such guidelines and what forces shape their use?At least two forces can be seen behind the press for guidelines. On the one hand, guidelines can be used to improve the quality of care by raising the general level of practice to meet at least the standards set by experts. (...) At the other, they become vehicles for cost containment.By international standards, the United States spends a disproportionate share of its gross domestic product on health care. The majority of spending increases are traceable to the growth in technology. Whether couched as a concern that resources could be better used to provide other parts of the population with more effective health care or as a general concern that money spent on health might be better used for other social goods, a notion exists that less is better. (shrink)

Discussions about the role of practice guidelines and the strength of the evidence on which they are based should begin with a set of more basic questions: What is the function of such guidelines and what forces shape their use?At least two forces can be seen behind the press for guidelines. On the one hand, guidelines can be used to improve the quality of care by raising the general level of practice to meet at least the standards set by experts. (...) At the other, they become vehicles for cost containment.By international standards, the United States spends a disproportionate share of its gross domestic product on health care. The majority of spending increases are traceable to the growth in technology. Whether couched as a concern that resources could be better used to provide other parts of the population with more effective health care or as a general concern that money spent on health might be better used for other social goods, a notion exists that less is better. (shrink)

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources be distributed If not all demands can be met?

The paper begins by drawing a distinction between “allocation” — the distribution of resources between different categories, and “rationing” — the distribution of scarce resources within a single category. I argue that the current allocation of funds to health care makes some form of rationing unavoidable. The paper next considers proposals by Daniel Callahan and Norman Daniels supporting age rationing publicly-financed life-extending medical care. I provide reasons for doubting that either argument succeeds. The final section of the paper sets forth (...) an alternative approach which holds that if people have any rights to health care, then they have a right to a decent minimum. (shrink)

Societal aging raises challenging ethical questions regarding the just distribution of health care between young and old. This article considers a proposal for age-based rationing of health care, which is based on the prudential life span account of justice between age groups. While important objections have been raised against the prudential life span account, it continues to dominate scholarly debates. This article introduces a new objection, one that develops out of the well-established disability critique of social contract theories. I show (...) the implications of this critique for the prudential life span account and for the special case of age-group justice. The result is that age-based rationing based on the prudential life span approach is not supported, and that the prudential life span approach itself is not the best way to think about allocating health care between age groups. I propose an alternative approach that avoids the disability objection, and consider its implications for specific proposals for age-based rationing of health care. (shrink)

Our response to death may differ depending on the patient’s age. We may feel that death is a sad, but acceptable event in an elderly patient, yet feel that death in a very young patient is somehow unfair. This paper explores whether there is any ethical basis for our different responses. It examines in particular whether a patient’s age should be relevant to the determination that an intervention is medically futile. It also considers the responsibilities of health professionals and the (...) rights of family members in situations where an interventions is clearly futile. (shrink)

Is age discrimination ethically objectionable? One puzzle is that we sometimes assume that the target of both age discrimination and ageism must be older people, yet in poorer nations, older people are generally shown more respect. This article explores the ethical question. It looks first at ethical arguments favoring age discrimination toward younger people in low‐income, less industrialized countries of the global South, using sub‐Saharan Africa as an illustration. It contrasts these with arguments favoring age discrimination toward older people in (...) high‐income, more industrialized countries of the global North, particularly the United States and United Kingdom. Finally, it considers what role, if any, differences in life expectancy, infant and child mortality, and prospects for healthy lives should play in the moral embrace of a particular view by a community. It argues that there can be reasons to favor different types of discrimination in different parts of the world. (shrink)

Daniel Callahan has argued that economic and social benefits would result from a policy of withholding medical treatments which prolong life in persons over a certain age. He claims 'the real goal of medicine' is to conquer death and prolong life with the use of technology, regardless of the age and quality of life of the patient, and this has been responsible for the escalation of health care expenditure. Callahan's proposal is based on economic rationalism but there is little evidence (...) to suggest that substantial economic savings could be achieved. Moreover, his argument raises serious moral objections. A policy of withholding treatments from members of a social group involves elements of compulsion and discrimination, both of which would intrude on the doctor-patient relationship, undermine the autonomy of elderly patients, and invoke the slippery slope towards involuntary forms of euthanasia. Life-death decisions should be based on more than the one criterion of age, and take account of more relevant factors such as the patient's usual state of well-being, her/his expressed wishes, informed consent and the type of illness. Any move to the implementation and enforcement of the policy Callahan recommends would be rejected by health professionals and the public. (shrink)

In the language of secular bioethics, autonomy is always accorded first place in the hierarchy of values that has come to be referred to as the “Georgetown mantra” A dictionary definition of mantra is “a verbal spell, ritualistic incantation, or mystic formula used devotionally,” and the value placed upon autonomy is largely of this nature: uncritical and uncriticised. That there should be and are limits to autonomy is obvious, but these boundaries are undefined, little discussed, and mostly unexplored. To use (...) another metaphor, our emphasis on autonomy is an index of how far the pendulum has swung in an understandable and partly justifiable reaction from, earlier paternalism; has this swing approached its proper limit, and should we be seeking a less extreme and more balanced assessment of autonomy as a bioethical value? (shrink)

The healthcare systems of the United States and United Kingdom are vastly different. The former relies primarily on private sector incentives and market forces to allocate medical care services, while the latter is a centrally planned system funded almost entirely by the public sector. Therefore, each nation represents divergent views on the relative efficacy of the market or government in achieving social objectives in the area of medical care policy. Since its inception in 1948, the National Health Services of the (...) United Kingdom has consistently emphasized equity in the allocation of medical services. It has done so by creating a system whereby services are universally free of charge at the point of entry. Conversely, the United States has relied upon the evolution of a perplexing array of public and private sector insurance schemes centered more around consumer choice than equity in allocation. (shrink)